Part 69

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.=

_Organic Hemiplegia_ _Hysterical Hemiplegia_

1. Paralysis unilateral. 1. Paralysis not always unilateral; especially facial paralysis, usually bilateral.

2. Paralysis not symptomatic., 2. Paralysis sometimes symptomatic; _e.g._, in unilateral facial facial paralysis almost always paresis, the paresis occurs also symptomatic. With complete when bilateral synergic movements unilateral paralysis, the muscles are being performed. of the paralyzed side may function normally during the performance of bilateral synergic movements.

3. Paralysis affects voluntary, 3. Voluntary, unconscious, or conscious, and unconscious or sub-conscious movements not sub-conscious movements; hence, disordered. Absence of platysma (_a_) platysma sign,[12] (_b_) sign and combined flexion of sign of combined flexion of thigh thigh and trunk. The active and trunk, and (_c_) absence of balance movements of arm may be active balancing arm movements lacking but there is no in walking contrasted with exaggeration of passive balance exaggeration of passive balancing movements. movements (limb inert on sudden turn of body).

4. Tongue usually slightly deviated 4. Tongue sometimes slightly to the paralyzed side. deviated to the paralyzed side; but sometimes contralateral deviation.

5. Hypertonicity of muscles, 5. No hypertonicity of muscles. If especially at first. The buccal facial asymmetry exists, it is commissure may be lowered, the due to spasm. No exaggerated eyebrow lowered; there may be flexion of forearm, and no exaggerated flexion of the pronation sign. forearm, and the sign of pronation may occur (hand left to itself lies in pronation).

6. Tendon and bone reflexes often 6. No alteration of tendon or bone disturbed at the beginning, reflexes. No trepidation of the either absent, weakened, or foot. exaggerated (almost always exaggerated.) In many cases, there is epileptoid trepidation of the foot.

7. Skin reflexes usually disordered. 7. No disturbance of skin reflexes. Abdominal and cremasteric reflexes, Abdominal and cremasteric especially at first, weakened or reflexes normal. Babinski toe abolished. On stimulation of sole, reflex and fan sign absent. toes, and especially the great toe, Defense reflexes not are extended on the metatarsals. exaggerated. Babinski toe reflex. Extension of great toe often associated with abduction of other toes (fan sign). Sometimes exaggeration of reflexes of defence.

8. Contracture characteristic and 8. The contracture can be non-reproducible by voluntary reproduced by voluntary contractions. The hand-grip contractions. yields a sensation of elastic resistance, automatically accentuated on passive extension of the hand.

9. Evolution of diseased regular 9. Evolution of disease contracture follows flaccidity. capricious. Paralysis may When regression of disorder remain indefinitely flaccid occurs, it is progressive. or may be spastic from the beginning. Spastic phenomena may sometimes be associated Paralysis not subject to ups (particularly in the face) and downs (motor defect fixed). with characteristic phenomena.

The disorder may get better and worse alternately several times, alter rapidly in intensity, and present transitory remissions which may last even but a few moments (motor defect variable).

[12] More energetic contraction of platysma on healthy side when mouth is opened or when head is flexed against resistance.

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

_Reflex_ _Hysterical_

1. Paralysis usually limited but 1. Paralysis usually extensive severe and obstinate even when but superficial and transient methodically treated. if treated.

2. In the hypertonic forms attitude 2. The hysterical contracture as of the limb does not correspond a rule resembles a natural to any natural attitude. attitude fixed.

3. Amyotrophy marked and of rapid 3. Amyotrophy, as a rule, absent, development. even when the paralysis is of long standing. If existent, it is not marked.

4. Vasomotor and thermic disorder 4. There may be thermo-asymmetry often very marked, accompanied by but it is slight. There are no an often very pronounced reduction very characteristic vasomotor in amplitude of oscillations disorders nor modifications in measured by oscillometer. amplitude of oscillations.

5. Sometimes very marked 5. No sharply defined hyperidrosis. hyperidrosis.

6. Tendon reflexes often 6. No modifications of tendon exaggerated. reflexes.

7. Hypotonia sometimes very well 7. Hypotonia absent. marked, and in arm paralysis _main ballante_.

8. Mechanical over excitability of 8. Over-excitability of muscles muscles, often accompanied by absent. slow response (?).

9. Fibrotendinous retractions of 9. No retractions even if rapid development except in the paralysis is of long rare completely flaccid forms. duration.

10. Trophic disorders of bone, 10. No trophic disorders. decalcification of the hairs and of the phanères.

=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