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.
=16.= =What are the responsibilities of government if the neurosyphilis
is due to a syphilis acquired during the war?=
Often such infection may be due to a tragical form of “negligence.”
But, as pointed out in a work on Neurosyphilis, 1917, I believe
that any form of licensing system, official or virtual, which would
permit the purchase of syphilis in or near military zones, abolishes
the argument of “negligence.” A man acquiring syphilis under the
connivance of government ought to stand as well as a syphilitic hired
by the government, when it shall come to the question of compensation
for incapacity. Yet, it may be argued, the man might have remained
continent after all. The point is left to the mercy of jurists.
=17.= =The share of neurosyphilis in the “crimes” and disciplinary
problems of the army= is intimated in three cases (Cases 11 to 13).
=18.= The latter part of the series (Cases 14 to 31) embraces =problems
of a more medical nature, touching traumatic paresis and “Shell-shock
paresis.”= Unusual, these cases may be readily conceded to be; but
their infrequency is not such as to put them out of the field of
consideration in the “Shell-shock” group.
Very intriguing to the diagnostician would be the cases of
_pseudo_tabes and _pseudo_paresis (Cases 23 and 26 of Pitres and
Marchand), were such cases at all frequent.
Case 28, in which shell-shock (the physical event) apparently caused
recurrence of a syphilitic (!) hemiplegia, is particularly instructive
and might better belong with the series (under Section B: Nature and
Causes, Cases 286-301) in which _ante-bellum_ weak spots were picked
out by shell-shock and war conditions. But Case 28 is placed here for
its syphilitic interest.
Case 29 stands out as a warning example not to crowd the hypothesis and
try to make syphilis sponsor for everything, even when it plainly is at
work.
Cases 32-34 are cases in which syphilis played a part, though possibly
a minor part, in certain peculiar mental reactions.
To sum up the part played by syphilopsychoses and syphiloneuroses in
the war, we find, that
=19.= =Syphilis may have occasionally a serious military effect=, as in
the case of desertion by a French officer of high rank.
=20.= =Important problems of pension, retirement, and compensation
are brought out=, and as no previous war has had the benefit of the
Wassermann reaction and other exact tests bearing upon the nature,
progress, and curability of neurosyphilis, we may hope for a far more
scientific determination of these questions by review boards during and
after the war.
=21.= We find a few instances in which neurosyphilis has played a
part in the discipline of troops. According to one author (Thibierge,
1917), syphilis has become a genuine epidemic among French soldiers
and mobilized munition workers. In Germany, also, it may be remembered
that Hecht has claimed that no less than an equivalent of sixty army
divisions has been temporarily withdrawn from fighting on the Teutonic
side for venereal diseases. In this connection, Neisser had recommended
the giving of salvarsan and mercury in the trenches. According to
Hecht, the appearance of syphilis should be a signal for sending a man
to the front. Hecht also made the somewhat bizarre suggestion that
special companies of syphilitics should be formed, for convenience of
treatment, on the firing line.
=22.= A more solid foundation is laid for the theory that =general
paresis= may be =evoked by trauma=--a conclusion already fairly well
established by civilian cases, notably those of industrial accident.
=23.= The question whether shell-shock (the physical event) can produce
general paresis is probably to be settled in the affirmative, for it
may always prove difficult to show that the physical shell-shock did
not actually produce mechanical molar lesions of the brain, permitting
the rapid advance of spirochetes. It is perhaps easier to prove that
shell explosion may precipitate neurosyphilis in the form of tabes
dorsalis (take, for example, Cases 21 and 22). The cases of most
importance in the question of traumatic neurosyphilis and traumatic
paresis are cases 20, 21, 22, 24 and 25.
=24.= The picking out of preëxistent weak spots by Shell-shock is given
clear illustration, as in the case of Shell-shock recurrence of an
old syphilitic hemiplegia (Case 28). Only on such a basis could the
syphilitic ocular palsy of Case 19 be satisfactorily explained.
=25.= =The coexistence of functional phenomena with organic syphilitic
phenomena is demonstrated= by Cases 29 and 30; perhaps also in Case 16.
=26.= It must be said that presumably there will be, unless our
authorities are more successful than in the past, a considerable
increase in venereal disease as the result of army life in wartime.
There will be a certain number of cases of neurosyphilis a number of
years after discharge from the army caused by infection acquired during
service. (Germany is said to have got its crop of neurosyphilis after
the War of 1870, in the early eighties of the last century.) The names
of all soldiers acquiring syphilis and not considered cured at the
time of discharge should, under ideal conditions, be given to health
organizations in their home states so that they may be accorded proper
care and treatment.
=27.= =Shell-shock and epilepsy.= The authorities have been somewhat
surprised by the number of epileptics that have gotten by the draft
boards. The statistics are not yet ripe, but certainly the enlistment
of an epileptic is not a rarity. There are some singular instances
in the war literature showing how hard it sometimes is to bring
out epilepsy. There is the English case, for example, of a man, an
epileptic’s son, who had himself been epileptic from 11-18, who
entered the Expeditionary Force at the outbreak of hostilities, went
through the retreat from Mons and through two years of active warfare
without having a single epileptic convulsion. In fact, in September,
1916, he was put in charge of eight men on guard duty. Apparently the
new responsibilities worried him, and two months later he had become
epileptic to the extent of petit mal.
Another man who had never been epileptic (though his sisters had been)
was wounded four times, was never worried by shell fire, got somewhat
depressed after the death of his father and five brothers in the
service, but did not become epileptic until finally he was blown up and
buried three times in one day, and it was a whole month later when he
became epileptic, although treatment by rest and bromides apparently
resolved the affair.
Other cases seem to show that war experiences can bring out epilepsy,
although in most instances it would appear that there was an epileptic
or otherwise neuropathic heredity in these cases.
=28.= There is one author, Ballard, who has actually propounded a
=theory of Shell-shock as epileptic=, pointing out the occurrence
of epilepsy long after the early symptoms of Shell-shock have
disappeared.[10] There does not appear to have been any increase in
epileptics as the result of the war, either from the standpoint of
Shell-shock or from the standpoint of brain injury, so far as the
records of the National Hospital for the Paralyzed and Epileptic in
London are able to show.
[10] In one instance, fugue and other minor symptoms were
later replaced by epilepsy; in another, an epileptic confusion
developed eight months after an explosion, and in a third,
a case of mine explosion, stammering resolved into mutism
and mutism finally into epilepsy. Of course there is a
so-called general resemblance among all forms of hyperkinesis
or irritative discharge of the nervous system. If we term
epileptic all the things that various authors have termed
epileptoid, we may be doing nothing more than to say that we
believe these cases all subject to epileptic hyperkinesis.
In that direction, of course, it has long been said that
dipsomania was really a form of epilepsy. Whether Shell-shock
is ordinarily subject to recurrence in such wise as to imitate
the recurrence of attacks of dipsomania, of manic-depressive
psychosis or of epilepsy, is, to say the least, doubtful at
this time.
=29.= As in all other instances of mental or nervous disease, when an
=epileptic returns from the war=, whether or not he was potentially or
actually an epileptic before the war, his relatives are bound to term
him a case of =Shell-shock=. I am familiar with a case in a hospital
in a certain Atlantic port, a case of pronounced and obvious epilepsy.
In the wards he is treated as the hero of every occasion. Not only the
nurses and attendants, but the other patients and often the physicians
can hardly resist thinking of him as somehow a case of Shell-shock. It
is a comment upon the status of mental hygiene in general that this
self-same epileptic, had there been no war, would have been, as it
were, a common or garden epileptic, mute and inglorious on some sunny
hillside.
=30.= In passing I may note how many instances in the medicolegal
part of the war literature there are of =epileptics who come up for
courtmartial= or for medical examination pending courtmartial. We may
suspect that many a case of epileptic fugue has been regarded as a
case of desertion. There is the case of an epileptic who left camp one
morning and got drunk. Investigation showed that he left camp before
anything epileptoid had happened. He developed in his drunkenness a
pretty clearly epileptic crisis with great violence, for which he had
a complete loss of memory. The French Council condemned him to five
years of labor, not admitting in this instance that responsibility was
diminished by reason of the man’s being epileptic. In short, from the
military point of view, he should, so to say, have known enough not to
have gotten drunk, and so have avoided getting his epileptic crisis. Of
course the decision was here very close, and a like decision would not
always be rendered. To add to the complication of this particular case,
the very first epileptoid crisis which caused it to be known that the
man fell into the epileptic group was due to Shell-shock, or at least
developed immediately after the bursting of a shell nearby. On the
whole, however, the relation between epilepsy and Shell-shock is not a
close one.
=31.= =The question of epilepsy in the war= is considered in a series
of 33 cases (Cases 53-85). The considerations range from banal cases
developing quite incidentally, up to cases regarded by one author
(Ballard) as illustrating a theory of Shell-shock as epileptic (Cases
82-84). First are considered two cases actually syphilitic. In the
first (Case 53), the diagnosis had to be revised from epilepsy to
neurosyphilis (the convulsions of this neurosyphilitic were brought
out by alcohol, and the reporter, Hewat, remarks that the serum of any
patient developing epileptiform seizures between 35 and 50 years of age
should be subject to test). In Case 54, the soldier got his syphilis
in wartime and the syphilis acted to bring out an epilepsy with which
the patient was hereditarily tainted (epilepsy syphilogenic, _i.e._,
reactive to syphilis).
Case 55 might perhaps better have been considered in the group of
hypophrenoses, as he was epileptic and imbecile. He was at first
condemned by court martial to five years’ imprisonment for leaving his
post in the presence of the enemy.
Another mixed case is Case 57, in which another feeble-minded subject
showed seizures of a psychogenic nature, which he was able eventually
to stop by clenching his teeth.
Seven cases (Cases 58-64) are cases of a disciplinary nature, amongst
which attention may be called to Case 62, the “specialist in escapes.”
The medicolegal questions of responsibility in the drunken epileptic
(Case 58) are particularly perplexing.
=32.= Case 64 is one of =epilepsy following antityphoid inoculation
one-half hour=. There were five attacks during a fortnight and then
no others. The antityphoid inoculation came eight weeks after a shell
wound of the thigh, which had not served to bring out the epilepsy in
this patient. Bonhoeffer had three other instances of the sort: one in
a severely tainted subject, and the others in alcoholics.
=33.= The next group of cases, 66-77, yields a series of the most
interesting =medical problems=, some of which scarcely belong in
an account of psychoses incidental in the war. Case 66 is one with
recovery from Jacksonian seizures after decompression of the upper
Rolandic region, which was edematous following an (apparently very
slight) scalp wound and shell-shock.
=34.= The cure by studied neglect (in Case 67) is one of
=hystero-epileptic= convulsions occurring in series. Case 68
demonstrates the superposition of hysterica phenomena over a genuine
epilepsy, a case therefore with two diagnoses: not hystero-epilepsy,
but epilepsy =and= hysteria.
=35.= The theoretical implications of Case 69 are striking: The
case was one of musculo-cutaneous neuritis (gross enlargement), in
association with which =Brown-Séquard’s epilepsy= developed, waxing
and waning with the disease of the nerve. Another case of possible
reactive epilepsy is Case 70, and a case of epilepsia tarda brings up
the same issue (Case 71). Cases 72-74 are cases with strong psychogenic
components, of which Case 74 is particularly instructive on account of
the gradual building up of a remarkable visual aura of an approaching
fire-wheel, this aura developing after scotoma from looking at the sun.
Cases 75 and 76 are cases of somewhat doubtful epilepsy, one of fugue
and the other of a solitary epileptic episode following 38 artillery
battles in two months.
=36.= Friedmann discusses =narcoleptic seizures=, regarded as due to
the =brain fag of trench life= (Case 77). Sham fits and epileptoid
attacks controllable by will appear in Cases 78 and 79 respectively.
Case 80 is a striking case of a man with epileptic taint, which two
years’ service, four wounds, the death of a father and five brothers,
and eventually Shell-shock and burial thrice in one day, served at last
to bring out.
=37.= =Shell-shock and bodily disease.= In civilian psychopathic
hospital practice, if a case is not syphilitic, not feeble-minded, not
epileptic, not alcoholic, and without signs of intracranial pressure or
disorder of reflexes, then we, as specialists, must consider whether
the disease in question is not due to some form of bodily disorder
outside the nervous system; for example, we think in practice of
infectious psychoses, of exhaustive states such as the puerperium,
of toxic states such as may be found in cardiorenal cases, and of
glandular phenomena such as we are familiar with in the thyroid
disorders.
Under the war conditions, it might be thought that these somatic
disorders yielding the so-called symptomatic mental diseases would be
frequently found.
Aside from these rarities in puzzling diagnosis, we find more commonly
in the literature evidence of
=38.= =The soldier’s heart, the so-called “D.A.H.,”= or disordered
action of the heart, of the English army reports. This soldier’s
heart is sometimes associated with hyperthyroidism, and sometimes
hyperthyroidism is found alone, with symptoms suggesting those of a
sort of diffuse Shell-shock.
One author claims rapid cures of hyperthyroidism by the relatively
simple process of hypnosis. Perhaps this is not too unlikely in view
of the still obscure relations between mind and hormones. A little
more surprising, perhaps, is the assertion met with that psoriasis is
sometimes a Shell-shock phenomenon.
The literature clearly shows, however, that, as in most special
problems, the internist is still in demand. I recall how one internist
was misled on the witness stand into stating that he was a “general
specialist.” This is what we would all need to be, were we to solve the
problems of Shell-shock in the time allotted to us by the war.
=39.= Following are =special cases= to show how near the somatic
(“symptomatic”) may be to Shell-shock.
The somatic group of psychoses, sometimes termed symptomatic, is
illustrated in 29 cases (Cases 118-146), and comprises cases ranging
all the way from rabic phenomena to those of hyperthyroidism. Possibly
the first two cases (Cases 118 and 119) might better be placed among
the encephalopsychoses. Case 118, one of _rabies_, was that of a farmer
without history of having been bitten by a dog, who eventually came
to autopsy and received the Pasteur Institute diagnosis of rabies. A
diagnosis of angina was at first made. When the symptoms became more
serious and masseter spasm developed, a question of tetanus arose.
Later the diagnosis of meningitis was suggested. At this point, the
symptoms became predominantly psychotic.
Case 119 was one of seven cases reported by Lumière and Astier, in
which delirium and hallucinations appeared as a complication of
_tetanus_. The case in question had been given anti-tetanic serum.
(Another case showed identical symptoms without having been given
anti-tetanic serum.)
That a local tetanus could be mistaken for hysteria might seem _à
priori_ unlikely, but Cases 120 and 121 indicate as much; and Case
121 is interesting on account of the officer’s own description of his
local tetanus and its treatment. A psychosis apparently related with
dysentery occurred in Case 122. Hysteria followed typhoid fever in Case
123. Another form of typhoid fever complication is perhaps shown in
Case 124, wherein the diagnostic question lay between dementia praecox
and a post-typhoid encephalitis.
_Paratyphoid fever_ has diagnostic complications, as shown in Cases 125
and 126, wherein the mental symptoms outlasted the fever (Case 125),
and psychopathic taint was brought out (Case 126).
_Diphtheria_ was also represented in the matter of nervous and mental
symptoms in Cases 127 and 128. In Case 127 the nervous symptoms
appeared eight days after evacuation for diphtheria. There were a few
sensory symptoms (hypalgesia, hypoacusia, and peculiar bone sensations)
in this subject. The phenomenon in Case 128 was apparently one of
hysterical paraparesis; nor does it appear in this case that the
hysterical paralysis was preceded by polyneuritis.
_Malarial effects_ are present in three cases (Cases 129-131), of
which Case 129 showed an amnesia, Case 130 a Korsakow syndrome, and
Case 131 anterior horn symptoms. Case 132 exemplifies 15 instances of
acroparesthetic disorders in so-called trench foot. This case, like
several others, is inserted in this group, not because the symptoms
are psychotic, but because they might cause diagnostic difficulty as
against hysterical phenomena.
Case 133 is an autopsied case of bronchopneumonia following bullet
injury of the spine. Microscopic examination of the spinal cord
showed small cavities in the first and fourth dorsal segments. This
myelomalacia was doubtless related with the bullet injury of the
spine, although the spinal cord was not itself directly touched by
the bullet. Case 134 might be regarded perhaps as one of Shell-shock
and should be considered in relation with the cases at the head of
Section B (Cases 197-209). The case might be regarded as functional,
except for a decubitus that developed. Despite this decubitus, there
was recovery. The case is placed in the somatic group on account of
_pulmonary phenomena_ which it seemed well to relate with those of Case
133. Compare also Case 136, in which reflex phenomena are associated
with a bullet wound of the pleura. Case 135 is a many-sided case,
with ante-bellum hysteria and certain Shell-shock phenomena. While
under observation, the patient caught typhoid fever and then developed
neuritis. This neuritis was very probably not post-typhoidal so much as
hysterical. Accordingly, the case should be considered in connection
with the ante-bellum weak spot series, Section B (Cases 286-301). There
was in this case a cure by reëducation.
The reflex hemiplegia with double ulnar syndrome in Case 136 seemed to
have followed a bullet _wound of the pleura_. According to the authors,
Phocas and Gutmann, there is considerable literature upon nerve
complications of pleura trauma, including syncope, epilepsy, and (more
rarely) hemiplegia.
_Heart cases_ are illustrated by Cases 137-139: the first one of
hysterical tachypnoea, and the others of the so-called soldiers’ heart.
_Diabetes mellitus_ seems to have followed war strain and shell wound
in Case 140.
It is doubtful whether shell-shock and burial had anything to do with
the appearance ten days later of _lipomata_, which proved to be the
initial phenomenon in a pronounced Dercum’s disease. (Case 141).
_Hyperthyroidism_ is illustrated in four cases (Cases 142-144).
The first (Case 142) appears to have been cured by inducing deep
somnambulism (Tombleson claims cures by suggestion in eight cases of
hyperthyroidism). Neurasthenia or questionable Graves’ disease (Case
145) followed Shell-shock. That of Case 144 followed 10 months’
service, at times under protracted shell fire. A _forme fruste_ of
Graves’ disease is shown in Case 145, in which the phenomena followed
gassing and shelling.
A somewhat curious _somatic complication_ in a case of Shell-shock
hysteria was the finding of a needle in the left upper arm, which was
then extracted. (Case 146).
THE NATURE OF WAR NEUROSES
=40.= Regarding our rough delimitation of the Shell-shock group as
well in hand, having put upon one side three of the most disturbing
groups (save one) in our process of demarcation, =we must proceed to
the Shell-shock material itself: a material now definable as assuredly
non-syphilitic, non-epileptic, non-somatic=,[11] as beyond question
without narrow relations with feeble-mindedness, alcohol and drug
states, schizophrenia and cyclothymia, and =as probably of the general
nature of the psychoneuroses=.
[11] In the limited _non-encephalic_ sense of the term somatic
(“symptomatic”) of some writers.
Note that in this epicrisis I have designedly not followed the order
of presentation of the text materials. The process of _diagnosis per
exclusionem in ordine_ which I find most serviceable in civilian
psychopathic hospital practice is the elimination of possibilities in
the order presented in Chart 1 or in Paragraph 10 of this epicrisis.
Because this book will find its greatest use in peace times as a
kind of illustrative commentary on the peace material that presents
itself in general practice or in psychopathic hospital voluntary,
temporary-care, and out-patient practice, I chose to arrange the
delimiting material according to the order of the practical key devised
for civilian practice. We may now profitably change our order of
consideration and consider whether
=41.= =The most practical key or sequence of consideration in the
endeavor to delimit Shell-shock neuroses is probably: Exclude (1)
syphilis, (2) epilepsy, (3) somatic disease= (of a sort able to produce
“symptomatic” effects somewhat like those of Shell-shock).
Below I shall still permit myself some general words concerning
the other more easily excluded groups because of the light which
feeble-mindedness, alcoholism, schizophrenia, cyclothymia, and even old
age can theoretically throw on the nature of Shell-shock.
=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.
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.=
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
=89.= We are now ready to consider in how far Shell-shock[13] is a
distinctive disease. The physical event, shell-shock[13] we have seen
at work in most of the major groups of mental disease and in some
groups of nervous disease. Shell-shock, the physical event, has started
up a “Shell-shock” paresis, a “Shell-shock” epilepsy, a “Shell-shock”
Graves’ disease, a “Shell-shock” dementia praecox, wherein the term
“Shell-shock” is merely a more specific term than the term “traumatic.”
The physical event, shell-shock, has in special ways also changed the
responses of the feeble-minded, the alcoholic, the cyclothymic, and the
psychopathic person of whatever ill-defined sort may get into military
service.
[13] I capitalize Shell-shock here (as elsewhere) to indicate
the name of a supposed disease entity and leave shell-shock
without an initial capital to indicate the physical event.
The physical event, shell-shock, has likewise caused focal irritative
and destructive brain disease, spinal cord disease, peripheral nerve
disease; and many well-recognized species of the so-called “organic”
diseases of the nervous system have been produced. Shell-shock
“organic” diseases have proved as difficult to tell from all sorts of
Shell-shock “functional” diseases as ever have been the organic and
functional analogues of these diseases in peace practice.
But, besides (_a_) sharing in the cause of mental and nervous disease
(in the sense of “Shell-shock” general paresis and “Shell-shock” tabes,
wherein at least one other factor, _viz._ the spirochete, is known to
be at work) and (_b_) producing mental and nervous disease by killing
or weakening or sensitizing neurones in the classical manner of the
“focal” lesion, the physical event, Shell-shock, (_c_) appears able to
bring out the subtler diseases and dispositions of mind which we term
psychoneuroses, that is, hysteria, neurasthenia, psychasthenia. Just
as we have for years spoken of “traumatic” psychoneuroses, so we may
now speak of “Shell-shock” psychoneuroses--nor should anyone believe
we cheat ourselves with the idea that the adjective “Shell-shock”
has helped us more _re_ genesis than the adjective “traumatic.”
“Shell-shock hysteria” and “traumatic hysteria” are on precisely the
same--slippery--footing in the matter of their origin. The physics and
chemistry of the psychoneuroses remain in Egyptian darkness.
The physical event, shell-shock, then, as the common man might say,
affects body, brain, and mind in a great number of familiar ways; and
these familiar ways remain as plain or as blind as the neuropathology
and the psychopathology of today leave them. If thunderstorms and
earthquakes got suddenly more frequent, we should have numbers of
“lightning neuroses” and “earthquake hysterias,” neither of which would
render the physics and chemistry of the psychoneuroses immediately a
whit clearer.
When the common man speaks of some one as suffering from lightning
stroke or earthquake, he is entitled to be met halfway by his hearer,
who readily understands that the victim is suffering some sort of
transient or permanent effects of the stroke or quake. In a like common
sense should the term shell-shock be taken. Stroke, quake, or shock,
each physical event is recognized as a factor in the situation. An
event has become a factor. A condition for which the noun “shell-shock”
was descriptive, in the present tense of some event, has passed into
history; and the adjective “shell-shock” is now explanatory of the past
cause, or one of the past causes, of a new situation. Shell-shock, the
physical event, takes part in a great number of pathological events
and as such lapses from noun to adjective.
But what are these pathological events, _viz._, the conditions of
disease, that supervene? So far, in our consideration of psychoses
incidental in the war, we have found Shell-shock _varieties_, perhaps,
of mental disease; again, possibly a few Shell-shock _species_,
using both these terms, variety and species, in a quasi botanical or
zoölogical sense. But in either instance we do not rise, under the
ordinary principles of nomenclature, beyond the adjective: Is there
any evidence that shell-shock, the physical happening, has issued in a
pathological event of greater dignity, namely, a _genus of disease_?
Can shell-shock rise to the dignity of a proper noun, Shell-shock,
so that we might think of _e.g._, a new genus of the psychoneuroses,
something coördinate with hysteria, neurasthenia, psychasthenia? None,
I believe, has the hardihood to propose a new genus of mental or
nervous disease for Shell-shock regarded as a pathological event. _A
fortiori_, it is unheard-of to think of Shell-shock, the pathological
event, as representing a new _order_ of such events, coördinate with
the psychoneuroses or the epilepsies, for example.
Shell-shock, the pathological event, we conclude, is a variety or a
species, hardly a genus or an order of mental or nervous diseases.
If we can keep in mind the obvious distinction between shell-shock,
the physical event, and Shell-shock, the pathological event, we shall
save ourselves much trouble. And if we can apply the ordinary criteria
for the differentiation of the great groups (or orders) and the
lesser groups (or genera) of mental and nervous disease to the given
concrete case, we shall not go far wrong therapeutically in any case of
so-called Shell-shock. For Shell-shock, the pathological event, becomes
a humble variety or species of disease whose therapeutic indications
are in larger part those of higher and comparatively well-recognized
genera of disease, _e.g._, hysteria, neurasthenia, psychasthenia.
A shock is not a smash, a crush, a breach. A shock literally shakes.
The shaken thing stays, for a time at least. Shaken up or down, the
victim of shock is not at first thought of as done for. The spirit of
the language is against the thought of shock as destruction or even as
permanent irritation. Shock ought to be a “functional” rather than an
“organic” thing, as medicine bandies these terms about. Shell-shock or
Surgical Shock, it is all one to the logic of shock, which is thought
of as a physical or chemical disturbance of mechanisms and arrangements
that are, or ought to be readjustable. The one character which the late
Professor Royce told me (in conversation) he could find in the term
“functional” was the idea “reversible.” Shock is or ought to be, as a
pathological event, reversible.
If this thought is in the backs of our minds as we think of
Shell-shock, it can readily be seen why the “organic,” that is,
non-reversible diseases, do not take kindly to the term Shell-shock.
Shell-shock, the pathological event, prefers to be an item in the
pathology of function. Can we further specify? The pathology of
function, neuropsychically taken, considers such great groups as the
psychoneuroses; (so far as we know) the cyclothymias; some of the
symptomatic psychoses; a portion of the alcohol and drug group; some
of the epilepsies; perhaps the dementia præcox group; not to mention
various unresolved psychopathias. The psychoneuroses are the group most
innocent of every “organic” taint: the machinery is assumed to be most
normal in them and presumably the effects of disorder most reversible.
Shall we not therefore accept the psychoneuroses as the group in which
to place those pathological happenings called Shell-shock? It will
do no harm to make this choice if we do it humbly in the spirit of
acknowledgment that we know next to nothing about the psychoneuroses.
The psychoneuroses should fall on their knees to Shell-shock rather
than that Shell-shock make obeisance to the psychoneuroses. For what is
a psychoneurosis? It is a functional disease of the nervous system in
which the mind plays an important part--it is also probably much else.
But the “much else” is as likely to be found in Shell-shock as anywhere
else during these particular years.
Thus, rehearsing in a broad way =the case arrangement of Section B=,
we find, first, autopsied cases and cases with lumbar puncture data;
then cases with prominent admixture of organic phenomena; a few cases
to illustrate the victims’ own impressions of their disease; the long
toe to top, or “cephalad” series (crural monoplegias and paraplegias,
campto-cormias, astasia-abasias, brachial monoplegias, brachial
paraplegias, deafmutism, blindness); the series to illustrate the idea
of reflex or physiopathic disorders; the series of delayed Shell-shock
phenomena; the series to show the picking out by Shell-shock of
ante-bellum weak spots and tendencies in the organism; cases touching
the hereditary question; peculiar and unique cases; examples of
Shell-shock equivalents; and cases of a psychopathic rather than local
hystero-traumatic trend.
=90.= At the outset of Section B (Shell-shock: Nature and Causes), we
face the question of the possibly organic nature of Shell-shock. It is
safe to say that the vast majority of cases of Shell-shock do not die
of Shell-shock, and the collection of material from true Shell-shock
cases that are killed by accident or intercurrent disease has proved a
matter of great difficulty under military conditions. Of course, it is
possible to answer the question _à priori_, by agreeing that any case
with structural lesion of whatever sort, is by the same token not a
case of Shell-shock.
=91.= Apparently the most informatory case yet presented is that
of Mott (Case 197). In this case, death came in 24 hours, and the
immediate cause of death was doubtless a small hemorrhage of the
spinal bulb. There was a congestion of veins in the bulb, as well as a
congestion of the pia mater over all other parts of the brain. Nor was
the bulbar hemorrhage unique, for there were a number of superficial
punctate hemorrhages. In short, the brain was not even grossly normal,
such as one might desire in a case of true Shell-shock as conceived
by _à priori_ workers. Yet, according to Mott, there are microscopic
changes of an intimate nature that lie nearer to the microscopic
possibilities in true Shell-shock. For example, in the bulb itself
there was a distinct and photographable change of nerve cells: =the
vago-accessorius nucleus had cells in a state of chromatolysis=. The
internal alterations of these cells, with dissolution of chromatic
material, may possibly indeed have been the direct cause of death or
an indicator of its direct cause. Here again, to accord full justice
to Mott’s contention, we are dealing perhaps more with a phenomenon of
the cause of death than with a Shell-shock phenomenon. According to
Mott, the Shell-shock symptoms themselves are due to capillary anemia
and to nerve cell changes such as he found in various regions. These
nerve cell lesions were of the nature of chromatolysis and identical
with those of the vago-accessorius nucleus. In this connection, one
thinks of the ideas of Crile concerning exhaustion and its effect upon
certain nerve cells and other cells, and indeed the whole conception
runs back to the early years of discussion of the meaning of chromatin
deposits in nerve cells, and to the work on fatigue of such cells.
It may well be that Mott’s suggestion is sound, and that changes of
the order of chromatolysis are what subtend some, if not most, of the
phenomena of Shell-shock. On account of the myriad interconnections of
neurones and the remote effects upon normal neurones of disturbances
of a microchemical or microphysical nature in a few neurones, it
would not do to throw out of court forthwith such a contention as
that of Mott by triumphantly pointing to the miracle cures of certain
Shell-shock phenomena; for it will not necessarily be the chromatolytic
(or otherwise microchemically or physically altered) cells that will
be directly responsible for the symptoms in question. Cells whose
activity is but temporarily in abeyance (perhaps by phenomena akin to
diaschisis) might be reached from an unusual source in the process
of “miracle cure,” whereupon the newly opened paths of energy might
conceivably remain open. Nevertheless, it cannot be denied that there
are considerable stretches of speculation in the thread of this
hypothesis.
=92.= Particularly important is the question, how frequently such
hemorrhages as those found by Mott in Case 197 occur. Cases are given
in the text which show such hemorrhages.
Rather often quoted in this relation is Case 201, a case of Sencert,
in which a shell exploded one metre away from a soldier and injured
him so that he died that night through the bursting of the pleura
of both lungs within a thoracic cage which was quite intact. This
sort of finding reminds one of cases in which the inner partitions
of houses are burst by explosion when the outer walls remain intact.
In particular, one thinks of the physical changes within an aneroid
barometer, which have been shown to come about when something is
exploded near by. If such an event may happen as the bursting of the
lungs within an otherwise intact body, so also is there evidence that
a similar event occurs in the nervous system. Clinical evidence of
this is obtained in the hemorrhage and pleocytosis of spinal fluid
obtained early in the clinical examination of certain cases. In fact,
in Case 205 (one of Souques), there is a pleocytosis of the fluid
as late as a month after shell-shock. When there is no pleocytosis
or hemorrhage, there may be a hypertension of the fluid,--a finding
sometimes attributed to Dejerine (see, for example, Case 207, of
Leriche). It might be inquired whether the fall sustained by the
patient as a result of the shell explosion could not be responsible for
the hemorrhage, and this may indeed be the fact in certain instances.
Babinski has offered in Case 209, an instance in which hematomyelia
(with later partial recovery) was produced in a subject who was lying
prone in the performance of machine-gun duty (the phenomena in this
case were well described by the victim himself, a veterinary student
who was six months a captive in Germany). Doubtless, it would not be
difficult to produce a complete series of cases with and without trauma
to the tissues investing the nervous system, with definite clinical or
autopsy evidence of organic lesions of the nervous system, whether by
mechanical impact, by the concussion (windage) of the air, or even by
the effects of muscular contractions.
=93.= A case of Chavigny’s (Case 198), in which there was an extremely
careful autopsy, showed a strongly blood-stained cerebrospinal fluid;
in fact, there was an intradural hemorrhage, though of minor degree and
possibly not the cause of death; and throughout the brain substance
there were slight hemorrhagic points. But there was no sign whatever
of fracture of the cranial vault or base. Another case of similar
meningeal hemorrhage but sharply localized, was Case 199, an instance
of minor explosion in which neither skin nor muscles, bone or viscera
showed any lesion; and the death, which occurred in seven days, seemed
hardly explicable on the basis of hemorrhage itself. In fact, this case
would require the sort of microscopic examination performed by Mott in
Case 197 for a proof of the cause of death, which was thought by the
reporters themselves (Roussy and Boisseau) to be within the field of
histology.
=94.= Case 200 seems to bring proof that there may be areas of gross
softening within the spinal cord produced by the concussion of the
cord from shell-burst, although there had been no fracture of the
spine itself and no penetration of splinters of shell or of bone into
the spinal canal or the substance of the cord itself. The argument
here is that the tissues that lie between the agent of violence and
the interior of the spinal cord are affected _en bloc_ by the impact,
the resultant gross or molar lesions being several millimetres or
centimetres from the point reached by the impinging body or force.
How complicated such a situation might be, we may recall from a case
previously studied, namely, Case 103 (Lhermitte), wherein a missile
struck the left side of the skull and produced lesions beneath its
point of impact, but at the same time apparently caused a _contre-coup_
effect upon the opposite hemisphere. That particular case did not come
to autopsy, but Lhermitte’s explanation of its queer association of
aphasia with ipsilateral hemiplegia seems sound enough. In fine, what
with the mechanical trauma to which many victims of shell explosion
are subject, what with the findings in sundry autopsies, and what with
the determination of hemorrhage in the spinal fluid early after the
shock, it might be conceived that the majority of cases of Shell-shock
are actually cases of mechanical injury to the brain or spinal cord in
which hemorrhage or laceration and overriding of neuronic tissues would
be found. Nor would such a hypothesis be _prima facie_ absurd with the
evidence afforded by certain cases of Shell-shock having an admixture
of reflex phenomena and other symptoms proved by the older neurologists
to be beyond peradventure organic. (Compare, for example, such a case
as that of Case 210, with herpes zoster and segmentary symptoms.) It
should be remembered, however, that Mott in the case cited above (Case
197) sharply distinguishes between the hemorrhages (especially the
bulbar hemorrhage which caused death) and the nerve cell chromatolysis
which he regarded as possibly at the basis of Shell-shock symptoms.
It is decidedly doubtful whether the hypothesis of microscopic or
larger hemorrhages, or of local areas of destruction of neurones will
suffice for the explanation of true Shell-shock. This is not to say
that in the diagnosis of true Shell-shock (that is, roughly speaking,
the psychoneurosis), we shall not need to concede and consider in
every case the possibility of =traumatic focal brain disease=. This
will always need =to be faithfully excluded= in all cases unless the
initial set-up of symptoms is so suggestive of immediately curable
psychoneurosis that without further ado miracle-therapy is undertaken
and executed. But in virtually all the slower cases, an exclusion of
organic brain and cord disease is undertaken. Admixtures of organic and
focal phenomena are quite in the order of everyday occurrence.
=95.= Especially good instances of this co-existence of functional
and organic symptoms are found in ear cases; and it may be suspected
that when, after the war, all these data can be suitably gathered and
compared, it will be from the field of otology that some of the most
fruitful hypotheses will be developed. In the cases of Shell-shock
deafness, mechanical peripheral factors are admixed with central
factors in phenomena admitting in some ways more exact diagnosis than
in other fields. We may await the correlation of these data by some
worker, equally skilled in otology and neurology, with the profoundest
interest. Analogous results may be hoped from a correlation of
neurological and ophthalmological conceptions.
=96.= Suffice it to say that the differentiation of organic and
functional phenomena has long been possible on the basis of what we
know concerning various reflexes (_e.g._, the Babinski reflex and
its congeners); and the net result of this work is that the majority
of Shell-shock cases,--that is, cases in which the physical factor
shell-shock has entered,--are probably not cases in which a coarse
organic disease could be proved to exist, or assumed with any color
of likelihood to exist. Even limiting ourselves to cases in which the
physical factor shell-shock or some sort of impact with or without
an external wound occurred, we shall find cases enough of a truly
functional nature, as indicated by their reflexes, to render it quite
impossible to assert that they are in the classical sense “organic”
cases. Putting these cases with the physical shell-shock factors
together with the other large series of cases in which precisely
similar symptoms occur without the presence of the physical shell-shock
factor, we shall find ourselves convinced that classical Shell-shock
phenomena are by and large what is called functional. We shall arrive
at the hypothesis that they are cases of hysteria or other form of
psychoneurosis, entitled to the diagnosis of traumatic hysteria (or
hysterotraumatism, in the sense of Charcot), or not, according to
whether the physical factor shell-shock was in evidence. What now
underlies the concept functional, as we use it in Charcot’s sense of
hysterotraumatism, or in the more modern phrase traumatic hysteria?
Do we perhaps mean some microchemical or microphysical change of a
reversible nature, similar to that described by Mott, _e.g._, in Case
197? It is not possible to answer this question at this time.
=97.= But if we give up the hypothesis of organic disease of the
nervous system (that is, the hypothesis of coarse lesions, small or
large, conceived to be the direct effect of mechanical impact), can we
incriminate any other factor? Chemical factors from the gas of bursting
shells may be thought of; yet in abundant cases there is no evidence
that these have been in play. They and a variety of other special
causes may be found working in a few instances but have nothing to do
with the moot question.
=98.= Upon giving up the organic hypothesis, the modern functionalist
is very apt to run directly into the embrace of hysteria. If a thing
is not physical, it must be psychical in its genesis, so runs the
argument. What, after all, is a neurosis? We mean ordinarily by
neurosis, something functional rather than structural. We often mean
something psychical rather than peripheral. Accordingly, as we have
seen, many writers rush to the hypothesis that Shell-shock effects,
except in a few unusual instances of organic disease, are functional;
and not only are they functional but psychic, and maintained by some of
the so-called “mechanisms” which abound in modern speculative writing.
=99.= Case 253, a case of Tinel, may serve to illustrate this point.
Tinel’s patient was not subject to shell-shock at all, but was wounded
in the arm. Three weeks later, he was able to flex his forearm only
by means of the supinator longus. It was found that the biceps was
soft and flaccid, though the electrical reactions of the biceps were
normal. Now, since flexion of the forearm is normally produced by a
synergic contraction of the biceps and supinator longus, the situation
in Tinel’s case was striking in that the functions of the biceps and
supinator longus had been separated out by a process which could not be
hysterica. The hypothesis is that in hysteria it has always been found
impossible to split the synergic action of these two muscles. What has
happened? In Tinel’s picturesque phrase, the biceps muscle has been
=stupefied= by a process which involved no destruction of a nerve trunk
or any important nerve elements. This process of stupefaction passed
away with a few weeks’ massage and rhythmic faradism. But what is this
process of stupefaction, as Tinel calls it? No definite answer can be
given. But is not the process analogous to what may happen in a variety
of cases of shell explosion in which, for one reason or another, sundry
neurones are, as it were, stupefied, stunned, anesthetized, or thrown
out of gear by some internal physico-chemical readjustment of unknown
nature? Perhaps that readjustment, though in Tinel’s case it probably
took place within the tissues of the arm itself, is analogous to the
chromatolytic process in nerve-cell bodies suspected by Mott to be at
the bottom of certain Shell-shock symptoms as in Case 197.
=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
These references were collected in the main by Sergeant Norman Fenton
both before and after his entering the army, in connection with
preparations for the work of one of the Neuropsychiatric Training
Schools (that at Boston), established by the Division of Neurology
and Psychiatry of the Surgeon-General’s Office, U. S. Army. The
work, through the year 1917, at least, is not a mere _vernis de
bibliographe_, but is based on a first-hand search through journals
available in the Boston Medical Library and the New York Academy of
Medicine (to whose officers thanks are due for very special privileges
accorded). After Sergeant Fenton’s departure for service in the war
neurosis hospital, 117, American E. F., France, the work was finished
by the writer in considerable haste by skimming the current indexes
and gathering the more prominent titles for 1918 (some for 1919).
The titles, be it noted, go beyond the scope of the case-material in
the body of the book and cover also a variety of reconstructional,
reëducational, clinical-neurological, neurosurgical, and other topics
bearing indirectly on neuropsychiatry. These auxiliary subjects are by
no means completely covered, but it was thought the titles might help
other inquirers. Under the war conditions numerous errors have no doubt
crept into the references, which errors we hope will not, by reason of
the short space of time covered by the bibliography, prove particularly
misleading. The auxiliary topics can be referred to in the Index under
page-numbers after the word “Bib.”
E. E. S.
=Abadie.= La neuro-psychiatrie d’urgence aux armées. Presse
Méd., Par., 1915, v. 23, p. 46.
=Abrahams, Adolphe.= A case of hysterical paraplegia. Lancet,
Lond., 1915, v. ii, p. 178.
=Abrahams, A.= “Soldier’s Heart.” Lancet, Lond., 1917, i, 442.
=Absence of neuroses in war.= N. York M. J., 1916, v. 103, p.
1178.
=Ackerley, R.= Treatment by physical methods of mental
disabilities induced by the war. Proc. Roy. Soc. Med., Lond.,
1917-1918, v. 10 (sect. Balneol.), pp. 37-38.