Part 5

567. Hysterical contracture (with physiopathic features) brutally conquered _Ferrand_, 1917 788

568. Paraparesis: Cure by exercises electrically provoked _Turrell_, 1915 790

569. Astasia-abasia: (“Lourdes-like” cure) _Voss_, 1916 791

570. Abasia: Rapid cure _Schultze_, 1916 792

571. Heterosuggestive brachial paresis: Electric suggestion and recovery in five days _Hewat_, 1917 794

572. Contracture of right index finger and thumb: Psychoelectric cure _Roussy_, _L’Hermitte_, 1917 795

573. Brachial monoplegic able to descend ladder with arms only _Claude_, 1916 795

574. Brachial monoparesis: Vicissitudes of treatment _Vincent_, 1917 796

575. Paresis and sensory disorder: Reëducation _Binswanger_, 1915 798

576. Seizures (of _ante bellum_ origin), astasia-abasia, anesthesias: Reëducation _Binswanger_, 1915 800

577. Progress in case of paresis of foot and spasticity of hip _Binswanger_, 1915 805

578. Mutism (Reëducation) _Briand_, _Philippe_, 1916 808

579. Stammering: Isolation and reëducation _Binswanger_, 1915 810

580. Deafmutism: Phonetic reëducation _Liébault_, 1916 814

581. Aphonia: Pressure on sternum and respiratory gymnastics _Garel_, 1916 816

582. Stammering: Reëducation _MacMahon_, 1917 817

583. Speech disorder: Reëducation _MacMahon_, 1917 818

584. Camptocormia: Psycho-electric cure: lameness cured by reëducation _Roussy_, _L’Hermitte_, 1917 819

585. Deafmutism: Speech recovery by suggestion and reëducation: Hearing by reëducation _Liébault_, 1916 822

586. Mutism; stammering; Reëducation; hypnosis _MacCurdy_, 1917 823

587. Anesthesias: Spontaneous gradual recovery: “Paralysis” cured by reëducation _Binswanger_, 1915 824

588. Deafmutism; head movements, anesthesia: Cure by faradism, massage and reëducation _Arinstein_, 1916 827

589. Amnesia and paralysis: Reëducation _Batten_, 1916 828

SECTION E. EPICRISIS

PARAGRAPH TERMINOLOGY 1-8

DIAGNOSTIC DELIMITATION PROBLEM 9-39

THE NATURE OF WAR NEUROSES 40-74

DIAGNOSTIC DIFFERENTIATION PROBLEM 75-99

GENERAL NATURE OF SHELL-SHOCK 89-102

TREATMENT: GENERAL OBSERVATIONS 103-114

A. PSYCHOSES INCIDENTAL IN THE WAR

La divina giustizia di qua punge quell’ Attila che fu flagello in terra.

Divine justice here torments that Attila, who was a scourge on earth.

Inferno, Canto xii, 133-134.

The data from all the belligerent countries, collected in this book, go far to prove that, whatever at last you elect to term Shell-shock, you must pause to consider whether your putative case is not actually:

A matter of spirochetes?

The response of a subnormal soldier?

An equivalent of epilepsy?

An alcoholic situation?

A result of neurones actually _hors de combat_?

A state of bodily weakness (perhaps of _faiblesse irritable_)?

A bit of dementia praecox?

One of the ups and downs of the emotional (affective, cyclothymic) psychoses?

An odd psychopathic reaction in which the response is abnormal not so much by reason of excessive stimulus as by reason of defective power of response?

On a simpler basis, is not our Shell-shocker just a banal example of hysteria, neurasthenia, psychasthenia; and is not this psychoneurotic more peculiar in his capacity to be shocked than are the conditions that purvey the shocks?

Put more concretely in the terms of available tests and criteria, open to the psychiatrist, does not every putative Shell-shock soldier deserve at some stage a blood test for syphilis? Should we not be reasonably sure we are not facing a man inadequate to start with, so far as mental tests avail? Should we not verify (even at considerable expense of time and money by so-called “social service” methods) the facts of epilepsy and epileptic taint? Of alcoholism? And so on? There can be no two answers to these questions.

Upon the following page is a practical grouping of mental diseases, devised in the first place, not for war psychoses, but for the initial sifting of psychopathic hospital cases. Now the psychopathic hospital group of cases constitutes in peace practice the closest analogue of the mental cases met in active military practice, because the “incipient, acute, and curable”[1] cases, for which psychopathic hospitals are built and which flock to or are sent to the wards and outdoor departments of such hospitals, are precisely the cases that early come forward in active military practice. They are precisely the cases in which that pathological event--whatever it is--we know as Shell-shock may be expected to develop. It is precisely the “incipient, acute, and curable” instances of mental disease which we hope to exclude from our American army by cis-Atlantic winnowing-out at the hands of neuropsychiatric experts--the best preventive we hope both of Shell-shock and of other worse mental conditions, if such there be. Military mental practice plainly deals, not so much with frank and committable insanity, as with mental diseases of a medically milder but a militarily far more insidious nature.

[1] Official phrase for the scope of the Psychopathic Hospital, Boston, Massachusetts.

A further inspection of this grouping of mental diseases shows not only that it contains many conditions not usually termed “insanity” (such as, e.g., feeblemindedness, epilepsy, alcoholism, sundry somatic diseases, psychoneuroses), but that these conditions are presented for practical purposes in a certain seemingly arbitrary order. Without attempting to justify this selection of scope (not too wide for modern psychiatry, most would readily acknowledge), I shall draw out a little further what I consider to be the virtues of the order selected. In the first place, all will concede, _some_ order of consideration of collected data is a prime necessity to the tyro. Without an order of consideration the diagnostic tyro is but too apt to find in the best textbooks of psychiatry (even more easily the better the textbook) all he needs to prove that the case in hand is--almost anything he selects to make his case conform to! And how much more dangerous this debating-society method of diagnosis (by choice of a side and matching a textbook type) may become in the fluid and elastic conditions of psychopathic hospital practice, can readily be observed by one who contemplates the _formes frustes_ and entity-sketches that the “incipient, acute, and curable” group of cases presents.

CHART 1

PRACTICAL GROUPING OF MENTAL DISEASES

The order adopted for these groups (which roughly correspond to botanical or zoological orders) is a pragmatic order for successive exclusion on the basis of available tests, criteria, or information: the actual diagnosis is a product of still further differentiation within the several groups.

The case-histories of this book will show that

(_a_) most shell-shock is in group X, Psychoneuroses,

(_b_) the diagnostic delimitation problem is chiefly against I. Syphilopsychoses, III. Epileptoses, VI. Somatopsychoses,

(_c_) the finer differentiation problem is between X. Psychoneuroses and V. Encephalopsychoses. (See Epicrisis, propositions 9-12, 40-43, 72-73.)

I. Syphilitic Psychoses SYPHILOPSYCHOSES

II. Feeblemindedness HYPOPHRENOSES

III. Epilepsy EPILEPTOSES

IV. Alcoholic, Drug, and Poison Psychoses PHARMACOPSYCHOSES

V. Focal Brain Lesion Psychoses ENCEPHALOPSYCHOSES

VI. Symptomatic (Somatic) Psychoses SOMATOPSYCHOSES

VII. Presenile-Senile Psychoses GERIOPSYCHOSES

VIII. Dementia Praecox and Allied Psychoses SCHIZOPHRENOSES

IX. Manic-Depressive and Allied Psychoses CYCLOTHYMOSES

X. Psychoneuroses PSYCHONEUROSES

XI. Other Forms of Psychopathia PSYCHOPATHOSES

No conclusions are intended to be drawn in these introductory pages. Such conclusions as are risked are placed in the Epicrisis (see Section E). But so much can be said: If we are ever to surround the problem of Shell-shock (_intra bellum_ or _post bellum_), we must approach it with no artificial and _à priori_ limitations of its scope. We must not even agree beforehand that Shell-shock is nothing but psychoneurosis: that would be a deductive decision unworthy of modern science. In the collection of these cases, I have tried to place the topic upon the broadest clinical base. Samples of virtually every sort of mental disease and of several sorts of nervous disease have been laid down, some obviously not instances of Shell-shock, some mixed with clinical phenomena of Shell-shock, others hard to tell offhand from Shell-shock--the whole on the basis that we shall earliest learn what Shell-shock, the pathological event, is by studying what it is not. As the sequel may show, we are perhaps not entitled to regard Shell-shock, the pathological event, as always associated with shell-shock, the physical event. We shall, therefore, find in Section A (see tables on pages 6 and 7).

(1) Cases without either physical shell-shock, or pathological Shell-shock--psychoses of various kinds incidental in the war (--+).

(2) Cases with physical shell-shock but without pathological Shell-shock--psychoses of various kinds seemingly liberated by, aggravated by, or accelerated by the physical factor of shell-shock (+-+).

(3) Cases without physical shell-shock but with both symptoms of pathological Shell-shock as well as of other psychosis (-++).

(4) Cases with physical shell-shock, with clinical phenomena of Shell-shock, as well as of other psychosis (+++).

At the end of Section A, accordingly, we shall be left with two more formulae for discussion in Sections B, C, and D, viz:

(5) Cases without physical shell-shock but with symptoms of pathological Shell-shock (-+-).

(6) Cases with physical shell-shock and pathological Shell-shock (++-).

The data of Section A will solidly prove that Shell-shock, however picturesque the term for laymen or in the _argot_ of the clinic, is medically most intriguing. As we cannot get rid of the term (even by suppressing it in parentheses or by condemning it to the limbo of the _so-called_), we must make the best of it by calling Shell-shock just the ore in the clinical mine. To say the least, the _term_ is harmless: it merely stimulates the lay hearer to questions. These questions he must ask of the expert. But every time that the expert suavely states that Shell-shock is nothing but psychoneurosis, that expert runs the risk of hurting some patient who may or not have a psychoneurosis but has been _called_ psychoneurotic. All the while, of course, the suave expert is perfectly right--_statistically_. In fine, the man you have called a victim of Shell-shock is probably a victim of psychoneurosis, _but only probably_!

Section A shows how he may--not probably, but possibly--be a victim of say ten other things. But it is not that he has an even chance of being one of these ten other things. As the reader watches the procession of cases in Section A, he will perceive that, amongst the ten major groups there studied, some have far greater diagnostic likelihood than others. Thus, syphilis, epilepsy, and somatic diseases will in the sequel prove more dangerous to our success as diagnosticians than, e. g., feeblemindedness or even perhaps alcoholism. But now let us look at these cases systematically, just as if we dealt with so many cases of Railway-spine or any other “incipient, acute, and curable” cases.

CHART 2

PSYCHOPATHIA MARTIALIS

⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫ ⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫ SHELL-SHOCK SHELL-SHOCK PSYCHOSIS (THE PHYSICAL FACTOR) (NEUROTIC SYMPTOMS) (SYMPTOMS NON-NEUROTIC)

ABSENT ABSENT INCIDENTAL

PRESENT ABSENT LIBERATED, AGGRAVATED, ACCELERATED PSYCHOSES

ABSENT COMBINED NEUROSES AND PSYCHOSES [2](FORMULA -++)

PRESENT COMBINED NEUROSES AND PSYCHOSES (FORMULA +++)

ABSENT NEUROSES ABSENT (QUASI SHELL-SHOCK)

PRESENT NEUROSES ABSENT (TRUE SHELL-SHOCK)

[2] For formulae see Chart 3 on opposite page.

CHART 3

PSYCHOPATHIA MARTIALIS

FORMULAE

⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫ ⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫ S, N, P[3] = SHELL-SHOCK SHELL-SHOCK PSYCHOSIS (THE PHYSICAL[4] (NEUROTIC SYMPTOMS) (NON-NEUROTIC FACTOR) PRESENT PRESENT SYMPTOMS) PRESENT

P = - - +

SP = + - +

NP = - + +

SNP = + + +

N = - + -

SN = + + -

[3] In the literal formulae, S = Shell-shock, N = Neurosis, P = Psychosis.

[4] These plus-or-minus formulae are not intended to imply that the physical factor, where present (+), must have worked a physical effect upon the nervous system: the effects of the physical factor might be wholly emotional or otherwise psychic.

I. SYPHILOPSYCHOSES (SYPHILITIC GROUP)

An officer of high rank deserts his command in a crisis: alienists’ report.

=Case 1.= (BRIAND, February, 1915.)

M. X. was an officer ranking high in the French army, having military duties of a critical nature and of great importance (social reasons forbid Briand’s giving informatory details). Suffice it to say that he was brought before court-martial for abandoning his post at the very moment when his presence was most urgently required. He turned tail, without taking the most elementary military precautions.

M. X. was passed up to alienists. He was not a case of Shell-shock unless of the anticipatory sort. He was somatically run-down and of lowered morale and now 65 years of age. The campaign had been fatiguing.

The alienists decided that the officer had not been responsible for his non-military acts. He had been, they found, in a state of mental confusion at the time of desertion, such that amnesia for his duties and heedlessness of consequences had allowed him to leave the front without looking behind him or securing substitution. This state of mental confusion had been preceded by overwork and several nights of insomnia.

Moreover he was palpably arteriosclerotic. Blood pressure was high. The history was one of slight shocks and a mild hemiplegia. The confusion at the front was only the most recent of a series of transitory attacks of confusion. At the time of examination this high officer was actually in a state of mild dementia.

M. X. was an old colonial man, malarial, and had been a victim of syphilis.

A naval officer sees hundreds of submarines: General paresis.

=Case 2.= (CARLILL, FILDES, and BAKER, July, 1917.)

A naval officer, 36, during August, 1916, asserted that he could see hundreds of submarines. At one time he imagined that he was receiving trunk calls in the middle of the ocean. He was admitted to Haslar, and the Wassermann reaction of the serum was found strongly positive. The spinal fluid was not at this time examined. The officer recovered to some extent, was given no special treatment, and was sent on leave.

He came under observation again in October, 1916, having become very strange in his manner, on one occasion passing water into the coal box, and talked about impending electrocution. His ankle-jerks were found sluggish and there was a patch of blunting to pin pricks. The diagnosis of general paresis was made. The spinal fluid was afterward examined and found to be negative to the Wassermann reaction but contained 15 lymphocytes per cubic mm.

Three full doses of Kharsivan freed him from delusions and left him apparently absolutely sane. It was recommended that he should be kept at Haslar to continue treatment. However, he had been certified insane and was therefore sent to Yarmouth, from which he was discharged in February, 1917, having been in good mental health throughout his stay there.

_Re_ syphilis and general paresis of military officers, as in Cases 1 and 2, Russo-Japanese experience was already at hand. Autokratow saw paretic Russian officers sent to the front in early but still obvious phases of disease. These paretics and various arteriosclerotics, Autokratow saw back in Russia in the course of a few months.

_Re_ naval cases, see also Case 5 (Beaton). Beaton thinks that monotonous ship duty, alternating with critical stress of service, bears on morale and liberates mental disorder.

Neurosyphilis may be aggravated or accelerated under war conditions.

=Case 3.= (WEYGANDT, May, 1915.)

A German, long alcoholic and thought to be weakminded, volunteered, but shortly had to be released from service. He began to be forgetful and obstinate, cried, and even appeared to be subject to hallucinations. The pupils were unequal and sluggish. The uvula hung to the right. The left knee-jerk was lively, right weak. Fine tremors of hands. Hypalgesia of backs of hands. Stumbling speech. Attention poor.

It appeared that he had been infected with syphilis in 1881 and in 1903 had had an ulcer of the left leg.

The military commission denied that his service had brought about the disease.

=Case 4.= (HURST, April, 1917.)

An English colonel thought himself perfectly fit when he went out with the original Expeditionary Force. He had had leg pains, regarded as due to rheumatism or neuritis. He was invalided home after exhaustion on the great retreat. He was now found to be suffering from a severe tabes. He improved greatly under rest and antisyphilitic treatment. He has now returned to duty.

=Case 5.= (BEATON, May, 1915.)

An apparently healthy man, serving on an English battle-ship, severed a tendon in a finger. The injury was regarded as minor. The tendon was sutured and the wound healed. During the man’s convalescence he was accidentally discovered to have an Argyll-Robertson pupil and some excess reflexes. Neurosyphilis had probably antedated the accident. But from the moment of this trivial injury, the disease advanced rapidly.

Overwork in service; several months exacting work well performed: General paresis.

=Case 6.= (BOUCHEROT, 1915.)

A lieutenant of Territorials, aged 41 (heredity good, anal fistula at 30, with ulceration of penis of an unknown nature at the same period). In 1907 when off service and married, his wife gave birth to a child; no miscarriages. Had been a good soldier in service before the war. The lieutenant was called to the colors August 2, 1914, and was detached for special duty, for the performance of which he was much praised by the commanding officers. The work, however, was too much for him and on April 1 he had to be evacuated to the hospital with a ticket saying “Nervous depression following overwork in service.” On April 14 he seemed well enough for a convalescent camp, but, apparently through red tape, was sent to a hospital at Orléans. On June 23 he had to be evacuated to the Fleury annex. His eyes were dull and features flaccid; his whole manner suggested fatigue. His pupils were myotic, tongue tremulous, speech slow and stumbling. Knee-jerks were exaggerated and gait difficult, the right leg dragging. Headaches. He could not perform the slightest intellectual work and was the victim of retrograde and anterograde amnesia. He was aware of the decline of his mental power and was fain to struggle against it, becoming restless and sad. The gaps in his memory grew deeper, he became more and more impulsive, even violent, and had spells of excitement. Dizziness and palpitation developed. Sometimes there were auditory and visual hallucinations of such intense character that he tried feebly to commit suicide with a penknife. He fell into semicoma, and then had a number of apoplectiform attacks. W. R. +

Apparently the moral and physical situation of the lieutenant was absolutely normal when the campaign began and, as he fulfilled detail duties with absolute correctness for a number of months, Boucherot argues that here is an instance of general paresis _declanché_ by overwork.

Syphilis contracted before enlistment. Neurosyphilis aggravated by service.

=Case 7.= (TODD, personal communication, 1917.)

A laboring man, 42, who always strenuously denied syphilitic infection, proceeded to France eight months after enlistment. He had not been in France three weeks when he dropped unconscious. He regained consciousness, but remained stupid, dull in expression, and with memory impaired. His speech was also impaired. There was dizziness and a right-sided hemiplegia.

He was confined to bed four months and was then “boarded” for discharge.

Physically, his heart was slightly enlarged both right and left; sounds irregular; extra systoles; aortic systolic murmur transmitted to neck; blood pressure 140:40. Precordial pain, dyspnoea.

Neurologically, there was a partial spastic paralysis of the right thigh which could be abducted, could be flexed to 120°, and showed some power in the quadriceps. There was also a spastic paralysis of the right arm, but the shoulder girdle movements were not impaired. There was a slight weakness on the right side of the face. There was no anesthesia anywhere.

The deep reflexes were increased on the right side, Babinski on right, flexor contractures of right hand, extensor contractures of right leg, abdominal and epigastric reflexes absent, pupils active, tongue protruded in straight line.

Fluid: slight increase in protein. W. R. + + +

The Board of Pension Commissioners ruled that the condition had been aggravated _by_ service (not “_on_ service”).

_Re_ general paresis, Fearnsides suggested at the Section of Neurology in the Royal Society of Medicine early in 1916, that in all cases of suspected Shell-shock the Wassermann reaction of the serum should be determined, and went on to say that cases of so-called Shell-shock with positive W. R. often improve rapidly with antisyphilitic remedies.

Duration of neurosyphilitic process important _re_ compensation.

=Case 8.= (FARRAR, personal communication, 1917.)

A Canadian of 36 enlisted in 1915, served in England, and was returned to Canada in February, 1917, clearly suffering from some form of neurosyphilis (W. R. positive in serum and fluid, globulin, pleocytosis 108).