Part 65

A careful examination about the middle of November showed the persistence of a severe paresis of the left arm, and a less marked motor weakness of the right arm. Both legs were paretic, and there were no spontaneous movements of the leg. This paresis of the legs was combined with complete anesthesia and analgesia. Sensory impairment was found only in the right arm and trunk, and there was no evidence of sensory impairment in the left arm. Both motor and sensory disturbances of the arm disappeared rapidly.

However, at the beginning of December, 1914, the complete insensibility of the lower extremities up to the groin still persisted. The anesthesia then began to retreat, so that four days later, the upper limit of anesthesia was somewhat below the groin. There could be found a circumscribed area of anesthetic skin over the os sacrum up as far as the second vertebra of the os sacrum; but the skin around this area, as well as over each tuber ischii, gave normal sensation.

The anesthesia continued to retreat: to the middle of the thigh at the middle of December; to a level 3 cm. above the knee-cap at the end of December; to the upper end of the knee-cap on the right side and the middle of the left knee-cap, January 1. January 11, the anesthesia had retreated to a level 10 cm. below both right and left patella. February 8, sensibility in the legs had entirely returned.

While the anesthesia was pursuing this favorable course, the motor symptoms failed to improve to any marked extent, although active motion of the legs with the patient in dorsal decubitus had gradually returned to a limited degree.

The diagnosis upon arrival at the Jena Nerve Hospital was “rheumatism of the left side of the body and dislocation of the spine.”

The treatment consisted at first of rest in bed and moist dressings of the legs, but the treatment had to depend greatly upon the diagnosis. The patient complained of difficult micturition; yet there were no other positive signs of organic disease, of spine or cord.

Hysteria was the diagnosis preferred to rheumatism, despite the fact that examination at the Jena Hospital failed to show any disorder in pain or tactile sense.

The patient was a rather tall man of slender build, with a slightly accentuated second pulmonic sound, decidedly increased tendon reflexes, weak plantar reflexes, and many points painful on pressure in various parts of the head, over the spine, and in the sciatic regions. The vertebral sensibility to pressure was most acute in the region of the third, fourth, and fifth thoracic vertebrae. There was a marked dermatographia. There was no other sensory disorder and no motor disorder of the arms, though the left hand-grasp was weak. All passive movements could be successfully carried out with the legs. Upon bending at the hip, there were subjective feelings of tension in the posterior parts of the thighs. In active motion there was a marked limitation in leg movements, which appeared to be executed with great difficulty with but small excursion and with considerable trembling. The knee-joint could be flexed only when the sole of the foot had support. The lower leg could not be extended. The excursion in the joints of the feet and toes was slight. Muscular strength was in general decreased. There were no feelings of pain in muscular action but merely feelings of great effort. Gait was slow, shuffling, unsteady, hesitating and only possible with support. Fatigue set in after a few steps. In walking, the legs could hardly be bent at the knee. The soles of the feet dragged on the ground. The patient was unable to stand upright, and when placed upon his feet, anxiously and stiffly clung to some support. Without support, he fell over backwards. When supported he could move his legs at the hip and lift the feet from their base by bending the knee-joints. The patient could not sit in a chair or in bed except with support; otherwise he would fall to the right side. In dorsal decubitus he complained of pain in the loins.

With this hysterical picture, treatment of a psychotherapeutic nature was carried out. The patient was given methodical exercises in walking and standing, during which affirmative suggestions about his new capacity to walk and stand were given with monotonous repetition.

For the first fortnight he walked with the support of two nurses for a half hour every day. He was very industrious and willing to execute this treatment; and later began to exercise with a cane. Two days later, he omitted the cane and found himself able to walk about without support. He was shortly able to stand without swaying, although for some time the walk was upon a rather wide base and somewhat slow and suggestive of spastic paresis.

The general condition of this patient remained good. His appetite and sleep were good. After the middle of March, 1915, there were no more peculiarities in walking, and the patient was able to take somewhat long walks in the city and vicinity. He applied for work in the airship division, for which he already possessed some experience.

The youth appears to have been of a normal mental and bodily development, though his mother is said to have been nervous and a sister died of convulsions in childhood.

Shell-shock with loss of consciousness: Deafmutism, rhythmic head movements, anesthesia, asymmetrical areflexia. Recovery by suggestion with faradism, massage and reëducation.

=Case 588.= (ARINSTEIN, September, 1916.)

A Russian private, 30, literate, lost consciousness upon the explosion of a large shell, November 10, 1915. He was brought to hospital, November 14, completely deaf and dumb, and with his head rhythmically swaying sidewise 60 to 70 times per minute. The swaying ceased during sleep. The head was carried inclined to the right; there was complaint of headache. The left leg, the trunk and the hairy part of the head were anesthetic. The knee-jerks were obtained with difficulty, the Achilles jerks were lively; the throat and conjunctival reflexes were absent; the abdominal and cremasteric reflexes were lively. The right plantar reflex was absent; the left normal. The vision of the right eye was impaired, and there was a monocular diplopia of this eye. The drum membranes were pulled in, and the disorder of hearing was explained on the basis of labyrinthine shock.

After a séance of written suggestion with faradism to neck and small palate and vibratory massage to throat, speech returned. November 26, the patient read in a loud voice a written phrase. He did not speak again independently until early in December, when he read aloud written matter. The return of spontaneous speech was gradual. Hearing returned December 5, when he was able to hear in the right ear by means of a tube. In the sitting posture there was less swaying of the head. If the patient lay down, rhythmic movements of the head became stronger and more rapid (120).

Shell explosion; unconsciousness: Amnesia; paralyses. Reëducation.

=Case 589.= (BATTEN, January, 1916.)

A corporal in the Belgian army was mobilized when the war broke out, and was in action continuously in the retreat from Liège, in the siege of Antwerp, and finally on the Yser until October 27, 1914, when the explosion of large shells rendered him unconscious. He recovered consciousness only in hospital at Calais. Though he was able to see and hear well, he was dazed and remembered nothing of what had happened. In fact, he did not understand what was said to him.

In a week’s time, his memory and intelligence returned, save for periodic attacks in which he was dazed. From the very beginning he had been quite unable to move his legs, and at first the arms were weak. He had a series of attacks of violent struggling in November and December, 1914, which the corporal himself called fainting attacks, claiming that he did not move his legs in the attacks but only his arms. In fact, he claimed that he could move neither head, body, nor legs, but only the arms. He said, “Sometimes I try hard and set my teeth, but I do not know how to move my head and my legs; I try but they do not move.” Sphincter control was maintained. Although he could see, when he attempted to read, everything went black.

He was finally admitted to the National Hospital for the Paralyzed and Epileptic on July 8, 1915, on the service of Major Walshe. He was thin and wasted. He was firmly convinced, according to the notes of Major Walshe, that he was seriously paralyzed. He said he could not lift his head; when his body was lifted, his head fell back, or rather perhaps was definitely thrown back, lolling about alarmingly. However as he lay in bed he frequently lifted his head unconsciously and placed his hands under it. When asked to lift his head, the sternomastoids were strongly contracted, but at the same time the neck extensors also, so that the head was stiffly and strongly held in an extended position. Despite the patient’s statement that he could not move the trunk muscles, he could turn over readily in bed, and when trying to move the head the trunk was fixed in a strong opisthotonos, and the abdominal walls were rigid. When requested to move his legs, he made no movement whatever, though during head movements the legs were strongly fixed in extension. On passive movements, there was no active muscular resistance. There was an indefinite blunting of all kinds of sensations. Reflexes were normal.

Major Walshe worked hard with the patient, inducing him first to lift his head from the pillow, and finally to move the legs. In three weeks’ time, the corporal could just sit up, and at the end of another month, he was able to stand in the walking machine. At the end of a third month, he was walking upon crutches, and at the end of another, he could walk upon two sticks with his feet wide apart, moving as if glued to the floor. To quote Batten, “The corporal will eventually get well but not, I think, before the end of the war.”

E. EPICRISIS[8]

Così od’ is che solava la lancia d’Achille e del suo padre esser cagione prima di trista e poi di buona mancia.

Thus I have heard that the lance of Achilles, and of his father, used to be occasion first of sad and then of healing gift.

Inferno, Canto XXXI, 4-6.

[8] Material is here drawn _passim_ from the compiler’s SHATTUCK LECTURE on =Shell-shock and After=, read before the Massachusetts Medical Society, Boston, June 18, 1918.

TERMINOLOGY

=1.= =Shell-shock, a lay term, usually refers to the medical entity or disease-group: functional neurosis, or more briefly, neurosis.=

The history of the term Shell-shock will repeat that of Railway Spine in the last century; the term will fall into disuse when the cases subsumed thereunder get their exact medical diagnoses--which, _statistically speaking_, will prove to be as a rule psychoneuroses, either hysteria (pithiatism), neurasthenia (nervous exhaustion, “prostration”), or psychasthenia (obsessive neurosis).

=2.= =But the laity cannot be got to use the term Shell-shock in this exact sense, because the laity cannot make exact diagnoses.=

In the post-bellum and reconstruction period the physician will need to guard against regarding all cases _called_ Shell-shock as really neuroses, merely on the ground that Shell-shock is _probably_ neurosis. Laymen will in the reconstruction period succumb to the lure of the 100 per cent and gossip about cures and failures in the same loose manner that is but too familiar in discussions of Lourdes, Christian Science, the Emmanuel Movement. It will be worth while to preserve a certain generality and comprehensiveness for the term Shell-shock, which will stand to medicine as the term weeds stands to botany.

=3.= =In short, keep the connotation but try not for any denotation of this lay term Shell-shock in the lay mind!=

The dangerous history of the term _dementia praecox_ may be recalled. Neither _dementia_ nor _praecox_ is an exact term except for the statistical majority of cases of schizophrenia. Yet does not the layman hearing the term _dementia_ feel entitled to assume that a victim must be _demented_ or become so?

=4.= =The term Shell-shock appears to be a perfect term for the ordinary man, as it means much and little, connotes enormously and denotes a minimum and casts the lay hearer back upon the expert.=

But confronted by the term _Shell-shock_, the ardent social worker or the ordinary man fails to get any incorrect notion about the nature, and especially about the prognosis, of the condition. If there is any suggestion of prognosis, it is the correct suggestion of curability possibly conveyed by the suddenness implied in the term shock; but I defy the ordinary man to get from the ordinary term Shell-shock very much that denotes anything in particular. All he gets is an enormous connotation. This connotation may run back for the race into tree stumps, savages brandishing spears, palatial decorations, the protrusion of animal spirits, the Leyden jar (sometimes familiarly known as the “shock bottle”), and the aspen shaking of the man in fear or its interior equivalent. But whether the slang runs back so far or no, and whether the shell is a shell of powder or a shell of fear, and whether the shock is of solid particles or in a moral sense, the problem is implicitly laid down in the slang (see historical discussion, Shattuck Lecture).

=5.= =The terminological difficulties are clarified somewhat by the French distinction of états commotionnels and états émotionnels in the Shell-shock group.=

The French very neatly distinguish what they term _états commotionnels_ from _états émotionnels_. They think of the _états commotionnels_ or commotional states much as we think of _commotio cerebri_, that is, of a physico-chemical happening in the brain of an essentially curable (or reversible) nature; that is, of something that falls short of being, as they say, _lésionnel_, namely, as bringing about a structural lesion. That is, they distinguish a brain with a visible focal lesion from one which has sustained a physical jar or commotion, and they distinguish the effects of both of these from the _états émotionnels_ or emotional effects of an injury. The nomenclature here brings out one of the most fundamental difficulties in the whole field of so-called Shell-shock, namely, the distinction between structural conditions, microscopic or macroscopic, on the one hand, and functional conditions of a psychopathic nature, on the other. The _commotion_ would affect the neurones themselves in some perhaps invisible but still genuine physico-chemical way, whereas the _emotion_ would affect these neurones merely after the manner of the normal emotional life, except that the neurones would perhaps deliver an excessive stream of impulses.

=6.= =Terminology, especially in the matter of explanations to laymen= (Americans demand monosyllabic explanations as a preliminary to taking suggestions!), =is not always assisted to clearness by physicians= on account of the old ontological fallacy that Charcot insisted on.

Would that the medical profession understood neuroses at their true value! Only too frequent is the impression on the part of the profession that _imaginary_ symptoms are by the same token _non-existent_! I have even heard a physician well-trained in somatic lines say that Shell-shock did not exist because Shell-shock was nothing but neurosis, and neuroses were characterized by imaginary symptoms,--accordingly neuroses, being imaginary, do not exist! All of which reminds us that many of the profession were entirely skeptical when Charcot made his original observations. Some men here in America felt that, whereas hysteria might occur in Paris, it did not occur to any extent in America. The Shell-shock data of this war will abundantly prove to the profession the existence of the neuroses, and I feel that physicians will have to brush up their ontology to the extent of conceding that _a symptom may be_ in a sense _imaginary and yet not_ in any sense _non-existent_.

=7.= =Babinski points out a case of hysterical paralysis of a leg which led the patient to lean so heavily upon his arm as to produce an organic crutch paralysis.= It would be to no point to argue that the hysterical paralysis was here non-existent. Of course we shall have to meet the false analogies drawn from methods of cure. If a paralysis can be cured in a few minutes by the electric brush, or by hypnosis, or on emergence from chloroform, or by some other modern miracle.

=8.= =Is it too much to ask the profession not ever to say that this rapid and seemingly miraculous cure was brought about because the disease was non-existent?=

DIAGNOSTIC DELIMITATION PROBLEM

=9.= =The delimitation problem=, taken up in Section A, =is not identical with the differentiation problem=, taken up especially in Section C but _passim_ in Sections B and D; by delimitation we may refer to the process of localizing the diagnostic battle through exclusion of the other great groups of mental diseases that _à priori_ =ought= not to come in question, but do come in question sometimes, before we slice down to the question.

=10.= =Is there or is there not evidence of destructive lesion in the nervous system of this so-called Shell-shocker? Is this man a victim of organic or of functional neurosis? This latter is what may be termed the differentiation problem.=

Confining ourselves now to the delimitation problem, what are the major groups of _mental diseases_ that might come in question?

I shall enumerate these. We think of mental diseases as I, syphilitic; II, hypophrenic (that is, feeble-minded in some of its phases, including even slight degrees of subnormality not entitled to be called feeble-minded in the ordinary sense); III, epileptic; IV, alcoholic (or due perhaps to some drug or poison); V, encephalopathic (in the sense of some focal brain disease); VI, symptomatic (in the sense of some somatic disease); VII, senile (or presenile). The seven groups so far enumerated, I believe, the general profession is pretty well equipped to consider, at least roughly to diagnosticate and to handle with due respect to the interests of the patient and of the community. I am bound to say that some of my colleagues would not go so far as to the competence of physicians in general in these fields, and one is aware that a plenty of mistakes have occurred even in these groups through the bad judgment of practitioners. Nevertheless, I hold to the conception that our profession is reasonably well equipped to handle these greater groups, having in mind all the while the appropriate temporary calling-in of the specialist. But there are two more groups, in addition to these seven, in which I am not so sure that the general profession knows as much as it should. I refer to VIII, the schizophrenic group, commonly known as the dementia praecox group; and IX, the cyclothymic group, sometimes termed the manic-depressive group. It is the victims of the diseases that constitute these latter groups that ought unconditionally to be excluded with few exceptions from the army; and it is the study of these conditions which ought to be carried out as a part of every man’s post-graduate training, not merely for his work on draft boards, but for his work in civilian and reconstruction practice. There is another group of, X, psychoneuroses, with which the profession regards itself as familiar, and with which it doubtless is familiar, in what might be called _blooming examples_ of hysteria, neurasthenia, and psychasthenia. But the nub of the situation lies in the fact that the diagnosis of instances which are not such blooming examples is difficult, and hence it was that I qualified my statement as to the competence of the practitioner in this tenth group. It is, of course, the tenth group, of psychoneuroses, into which the majority of the Shell-shock cases fall.

=11.= =Now a study of the literature of the belligerents having Shell-shock in mind as its special topic and aim proves to require a study of war literature in all of these groups.= There are cases of so-called Shell-shock which even well-prepared medical men have placed in the neurosis group, when they should have been placed in one or other of the groups mentioned.

=12.= In short, =whereas the Shell-shock delimitation problem deals= with groups, I, II, III, IV, VI, VIII, IX and (as our compilation shows) =especially with groups I, III and VI=, on the other hand =the shell-shock differentiation problem= deals primarily with groups V and X.

To clear the decks for action _re_ the differentiation problem, let us dismiss the major troubles of the delimitation problem as shown in groups I (syphilitic), III (epileptic), VI (somatic) and thereafter very briefly refer to the residue of the delimitation problem. For convenience of reference, a few out-standing remarks concerning the general relations of these divisions to war and peace conditions are inserted here. We dealt in the diagnostic order of exclusion with 190 cases, distributed as in the table below (bear in mind that the method of this book precludes attaching great statistical weight to the comparative figures, since the various authors published their cases for their special rather than their typical interest).

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

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

=13.= =The neuropsychiatric side of syphilis in the war= is presented in 34 cases (Cases 1 to 34). The syphilitic basis of sundry military difficulties, quite unsuspected by the laity and probably not too well understood by service men, is suggested by Case 1, a case of desertion by a French officer of high rank. Nor is Case 2, in which visions of submarines proved syphilitic, without its warning. Such cases point only too obvious a moral:

=14.= =Neurosyphilitics have no place in the army or navy.=

Eight cases (Cases 3-10) follow in which the aggravation or acceleration or liberation of neurosyphilis has come about under the conditions of war. Some of these cases suggest the gravity of the problems of compensation, allowance and pension that may arise. We might ask,

=15.= =Should not a government which enlists a syphilitic pay full allowances to him when under war conditions he becomes a neurosyphilitic?=

For the government was theoretically able to learn at the start (within a small margin of error by means of the serum test) whether the man was syphilitic. If a one-eyed man loses his remaining eye in an industrial accident in civil life, his damages are often fixed at damages for total blindness; for the industrial firm should not have employed a one-eyed man in an industry dangerous to eyes. The principle cannot differ with a man hired in a spirochete-bearing state: The company has hired a man who may under traumatic conditions become an incompetent neurosyphilitic, and should pay damages accordingly when the aggravation begins.