Part 67

=42.= Suppose then that syphilis, epilepsy, and somatic (non-nervous) disease are out of the running, =we come practically down to the psychoneuroses=, knowing that knotty problems are at hand in telling them from structural traumatic effects: =But, after all, what are functional neuroses?= What do we really know about the neuroses other than to say that they are _not_ distinguished by the existence of the structural lesions which characterize organic disease of the nervous system? Is not the definition of neurosis purely by negatives? However true this definition by negatives may be from the genetic and general pathological viewpoint, the work of Charcot and in particular of Babinski has yielded a number of positive features from the clinical viewpoint, which to some degree make up for the lack of anything positive in the neurones themselves as studied post-mortem. An eminent German has recently declared that the data of this war itself go far to prove some of the long dubious contentions of the Frenchman, Charcot; and the work of Babinski during the war has strengthened and developed the conceptions of his master, Charcot, as well as the ante-bellum conceptions of Babinski himself.

=43.= Let me insist that =the problem is practical enough: Organic versus functional neurosis=. The point I want to make is that, when so much theoretical doubt concerning organic and functional neuropathy holds sway, the practical doubts in the individual case under the varying conditions of civilian practice and in the upheavals of military practice, must be still more in evidence. Case after case described in the literature of every belligerent has passed from pillar to post and from post to pillar before diagnostic resolution and therapeutic success. Colleagues meeting, for example, at the Paris Neurological Society, find themselves reporting the same case from different standpoints,--the one announcing a semi-miraculous cure of a case which another had months before claimed only as a diagnostic curiosity. In the midst of such discussions and controversies, there must inevitably be a renaissance in neurology.

=44.= =In cases of alleged Shell-shock, the hypothesis of focal structural damage to the nervous system or its membranes has to be raised.=

Shell bursts and other detonations can produce =hemorrhage in the nervous system and in various organs without external injury=. Thus a man died from having both his lungs burst from the effects of a shell exploding a meter away. Hemorrhage into the urinary bladder has been identically produced. Lumbar puncture yields blood in sundry cases of shell explosion without external wound, and Babinski has a case of hematomyelia produced while the victim was lying down, so that the factor of direct violence through fall can be excluded. In sundry cases, not only blood but also lymphocytes have been found, sometimes in a hypertensive puncture fluid.

=45.= Moreover, =in cases of alleged Shell-shock there may be a combination of structural and functional disease=.

A herpes or the graying-out of hair overnight can suggest organic changes. A case may combine lost knee-jerks (suggesting organic disease) with urinary retention (suggesting functional disorder).

=46.= Again, =there is a group of war neuroses=, especially clearly brought out in cases of ear injury, =in which the functional disorder surrounds the organic as a nucleus=. But these “periorganic” neuroses are no proof that the neuroses in question are organic in nature. Hysterical anesthesia, paralysis, or contracture may occur on the side of the body which has received a wound: =the process of such a peritraumatic disorder is, nevertheless, a functional process=.

=47.= But, when the problem is statistically taken, =the majority of cases of alleged Shell-shock without external wound prove to be functional, as indicated by their clinical pictures=. Thus, after a mine explosion, a man was hemiplegic, tremulous and mute. After sundry vicissitudes, the tremors were hypnotized away. Then the mutism vanished, to be supplanted by stuttering. Finally the hemiplegia remained. So far as the mutism and the tremors went, this man might belong in the =majority group of Shell-shock cases, namely, the functional group=. Assuming the hemiplegia to be really organic, we should regard this man as a mixed case, organic and functional.

=48.= =But do we not know all= we need to know or all we are likely to know =about the neuroses already= from old civilian studies? There are some cases without very close relations to the war: Thus, we conceive of (_a_) psychoneuroses incidental to the war and such that they might very probably have developed without the entrance of war factors; and on the other hand, we conceive of (_b_) psychoneuroses (to be dealt with _in extenso_ later) in which war factors (either physical Shell-shock or other factors) forcibly enter. There are in this group of incidental psychoneuroses 12 cases. The first, described as a constitutional _intimiste_, a psychasthenic _en herbe_, was one in which a hallucination was developed in the field, and in which three phases of a psychopathic nature--(_a_) over-emotionality, (_b_) obsessions, (_c_) loss of feeling of reality--developed. In this case the war work at first seemed to better the man’s general condition, and he gave two years of effective service. This officer in effect =invented his own Shell-shock equivalent= in a hallucination of Germans appearing in his trench. The case may be compared with one described in Section B, namely, Case 347: that of a Russian soldier who developed perfectly characteristic war dreams, though his entire service had been rendered in the rear and he had not had experiences in action.

Possibly Case 171, that of _hysterical fugue_, might be regarded as one of Shell-shock, since two shells burst near him prior to his fugue. The man had had analogous crises, certified by Régis, in adolescence, and had received the diagnosis hysteria. In this instance, we are dealing merely with an habitual somnambulist who has a characteristic fugue following explosion of two shells. The war is in a sense responsible for the fugue, yet not directly, and the fugue would, without the stress and strain of war, probably never have developed (see sundry cases in the group in which ante-bellum phenomena are newly evoked in war: Cases 286-301).

The hysterical psychosis of an Adventist (Case 172) might be regarded as liberated by military service; the terrible fear of the guns shown by the psychoneurotic (Case 173) proceeded to the point of fugue. A Shell-shock victim whose war bride was pregnant, developed fugue with amnesia and mutism (Case 174). Under hypnosis, it appeared that his fugue began with his running away from shells. Case 175 was that of a neurasthenic who volunteered and had to be sent back from the front after three months. In this case, war dreams were supplanted by sex dreams, and the fear of insanity became ingrained. The phenomena here were largely ante-bellum and the war brought them out once more, as might other disturbing experiences.

Case 176 is here introduced to show that =neurasthenia may develop in a man without hereditary taint= or acquired soil. There was a very slight shrapnel injury of the skull, which somewhat clouds the diagnosis in the case. Five months’ war experience brought out the neurasthenia. Case 177 deals with a point in the diagnosis of psychasthenia, which, according to Crouzon, shows arterial hypotension, a condition important to distinguish from that of pulmonary tuberculosis and of Addison’s disease. Compare this case with Case 169: a case of depression treated by pituitrin. Case 178 is a case of psychasthenia following several months’ service by a man who probably should never have entered military service.

Another case of ante-bellum origin is Case 179. _Antityphoid inoculation_ appears to have been the initial factor in the case of _neurasthenia_ No. 180. Compare Case 65, epilepsy after antityphoid inoculation. Case 181 was that of a non-commissioned reserve German officer whose neurasthenia was distinguished by _sympathy with the enemy_. He did not want to let his men shoot at the enemy because the idea came forcibly to him that the enemy soldiers had wives and children. This symptom of sympathy with the enemy was also shown by another German (Case 229). Compare the sentiments of a Russian under narcosis (Case 555).

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

Examples are available of hysteria (Cases 171, 172, 173, 174), of neurasthenia (Cases 175, 176, 179, 180, and 181), and of psychasthenia (Cases 177, 178, and possibly 170).

=49.= =Let us now contrast with these specified ante-bellum or non-war cases= the situation which will face us in =the war group=.

Section B contains 174 cases (Cases 197-370). Autopsied cases (Cases 197-201) are put first and are followed by cases in which lumbar puncture data are available (Cases 202-207). A third group of cases is that in which so-called organic symptoms are much in evidence, either independently or in association with functional symptoms (Cases 208-219). There follows a small group of three cases with shrapnel wound (Cases 220-222), in which hysterical symptoms were prominent, as against the prevalent and correct conception that wounded cases are not so prone to psychoneurosis as non-wounded cases. Three cases specially marked by tremors (Cases 223-225) follow, the last of which gives the victim’s (a French artist) own account of his feelings. The next two cases (Cases 226 and 227) give respectively a German and a British soldier’s account of Shell-shock symptoms.

There then follows a great group of =cases= (Cases 228-273) =arranged according to the part of the body= chiefly affected by hysterical symptoms. The arrangement is one of toe to top, or as one might more technically say, cephalad. This =cephalad arrangement= naturally begins with cases with symptoms affecting one leg or foot (Cases 228-235). Then follow cases of paraplegia (Cases 236-241). As we proceed cephalad then follow four cases of the so-called hysterical bent back, or camptocormia (Souques). Then come walking disorders (Cases 246-248). Still proceeding cephalad, disorders of one arm and hand are considered in a series of six cases (Cases 249-254). Bilateral phenomena, symmetrical or asymmetrical, follow in Cases 255-258. Now reaching the head, we deal with cases of deafness (Cases 259-260), of deafmutism (Cases 261-263), of speech disorder (Cases 264 and 265), with two special cases (Cases 266 and 267). Eye symptoms are dealt with in a series of cases (Cases 268-272), and Case 273 deals with cranial nerve disorder supposed to be due to shell windage without explosion.

The idea of the above arrangement of 46 cases (Cases 228-273) is that the reader dealing with cases of hysterical disorder due to physical shell-shock, or some equivalent thereof, may inspect the data in a few analogous cases described more or less fully in the literature. By reference to the index, the reader will be able to find still further cases to illustrate the symptom in question.

The next series of cases (Cases 274-281) are to illustrate the contentions of Babinski concerning the elective exaggeration of reflexes under chloroform, and the =conception of reflex or physiopathic disorders= based thereon--a topic to which return is made in Section C on Diagnosis, and elsewhere. A small group of cases (Cases 282-285) illustrate the delay of Shell-shock and kindred symptoms in certain instances, cases that suggest a refractory period of greater length than usual, or the interposition of some unusual factor.

The next group of cases (Cases 286-301) is of special note, bringing out what is discussed below, namely, =the emphasis, reminiscence, or repetition of antebellum phenomena=, and the picking out of weak spots in the organism by Shell-shock. Possibly Cases 302-303 belong in the same group of illustrations of the driving in of ante-bellum effects. Cases 304 and 305 are definitively cases in which hereditary instability is a factor, whereas Cases 306 and 307 form a foil to these, in that the phenomena develop in subjects confidently stated to be without hereditary or acquired psychopathic tendency.

The next series of cases (Cases 308-320) shows =peculiar phenomena=; _e.g._, monocular diplopia, shell-shock psoriasis, synesthesia, puerilism, and the like. Shell-shock equivalents of various sorts are placed in a group of cases (Cases 321-325). The next series of cases (Cases 326 to the end of this Section: 370) show tendencies to general neurasthenic, psychasthenic, and other psychopathic phenomena, rather than the more definite phenomena discussed in the early part of this section in the series arranged “cephalad.”

=50.= Rehearsing more briefly these findings, what is the nature of these disorders? The literature is practically unanimous on the point: =We have to do merely with the classical problem of the neuroses=, and when all the data are some day united, we shall doubtless know a great deal more about the neuroses.

=51.= =Locus minoris resistentiae.= That the process, whatever else it does, is rather apt to pick out pre-existent weak spots in the patient (the habitual gastropath becoming subject to vomiting; the old stammerer stammering once more or even becoming mute; the man always “hit in the legs” by exertion, now becoming paraplegic) is obvious. The striking instances in which an old cured syphilitic monoplegia, or an old hysterical hemichorea, comes back under the influence of shell explosion in precisely the limits and with precisely the appearance of the former disease, indicate how various a factor may be the =locus minoris resistentiae=.

=52.= But, =without= weak spot, =without= acquired soil, =without= heredity, we must now erect the hypothesis that, =the classical neuroses may= in some, though certainly a minority of cases, =afflict normal men=. Under the war conditions of investigation touching the family and personal histories of the men, perhaps we should not be too sure of this hypothesis; but the army records will after the war allow us to make or break the point forever and thereby throw the clearest light upon the vexing problems of industrial medicine, wherein progress in general has been so slow on account of the partisanship of the corporation and plaintiff’s attorneys.

=53.= =Purely psychogenic war cases exist=: Though Shell-shock denotes, to say the least, _shocks_ and _shells_--yet we know Shell-shock _sans_ any shock and _sans_ any shell, nay _sans_ either shell or shock.

The fact that a soldier may get war dreams though he has never been in the fighting zone and never by any chance observed the circumstance of war, or the fact that a man can become mute on the second day after a shell explosion because the night before he had dreamed of some hysterically mute patients in his ward--these facts again, although they argue a psychogenic origin for the phenomena of so-called “Shell-shock,” do not at all mean that actual physical explosion in other cases may not be tremendously important.

=54.= This is shown by the exceedingly interesting phenomena of =localization or determination of symptoms= to a given region under the special local influence of the explosion. Thus, in the schematic case, an explosion to the left of the soldier produces anesthesia and paralysis on the left or exposed side. Now and again a case will show such anesthetic and paralytic phenomena upon the side exposed to the explosion and some hypertonic, irritative phenomena upon the other side. One gets the figure in one’s mind of an organism fixed, immobile and numb, on the spot by the explosion--and the other half of the body, as it were, attempting to run away from the situation. One side of the body, as it were, plays ’possum, the other tends to flight.

=55.= Of course these physical phenomena should not blind us to the emotional ones. Now and then the multiple causes of a case may be analyzed, as, for example, one of blindness in which a =series of factors= emerged, such as =excitement, blinding flashes, fear, disgust and fatigue=. I cannot here go further into these details, and I need no longer insist upon the fact that =surrounding the problem of Shell-shock means surrounding the problem of nervous and mental diseases= as a whole, and that thus to be a Shell-shock analyst means to be a neuropsychiatrist.

=56.= The organic problems of the nervous system are brought up constantly in differential diagnosis, but the functional problems divide themselves up in a perturbing manner into a fraction properly termed the “psychopathic” (that is, after the manner of hysteria), and “non-psychopathic” (that is, after the manner of reflex disorders of Charcot, newly named “physiopathic” by Babinski).

=57.= For the moment we are not discussing differential diagnosis, but are merely trying to circumscribe the features we wish to call =Shell-shock features: We have concluded to call them functional--but what is it to be functional?=

Too simple is the reply:

FUNCTIONAL = NON-ORGANIC.

Inaccurate and misleading is the reply

FUNCTIONAL = PSYCHIC.

We may more correctly express the situation, pathologically speaking, in the following categories (see chart, page 870):

ORGANOPATHIC (Lesional, destructive):

(_a_) gross, or (_b_) microscopic, or perhaps (_c_) chemical.

DYNAMOPATHIC (functional, irritative, inhibitory,--but reversible _ad originem_):

(_a_) psychopathic; (_b_) physiopathic (“reflex”).

=58.= As to the high psychic functions, we had thought of them as split in hysteria, in dissociation of personality. And we had roughly distinguished these conditions as =psychopathic= from conditions we called =neuropathic=, regarding the latter neuropathic disorders as on the model of the effects of cutting off or destroying certain necessary neurons. However clear or unclear we were as to the nature of the neuropathic, it does not here matter. Babinski’s point is that there is another kind of dynamic disease that operates, not after the manner of hysteria, but after a manner reminding one of the forgotten “reflex” disorders of Charcot--disorders that fitted the textbooks so poorly that the textbooks dropped them out. In short, what you might call =the dynamopathic or functional in nervous disease has been shown to fall into two parts=--a =psychopathic= fraction and a non-psychopathic fraction. Babinski calls this non-psychopathic fraction =physiopathic= or reflex. And these reflex or physiopathic disorders have a different order of curability from that of hysterical or psychopathic disorders. By what simple device did Babinski prove this? By chloroforming the patient. Under chloroform, when all the other reflexes were stilled, Babinski could bring out, in relief as it were, certain reflexes, or even hypertonuses, that were in the waking life wholly concealed,--yet at the same time consciousness, in the usual sense of that term, had vanished. Accordingly, the proof of a new type of functional disease, at times concealed by the overlay of higher neurones, was now plain. Does not this offer new leads of the greatest value in that most intricate of fields, psychopathology? Is not the model here offered of diseased =nervous functions=, =non-psychic= in nature (in the ordinary sense of psychic) =but of almost equally complex nature=:

Whoever wins the great war from the military point of view, there can be no doubt as to what writers contributed most from the war data concerning the doctrine of hysteria, especially concerning the theoretical delimitation of hysteria from other forms of functional nervous disease: There can be no other answer than that, in theoretical neurology at least, the French have already won the war, if only by means of the remarkable concept set up by Babinski of the so-called _physiopathic_ (that is, non-neuropathic and non-psychopathic).

But how has this splitting of functional neuroses into psychopathic and physiopathic been rendered certain? By the tremendous modern sharpening of differential diagnosis dating from, _e.g._, the discovery of the Babinski reflex. This brings us to the brink of considerations concerning the differential diagnostic problem.

First it may be well to regard the whole problem in the light of those mental diseases that we slid over when we were delimiting Shell-shock as against syphilis, epilepsy and somatic disease.

=59.= =Why do some authors think of Shell-shock as an “officer’s disease”?= It is clear that they cannot be thinking so much of the physiopathic cases as of the psychopathic ones. But psychopathic conditions are obviously more readily brought about in complex and labile apparatus. This point comes out strongly in relation with the =comparative stability of the feeble-minded=, at least of most feeble-minded, that get into war relations.

The possible relations of Shell-shock to feeble-mindedness are of some interest. We know that Shell-shock picks out certain nervous and mental weaklings and indeed that one author claims as high a percentage as 74 for war neuroses having a hereditary or acquired neuropathic basis. How far does feeble-mindedness itself count among these supposedly susceptible nervous and mental weaklings? Is a feeble-minded person especially in condition for Shell-shock?

There are rumors of experiments to show that if in an aquarium containing some jelly fish alongside bony fishes, you explode a substance, the jelly fish ride through unscathed whereas the bony fishes are killed by the shock. The jelly fish presumably had too simple an organization.

There is something to be said for the idea that in man also the higher and more complex specimens are more susceptible to Shell-shock, that is, to the neuroses of war, than are the lower and more simple combatants. Some statistics indicate that officers, who are in the main of a higher and more complex organization than the private soldiers, are much more susceptible than are private soldiers to the neuroses of war. Doubtless we shall not be able to verify these statistics until long after the war and, so far as I know, no very inclusive statistics have been presented.

On the whole, I judge from the case history literature that the feeble-minded, unless they be of that very high level sometimes called subnormal, are not particularly susceptible to the neuroses. It is obvious that idiots and, for the most part, imbeciles, do not get into military service. As for what the English term the feeble-minded or what we in America are now terming morons, it may well be that our draft boards do not always exclude. High French authorities have specifically determined in certain instances that the high-grade feeble-minded would be perfectly suitable for certain branches of the service. There is the case, for example, of a sandwich man of Paris who somehow got into the French army and was being perpetually sent to look for the squad’s umbrella and the key to the drill ground, but sang and swung his gun with joy as he went to the front, and apparently did very well there. This man had been a state ward and, as you know, well-trained state wards are frequently exceedingly good at elementary forms of drill.