Part 68

Then there is another case of an obvious imbecile who was quite without any idea of military rank and often got punished for treating his superiors like his comrades and was the butt of his section, but on the firing-line remained cool, careless of danger--a magnificent example to his comrades--at last surrounded and taken prisoner. Here the story might have ended and the folly of enlisting imbeciles in the army might have seemed perfectly plain, except that our imbecile forthwith escaped from the Germans, swam the Meuse and got back to his regiment!

Here then are cases in which the slight degree of hypophrenia--it seems unwise to give it the opprobrious title “feeble-mindedness”--would have been entirely inconsistent with the development of Shell-shock. Such men are, perhaps, =too simple to develop neuroses=. On the other hand, it would appear that certain of the slight degrees of hypophrenia, such as we might find in so-called subnormal or stupid persons, would prove capable of “catching Shell-shock” as it were, and then find themselves entirely incapable of rationalizing the situation. In short, =there may be a group of psychic weaklings, just complex enough to fall into the zone of potential neurotics, but just simple enough to render the processes of rationalization= (or what one author terms _autognosis_) =and of psychotherapy in general entirely unavailing=.

After the war we may be confronted with a number of persons with their edges dulled by the war experiences. One has met even brave officers who, after months of furlough, still maintain that they will never get back to their normal will and initiative. Whether these =hypoboulic persons= have not been reduced to subnormality so as to resemble the slighter degrees of hypophrenia or feeble-mindedness can hardly be determined now. They will form =important problems in mental reconstruction=, for with the best will in the world, the occupation-therapeutist with all her technic, may be unable to force or coax the will of such hypoboulics into proper action. Nor will the ordinary environment of home and neighborhood turn the trick properly. Expert social work in adjustment, both of the returned soldier to his environment and of the environment to the returned soldier, may be necessary. I speak of this problem here not because these persons are hypophrenic or feeble-minded in the ordinary sense, but we must constantly bear in mind our experience in the teaching of hypophrenics (both in the schools for the feeble-minded and in the community) when we are facing problems of mental reconstruction.

=60.= As for =alcoholism=, Lépine’s figures bespeak its importance as a hospital-filler and a good deal of prime interest surrounding alcoholism has been developed in the war; but on the whole, so far as I can determine from the war case literature, there is little or no direct relation between alcoholism and Shell-shock, despite the fact that in a number of instances alcohol has complicated the issue and very possibly helped in a general demoralization of the victim. However, the alcoholic amnesias and particularly a few instances of the so-called pathological intoxication have exhibited a certain medicolegal interest, recalling what was just said above about the responsibility of a drunken epileptic. Alcohol remains, I should say, pending exact monographic work upon this topic, purely a contributory factor for the war neuroses.

It must be that the exigencies of the war have prevented full reports of alcoholic cases; or perhaps they are regarded as of such every-day occurrence as not to demand case reports. The alcohol and drug group is represented by 17 cases (Cases 86-102).

The so-called pathological intoxication is illustrated in Cases 86 and 87. Case 86 was entirely amnestic for an attack of hallucinations in which he tried to transfix comrades with a bayonet. Cases 87-97 are cases of disciplinary nature,--the majority from a German writer, Kastan. Case 88 illustrates desertion in alcoholic fugue, and Cases 90-92 are three further cases of desertion in alcoholism.

Cases 94 and 95 give a =partial explanation of some German atrocities=. At least, here are cases in which the atrocities, with attempted murder and rape, are described more or less fully in transcripts of medicolegal reports. Case 98 throws a curious cross-light upon the war, in that a drunken soldier got an unmerited long leave after paying 100 sous for an injection of petrol in his hand. Cases 99-102 are cases of morphinism, illustrating the effects of the war upon the fate of morphinists.

=61.= =That war makes nobody go mad= in the asylum or lay sense of the term =has been abundantly proved by the data of this war--and this conclusion is of value in our medical endeavors to establish a proper lay conception of the nature of Shell-shock=. Consider first schizophrenia (dementia praecox).

That the causes of dementia præcox, still unknown as they are, lodge more in the interior of the body or in special individual reactions of the victim’s mind, seems to be shown by the phenomena of this war, since there seems to be no great number of dementia præcox cases therein produced. To be sure, some schizophrenic subjects do get into the service, and sometimes their delusions and hallucinations get their content and coloring from the war. Thus a Russian, wounded in the army, developed delusions concerning currents running from his arm to the German lines and felt that he was, so to say, the Jonah of the Russian front, as he could determine shell fire to the spot where he was by the arm currents.

Now and then a case shows a scientifically beautiful admixture of ordinary dementia præcox phenomena with the effects of shell wound or shock. A picturesque case from the standpoint of German psychiatric diagnosis is one of a soldier who boxed the ear of a kindly sister who tried to steer him from a room where the examination of another patient, a woman, was going on. On the whole, the eminent German psychiatrist who examined him felt that the case was really one of psychopathic constitution, as he had shown somewhat similar irascibility on a slight occasion before. However, much to the astonishment of all, the patient developed further symptoms. His ego got terribly swollen. At last he was fain to utter a denunciation of the entire _Junkertum_ and of the Kaiser: he said in fact that he was an Inhabitant of the World and not of Prussia merely. Over here we allow such persons to edit newspapers and write books with impunity, but the eminent German psychiatrist, before mentioned, was constrained to alter his diagnosis of this cosmopolite from psychopathic constitution to dementia praecox!

The group is represented by 16 cases (Cases 147-162).

=62.= There are four cases (Cases 148-151) of a =disciplinary= nature. The first (Case 148) was actually arrested as a spy because he was making drawings near a petroleum tank. Of two cases of desertion, one was due to a fugue of catatonic nature (Case 149), and the other (Case 150) was one of desertion with behavior suggesting schizophrenia. However, this man was determined to be responsible for his act, and condemned to 20 years in prison. This latter case might be considered also in connection with Group III (the epilepsies), Group IV (the pharmacopsychoses), and possibly Group XI (the unresolved psychopathias).

Case 151 was likewise alcoholic and disciplinary: the man went so far as to keep a cigar in his mouth while the captain was rebuking him and was, in fact, an old sanatorium case, afflicted with some sort of degenerative disease, presumably dementia praecox.

=63.= That =schizophrenic symptoms may be aggravated by service= is shown likewise in the case that follows, namely, Case 152, a man who had been hearing false voices for some two years, had heard his own thoughts, and felt his personality changing. The military board decided that the mental disease had been aggravated by service. Case 153 might offhand be regarded as a malingerer, as he shot himself in the hand. Upon military review, a delusional state set in, and in the course of no very long time a state of schizophrenic apathy. In point of fact, however, this man had already been in several hospitals for previous examination, and had served in the army in relatively normal intervals. Case 154 is that of a dementia praecox who volunteered for three years in French infantry but forthwith gave indications of mental deterioration. This case of a dementia praecox volunteer may be compared with Case 36: that of a superbrave imbecile who swam the Meuse, back from a German prison; with Case 47, that of the feeble-minded person with an insubordinate desire to remain at the front; with Case 163, a maniacal volunteer; and Case 175, a neurasthenic volunteer.

=64.= =Diagnostic questions= are brought up by Cases 155-166, in the former of which Bonhoeffer made at first a diagnosis of some form of psychogenic disease, possibly hysterical, but had eventually to alter the diagnosis to hebephrenia or catatonia. Case 156 was possibly one of Shell-shock, though the man remained on duty for a month with but one symptom, trembling of the arm. For nine months he showed a variety of symptoms apparently consistent with the diagnosis hysteria, but then developed catatonic and paranoic symptoms clearly warranting the diagnosis dementia praecox.

=65.= Schizophrenia may not only be aggravated by service, but as Case 157 shows, =war experience may have a definite effect upon the content of hallucinations and delusions=. Thus, a man wounded in the left shoulder built up the idea of currents running from his left arm to the Germans, such that if anything were touched by the arm, bombardment of the Russians would at once start up. The arm, in short, was charmed.

=66.= =Psychopathic bravery= is not shown in the feeble-minded only: Case 158 is that =of an Iron Cross winner= who, after an hysterical-looking attack with hallucinatory reminiscences of a Gurkha whom he had bayoneted, turned out to be =hebephrenic=. Case 159 might at first sight have been placed among the encephalopsychoses on account of the trauma to the occiput, and in fact the mystical hallucinations shown were of a visual nature (a rainbow-colored bird with the face of the Holy Virgin). In point of fact, there was probably no causal relation between the mystical delusions and the brain injury.

=67.= Case 156, above mentioned, might perhaps be interpreted as one of =Shell-shock dementia praecox=, but the interval of nine months, though filled with hysterical symptoms, is decidedly long in which to suppose that shell-shock factors could be in process of causing dementia praecox. Cases 160 and 161 are more suspicious. Six German soldiers were killed by a German shell within the zone of German fire, two steps away from the subaltern officer (Case 160), who carried on for some hours, made his report duly, but thereafter developed tremors and lost consciousness. According to Weygandt, the case is one suggestive of dementia praecox, but very possibly should be regarded as one of psychoneurosis. At all events, it would be dangerous to found a doctrine to the effect that dementia praecox can be initiated by shell-shock upon such a case as 160. Case 161 is similarly doubtful. There are a number of symptoms in this man (the sole survivor of an explosion in a blockhouse) consistent with the diagnosis Shell-shock, and a number of others which hardly can be given any other interpretation than that of catatonic dementia praecox. But the available medical data do not begin until five months after the shell explosion. We must conclude here also that no definite evidence exists that dementia praecox can be initiated by the physical factor shell-shock. Case 162 is one in which there are shell-shock factors and fatigue factors in a man who had once ante-bellum shown signs of mental disorder, and who developed delusions subsequent to a fugue following shell-shock. The most one could make of this case would be to say that a latent schizophrenia had been liberated by shell-shock.

=68.= To sum up concerning the schizophrenias (dementia praecox group), there are =cases of great disciplinary interest= in which alleged espionage and desertion =turn out actually to be schizophrenic phenomena=. Again, there are interesting diagnostic problems in the differential diagnosis of hysteria and catatonia. There is evidence that experience in the war may be woven into the hallucinatory and delusional contents of cases of pre-existent psychosis.

=69.= As to the important question whether shell-shock can initiate dementia praecox, the evidence from these reported cases is against the hypothesis; but if the query be, whether Shell-shock might not aggravate dementia praecox, it may be stated that =a military board has decided that dementia praecox may be aggravated by some forms of military service. There is no reason to suppose that shell-shock factors might not operate in this way.= Cases 152 and 162 will be of service in the proof of this contention; and Case 162 seems to be definitely one in which a latent schizophrenia, showing itself in one ante-bellum attack, was liberated once more after shell-shock. Of course, the plan of this book and the method of choice of its cases precludes any statistical conclusions of great weight from the relative number of cases found in the different groups; and it might well happen that psychiatrists would not report cases of an everyday and commonplace nature which might yet be very frequent. On the whole, however, it would not appear that dementia praecox is at all a frequent phenomenon in the war.

=70.= =Nor can the cyclothymias= (manic-depressive psychoses) =be charged up to war factors= to any important extent.

On account of the somewhat close resemblance between the phenomenon of manic-depressive psychosis and what we ordinarily feel ourselves--a logical situation reflecting merely the fact that the phenomena of over-activity (mania) and of under-activity (depression) are merely quantitative variations from the normal--it might be supposed that the war life and its shock and strain would start up the cyclothymias in some numbers. Why should not a shell explosion start up a mania or throw a man into a depression? In point of fact the literature somehow does not agree with this presupposition.

Some years ago in Massachusetts a brief investigation was made of the assigned causes of the successive attacks in a great number of cyclothymic (manic-depressive) cases, and it was found that each successive attack progressively had less of the physical in the previous history. Something like 45% of all the first attacks had a pretty obvious cause in the soma, such as a kidney disease, a heart disease, a puerperal condition and the like, but the second attacks failed to show even 20% of such obvious somatic causes, and the third attacks even less than 10%, and so on.

Now war conditions and even the shell explosions themselves have apparently not set up any such conditions as those of mania or of depression. Most of the instances of cyclothymia are instances of men who are cyclothymic before they enter the army. These experiences, when after the war we can sift them all out, may allow us to form better ideas as to the etiology of many of the psychoses, and the great war may thus prove a gigantic experimental reagent which will aid in solving some of the major problems of mental hygiene.

=71.= =The cyclothymic or manic-depressive group is represented in strikingly few cases=, seven in number (Cases 163-169). One of the ideas in the literature concerning the manic-depressive group has been that it is very possibly remotely allied to Graves’ disease, a hypothesis upheld by Stransky in Aschaffenburg’s Handbook. Hyperthyroidism itself has been, of course, a rather striking feature in the foreground or background of many sick patients in the war. However, war factors have proved able to bring out very few instances of cyclothymic (manic-depressive) disease. Amongst our seven cases, the first (Case 163) was that of a maniacal Alsatian of 59 years, who volunteered because of his hypomania. Case 165, the case of a German who pelted French trenches with apples from an appletree in No Man’s Land, was another case in which the war had little or nothing to do with the development of the mania. One of fugue (Case 164) was a case of melancholia and anxiety not closely related with war experience. In three further cases trench life and war stress may be thought to have liberated the cyclothymic phenomena. Case 166 was that of a man of 38, previously referred to, who developed arteriosclerosis and whose depression and hallucinations had followed four months of trench life devoid of battles or injury. It is possible that this case should be regarded rather as syphilitic or of some unknown organic origin. At all events, it is not clear that it could be made to bear a heavy weight of hypothesis concerning the genesis of cyclothymic psychoses. Case 167, a naval officer who distinguished himself greatly by work on land in Belgium, was regarded by its reporter as one of manic-depressive psychosis with the fatigue of war as its base. It might be queried whether the man’s distinguished work was not due to an early phase of hypomania, after which the cyclothymic effects began. In Case 168 there was some evidence of the effect of war stress, as certain hallucinations grew more intense after the bombardment of Dunkirk; but in point of fact, this man had shown a predisposition and indeed a period of so-called neurasthenia ante-bellum. It is doubtful, therefore, whether there is any case here abstracted which can be used to support the hypothesis that the manic-depressive (cyclothymic) group of mental diseases has had or is likely to have its genesis in war stress. The remaining case (Case 169) is one illustrating a method of treating low blood pressure in depression.

To sum up concerning the cyclothymias: War stress seems to have had singularly little effect in the production of fresh attacks, and so far as we are aware, no effect in starting up a manic-depressive diathesis, unless Case 167,--that of the naval officer who distinguished himself in land battles,--looks in that direction. It is, of course, to be conceded that hypomania might readily be overlooked under war conditions, and that suicidal melancholias, belonging in this group, might be interpreted as natural war-made depressions. Very possibly, therefore, this result (running to the effect that the cyclothymic forms of mental disease are rare in military life) may need revision.

=72.= =Summary of general considerations concerning the nature of the Shell-shock neuroses (paragraphs 40-71).=

=Having= (_a_) =roughly delimited the Shell-shock neuroses from syphilis, epilepsy, and somatic disease, we inquired=

(_b_) =What, after all, are functional neuroses? We remained dissatisfied with a definition by negatives.= But we found that

(_c_) =practically the problem seemed to reduce to telling the organic apart from the functional= and we found that

(_d_) =in almost all cases we have to raise the hypothesis of the organic=. Also that

(_e_) =the absence of external injury is no guarantee against the existence of internal injury=. Also that

(_f_) =cases are frequent enough in which organic and functional phenomena are combined=. Also that

(_g_) =essentially functional cases may be peritraumatic or metatraumatic= (in the sense of Charcot’s hysterotraumatism). But

(_h_) =the statistical majority of cases remains essentially functional=.

(_i_) =We then looked over a series of cases developing incidentally in the war= and

(_j_) =we compared these with the war cases, the latter arranged cephalad=.

CHART 17

DIAGNOSTIC ALLIANCES OF THE SHELL-SHOCK NEUROSES

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

Note arrow lengths: _Practically_ we find shell-shock neuroses very different from certain functional (or but mildly organic) disorders and not so different from certain seriously organic disorders.

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

Note arrow lengths: _Theoretically_, shell-shock neuroses, being presumably in large part functional, ought to ally themselves more closely with the left-hand group than with the right-hand group. But they do not!

In short, these _functional_ diseases are not so hard to distinguish from various other functional diseases as they are from certain organic diseases. The most serious diagnostic problem is between the war neuroses and organic brain disorders.

CHART 18

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

e.g. neurosyphilis paretica | Hysteria e.g. \ | / \ | / \ | / \ | / ORGANO- | DYNAMO- PSYCHOPATHIC | PSYCHOPATHIC | | | -------------------------------+----------------------------- | | | | ORGANO- | DYNAMO- NEUROPATHIC | NEUROPATHIC / | \ / | \ / | \ / | \ / | Babinski’s “reflex” \ e.g. neurosyphilis tabetica | or physiopathic disorders e.g.

A frequent error of neurologists has been to identify “functional” with “psychic” when it came to a question of the classical functional neuroses. The above diagram indicates that “functional” contains more than “psychic.” Doubtless much that goes under the name “unconscious” belongs in the right lower quadrant of this diagram. See discussion in text.

(_k_) We found many war cases showing emphasis, reminiscence, or repetition of ante-bellum phenomena (weak spots, locus minoris resistentiae, imitation), but

(_l_) we also found that perfectly sound untainted men could succumb to Shell-shock neurosis.

(_m_) We found a few purely psychogenic cases without sign or suspicion of physical shock.

(_n_) We studied the localization (traumatotropic) group.

(_o_) We arrived, with the aid of Babinski, at the necessity of splitting functional cases into psychopathic and physiopathic.

=73.= =Summary of general considerations: continued.=