Part 71

=100.= Are there, then, phenomena of peripheral nerve shock analogous to the phenomena of spinal cord and brain shock which we find in so many cases? But if so, it is clearly unnecessary, and indeed injurious for us to conceive that cases proved not to be organic must necessarily be hysterical. Several authors have called a halt upon this undue extension of the concept of hysteria to include all the non-organic phenomena. Take, for example, the case of the Victoria Cross winner (Case 529), reported by Eder, in which a contracture was shown by hypnosis to be a representation of the patient’s clutch upon his bayonet (he had been at Gallipoli and was wounded in fourteen places during a bayonet fight with Turks). It would not be possible--in fact, it would seem almost impolite--to refuse to entertain the hypothesis of a kind of symbolism in the bayonet-clutch contracture of Eder’s case; but it would, on the contrary, be far from exact to consider all cases of contracture to be even probably or possibly symbolic in the manner of the bayonet-clutch. There are, many workers feel, many functional phenomena that are non-hysterical, and as it were infra-hysterical in the sense that the “mechanisms” (to use that over-worked term) are in neurones below the level of complexity required by hysteria. This theoretical possibility (that the functional should be divided into the psychical and the infrapsychical) has been given a new status by the work of Babinski and his associates. That work seems to show that the older doctrines of Charcot concerning the existence of “reflex” disorders, are perfectly sound.

=101.= Babinski has been able to bring into the light of observation the morbid operation of certain of these reflex arcs. Even in cases where in the waking life the central nervous system is able to overpower the reflex arcs in question and permit the limb or limbs to work reasonably well and smoothly, the process of chloroform anesthesia will quickly bring out an odd and unsuspected interior situation. The chloroform suspends the operation of numerous neurones, including those that have to do with the downflow of cerebral inhibitions, those silent streams of impulse that serve to keep the knee-jerks, for example, in leash. Now at a time when all the other muscles of the body are relaxed, the withdrawal of the cerebral inhibitions by chloroform anesthesia may cause a phenomenon to appear in certain reflex arcs that argues an excess of activity; thus in the leg, for example, an ankle-clonus, or a patella-clonus, or a degree of contracture, may be brought about early in chloroform anesthesia, though there had been little or no suspicion of such a tendency in the waking life. The cerebral inhibitions in the waking life have been enough to dampen the ardor of the reflex arc in question. It must be remarked that these cases of reflex, or, as Babinski termed them, _physiopathic disorders_, as a rule occur in cases locally wounded. It is the locally wounded limb that develops functional excess of contained reflex arcs. Does this occur by a process of neuritis, or by some other unknown process? Whatever the answer to this question, Babinski and his associates appear to have shown the existence of a group of physiopathic or reflex disorders; disorders below the level of the psyche and below the theatre of operations of hysteria.

=102.= Practically speaking, also, it is important not to consider every functional situation hysterical, since the non-hysterical functional changes may be extremely obstinate to treatment. Both physician and patient suffer if the patient is treated along psychotherapeutic lines for hysterical symptoms, some of which turn out on investigation to be functional enough but non-psychic. The peculiar configuration of symptoms shown in cases with the physical shell-shock or its equivalent, is perhaps dependent upon what neurones are locally affected. If there has been good evidence of near-by explosion or of wound, it will be especially important to learn just what parts of the nervous system and just what synergic neurones and other structures were affected. Whether the process within these neurones be one analogous to the dissolution of chromatin, or whether the process is more like one of narcosis, or narcosis and stupefaction, or whether the process is more like that of a stun, or like the plight of the nerves in a foot for a long time “asleep,” it may be impossible to say; but it is entirely unnecessary to soar directly to the higher mental process, unnecessary in short, to assume a hysterical dissociation when the dissociation may be far lower down in the nervous system.

THE TREATMENT OF SHELL-SHOCK NEUROSES

=103.= We have pictured the practical situation in which the neuroses of the war find themselves--a situation bristling with diagnostic difficulties. The great proposition deducible therefrom is,

=The diagnostic problem in Shell-shock is the diagnostic problem of neuropsychiatry at large.=

The neuroses of war have this in common with the neuroses of peace--that they need to be distinguished from all other nervous and mental diseases. One cannot be a specialist in Shell-shock unless one is a neuropsychiatric specialist; even the neuropsychiatrist has much to learn from the internist, the orthopedist, the neurosurgeon, as well as from the psychologist.

=But however wide the diagnostic field for Shell-shock, the therapeutic field is wider still.= For the neuropsychiatric reconstructionist has to face the peculiarities of the military status of his ward, the difficulties of demobilization into civilian life (a canal system with very precise technic for the opening and closing of locks), the choice and timing of the proper measures of bedside occupation, of occupation therapy in a broader sense, of prevocational and vocational training--the whole complicated by the character changes that may have set in to bowl over all one’s preconceptions. The nub of the matter, after the era of the _manière forte_, the brusque psychotherapy, the rough jarring of the man back into approximate normality is, perhaps, this potentiality of subtle character changes defying possibly anybody’s analysis, but stimulating us all to our best endeavor, whether we are physicians, psychologists, occupation-workers, social workers, or nurses. Now that all sorts of reconstruction programs are in the air, each claiming its share, or more than its share, of attention, let us not forget that no one can stake out in any small plot the measures of refitting, readjustment, readaptation, rehabilitation--all these terms with slightly differing denotation have been used--especially when we take into account that not only must the patient be refitted to his entourage, but also not seldom the entourage to its returned Shell-shocker.

=104.= It is proper to place these general considerations first because =the slow, patient, prosaic measures of reëducation are apt to be forgotten in our enthusiasm for the lightning-like cures of the hypnotic, the psychoelectric, the pseudo-operative, and other psychotherapeutic forms=. Psychotherapy in all its forms has come into its own in Shell-shock. Miracles or their equivalents are daily wrought by men who are not prophets. Lourdes and Christian Science have their unassuming rivals. Let us remember, however, that even Lourdes and Christian Science never solved 100% of the problems placed before them, even though the votaries have the best will in the world to be cured. If the will itself is disordered, what can be done save investigate? And the _mauvaise volonté_ is by no means absent from some of our prospective patients; witness one man, a Frenchman, who so resented being cured by _torpillage_, _i.e._, by the electric brush, that he carried his case against Clovis Vincent, who cured him of his hysteria, clear to the Academy! And, even after we have cured our cases by these modern miracles, let us not be too proud of ourselves! One soldier sent back to Australia, hysterically mute for months, got his voice back after killing a snake--a peculiar instance of occupation-therapy, not enumerated in courses on reconstruction. And remember the man who jumped the wall and got drunk, breaking back into the hospital to show his doctor how his refractory voice had at last come back. Thus there are cures and cures (even a newspaper cure of mutism by a moving picture vision of the antics of Charlie Chaplin), and spontaneous non-medical cures as well as medical ones, and slow cures due to _vis medicatrix_, as well as to shrewd reëducation measures.

=105.= I shall not attempt to cover systematically the topic of Shell-shock therapy in this epicrisis. The reader must go through the treated cases, especially in Section D but _passim_ elsewhere, if he is to obtain a proper conception of all the methods so far employed--and at the end he cannot know the ultimate outcome of the cases. Patrons of the miracle cures and the _manière forte_ are having their day: on the whole, the law of =sudden onset, sudden ending= has much to say for itself in the hysterical (pithiatic) group. Forebodings of relapse in these =torpedoed= cases may indeed have some foundation: but figures are yet lacking, and relapses may be as expectantly predicted in the =slow-onset, slow-cure= group. =The decision must be post-bellum.= Nor must the fact that a few absolutely normal subjects have succumbed _de novo_ to Shell-shock blind us to the fact that, statistically speaking, most cases are _ab ovo_ psychopaths in whom relapses, recurrences, or new instances of neurosis may be confidently expected. For these _ab ovo_ psychopaths, what can suffice but (_a_) removal of the disease by the _vis medicatrix naturae_; or (_b_) reëducation, intellectual or (_c_) moral (as the case may be); or else (_d_) some plan of environmental shielding from new occasions of disease?

=106.= I shall content myself with a brief survey (insisting that the details be read of at least the leading cases in each treatment subgroup) of the cases offered in Section =D= (Shell-shock: Treatment and Results), consisting of 117 cases (Cases 473-589). The cases are in general arranged with the =spontaneous and quasi-natural cures= at the outset,--a series of 11 cases (Cases 473-483). The remainder of the section deals with cures under medical conditions, although many cases naturally show an interplay of non-medical factors in the cure or persistence of one or more symptoms.

A few cases illustrative of the =physical value of hydrotherapy=, =mechanical therapy=, and =drugs= are given in a short series (Cases 484-489). A treatment of hysterical contractures by =induced fatigue= is dealt with in Cases 489-493; and the occasional value of =surgery= is shown by Case 494.

The simpler methods of =persuasion and explanation= follow in a series of 19 cases (Cases 495-513).

=Pseudo-operations= and =suggestive operative manipulation= of avail in the treatment of certain local hysterical phenomena are considered in a series of eight cases (Cases 514-521). The comparatively long =hypnotic series= follows: 27 cases (Cases 522-548). The above-mentioned cures by pseudo-operation and by hypnosis may be classified with those that follow, _i.e._, mainly rapid cures by =psychoelectric= methods and by =suggestion on emergence from anesthesia= (Cases 549-574), as modern miracles. These cases of modern miracle are followed by a briefer set of =reëducative cases= (Cases 575-589).

Throughout the treatment section are scattered instances in which, not a cure, but merely a modification or even a persistence of symptoms was the outcome. It is useful to bear in mind, while reading cases in the etiological and diagnostic sections, these main divisions of treatment into what might be called (1) spontaneous, (2) rapid (or “miraculous”) and (3) slow or reëducative.

=107.= It is beyond the scope of this book to deal systematically with the hospital and administrative side of these questions. Especially the zone question is of practical importance, that is, the question of arrangements at the front, on evacuation lines, and in the interior. Roussy and Lhermitte have particularly discussed these matters.

After thirty months’ experience in the psychiatric centers of two armies, Damaye suggested an organization of psychiatric centers in two parts,--First, a service draining patients =from the firing line=, rapidly give them first care and evacuate them, =in charge of special attendants=, to: Second, a psychiatric or neurological =center in the communication zone= (_étapes_) without danger of bombardment and at a distance from the guns. The more serious cases will then be evacuated, thirdly, into the interior from these centers along communication lines. But most will have gotten well at the front.

=108.= By orthopedists and mechanotherapeutists too much stress may indeed be laid on non-psychiatric measures, as Duprat hints. Yet perhaps neuropsychiatrists may need as much coaching in the opposite direction. One must remember the non-psychopathic fraction of these Shell-shock disorders and their need of diathermy (Babinski). Duprat says that the centers for physiotherapy cannot effectively do the work of all Shell-shock therapy, as the physiotherapists have their aims fixed on nerves and muscles rather than the mind. Each case requiring psychotherapy ought to be studied in an =experimental psychological laboratory= from a number of points of view such as mechano-motor capacity, the sensibility, emotional and intellectual sides, memory, impulses and the like. Testing apparatus should be available together with dynamometers, sphygmometers, chronoscopes, ergographs, pneumographs, cardiographs and recording apparatus.

CHART 19

PSYCHOELECTRIC AND REËDUCATIVE TREATMENT

PHASE I. PERSUASIVE TALK IN CONSULTING ROOM

PHASE II. ISOLATION, REST IN BED, MILK DIET (a few days)

PHASE III. FARADIZATION

PHASE IV. REËDUCATION (Physiotherapy and Psychotherapy)

PHASE V. AFTER-CARE

Curing a psychoneuropath means victory in a moral battle!

After Roussy and Lhermitte

CHART 20

TREATMENT FOR INVETERATE HYSTERICS

PHASE I. “TORPILLAGE” AND INTENSIVE REËDUCATION

PHASE II. FIXATION OF PROGRESS BY EXERCISES

PHASE III. PROLONGED SPECIAL TRAINING

After Clovis Vincent

Specialists for consultation should be available, including ophthalmologists, otologists, laryngologists and electrical specialists. The tests over, the patient should be examined as it were, in a free state and his habits and character noted. Hypnosis may be tried but it should not be prolonged. Psychic contagion is to be avoided especially in the case of subjects with epileptoid crises.

It would be well to establish for the cases regarded as susceptible to psychotherapy, =reëducation centers= like those for the re-adaptation of the tuberculous. The improved tuberculous are sent to health centers under the Ministry of the Interior for three months at the maximum and emerge much better able to support the exigencies of life. According to Duprat, there ought to be =psychotherapy centers= which should not in any sense recall asylums for the insane. Set in the country but not far from the city, managed by the psychological physicians and “_médecins psychologues, plus éducateurs que médecins_.” The personnel should consist of students going into psychiatry and of teachers whose pedagogical practice ought to enable them to second the efforts of the psychiatrists. In this way we might avoid the perpetuation of some of the psychopathies of war.

=109.= Possibly “putting forward the best foot” may yield a wrong impression of the proportion of what I have termed “miracle cures.” Other devices of a slower nature are mentioned throughout the book. Perhaps much depends on the temperament of the psychotherapeutist, as _e.g._, Laignel-Lavastine has remarked about the method of psychotherapy by means of conversation: that =one might easily remain in a honeymoon state in military psychotherapy=. When hundreds and thousands of functional nervous cases pass through one’s hands it is necessary to remember that behind the conversation there stands the imposing finger of material force.

Compare the work of Clovis Vincent, Yealland, Kaufmann.

=110.= On the other hand, Rows points out that shock is a term that does not explain at all adequately the great variety of mental illnesses occurring in the soldiers at the front. The term is popularly used for cases which recover quickly, but in the majority of cases there is a residuum after the shock has disappeared. Accordingly Rows’ work has dealt chiefly with underlying causes, conditions, and factors. Here we may consider

(_a_) The =war strain= before breakdown;

(_b_) =Special causes= of shock, such as death of comrades near by, near-by shell explosions and blowing up of trenches;

(_c_) =Fatigue and exhaustion= with lowered capacity of resistance.

The men themselves find that they have

(_d_) undergone a =change of character=, having become irascible, unable to sustain interest and attention; solitary and morose, and less capable of self-control. Anxiety, worry and a state of morbid expectancy set in. Everyday trifles are exaggerated.

But below these cases are still deeper ones, such as

(_e_) revival of =horrible memories and terrifying dreams= of war scenes, together with memories of incidents of past life.

(Rows attributes to Dejerine the idea that the cause of all cases of hysteria and neurasthenia must be sought in antecedent emotion.)

Emotion compels attention, and to such a degree in some cases that the memories and attendant fears and anxieties cannot be expelled. Hallucinations and delusions may then develop. The patient is largely incapable of reasoning about his status; he lacks “insight into the nature and mode of origin of his mental illness. This insight can be provided by explaining to him in plain language the mechanism of simple mental processes, by enabling him to understand that every incident is accompanied by its own special emotional state, and that this emotional state can be re-awakened by the revival of the incident in memory.” The patient and the physician now “begin to realize that they have some ground in common.… The mystery of the illness will be swept away and the physician will be able to … show him how he can educate himself to regain that which was lost.” “The patient can be induced to face the trouble.” “The excessive emotional tone will thus be stripped away and the patient will thus become able to appreciate the real value of the incident.” “The reëducation must vary with each case in order to overcome the difficulties connected with the specific cause which has been discovered.”

Rows’ work has been done at the Red Cross Hospital at Maghull, and several of the Maghull cases have been reported in Elliot Smith and T. H. Pear’s book on Shell-shock. A somewhat similar point of view has been maintained by Wm. Brown, who has suggested the neat term _autognosis_ for psychoanalysis. W. A. Turner speaks of the Maghull point of view as one of modified psychoanalysis.

=111.= Or again a species of combination of the _manière forte_ and the _manière douce_ (operations, shall we say with William James, of the “tough-minded” and the “tender-minded” respectively?) may be used as in the formula

SYMPATHY + FIRMNESS (MOTT).

=112.= More special devices, suggesting faintly the methods of animal training, may be used, as described in the following account of a new =isolation and psychotherapeutic service= established in May, 1915, at the =Salpêtrière= for soldiers with functional nervous diseases. The basic idea has long been held by Dejerine,--the avoidance of heterosuggestion by other patients, imitation, ill effects of visits from members of the family. The functional additions that come from near-by organic patients are among the disadvantages of the ordinary treatment. The isolation service of the neurological center is composed of 34 beds, arranged in two halls, with three extra rooms. Each bed is isolated. The régime in one of the rooms is more rigorous than in the other, and =it is an advance for a patient to be moved from the first to the second room=. The patient on wakening has no right to leave his box or communicate with his neighbors. He leaves only to be treated by hydrotherapy or electrotherapy. He takes his meals in isolation, receives no calls, and has no leave to go out. The physician sees the patient twice a day and carries on psychotherapy and motor reëducation, as well as special treatments.

Women nurses care for the patients. A system of control and of =progressive rewards= has been installed, being a sort of metric evaluation of the process of cure. As the cure proceeds the patient’s lot is progressively mitigated, or if he gets worse the regime is clamped down. Suppose a man a victim of paralysis of leg--the height to which he can lift his leg is measured in centimeters daily as well as the time during which he can hold the leg in air; or, the progress of an ankle, or of the forearm or the arm in a case of arm contracture, is measured. The grade obtained by our =scholar in psychotherapy= is inscribed upon a slate. Finally, walks, concerts, visits and eventually permission to go out into the town are granted.

=113.= =Can Shell-shock neuroses be prevented=, other than by stopping or modifying the war or by weeding out Shell-shock candidates as they volunteer or are drafted? Morton Prince offers points of some suggestive value. The very various proportions of neurosis observed in different units and arms of the service suggest that various degrees of preparedness may have played a part. Bernheim says =suggestion= is an =idea accepted=. Aside from a possible increase of simulation, much might depend on what idea administered really got accepted! Morton Prince’s plan is that the prevention must be based upon the education of the mind. This therapeutic education should be based, however, on a preliminary systematic study by a board of specialists in the psychoneuroses of (_a_) the mental attitude of minds generally toward shell fire, and (_b_) clinical varieties of this “shock” neurosis as it occurs in trench warfare, (_c_) its frequency and disabling incidence, and (_d_) the state of mind previous to the trauma of those suffering from it.

On the basis of the findings of such a study, first, the regimental surgeon through lectures and clinical demonstrations would be instructed systematically in the symptoms and pathology of the disease and the methods of psychotherapy for its prevention.

Second, soldiers, including officers, could then, in units of say 100, in turn be instructed in the nature of the disease through lectures by regimental surgeons. Shell-shock, they should be told, is a form of hysteria caused by mental factors. The work of the instruction should be done in France in the atmosphere of the war, wherein would be formed an attitude of healthy mental preparedness instead of an attitude of fear and mystery. Has mental hygiene this great scope? =Is morale merely education?=

=114.= =What after all, is Morale?= We hope to learn a little about it from this war for use hereafter, when we can say with the Florentine

_e quindi uscimmo a riveder le stelle_

And thence we issued out again to see the stars

Inferno, Canto XXXIV, 139.

BIBLIOGRAPHY