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

(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
CYCLOTHYMIA
MORONITY
ALCOHOLISM

SHELL
SHOCK
NEUROSES

NEUROSYPHILIS
EPILEPSY
SOMATOPATHY

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
CYCLOTHYMIA
MORONITY
ALCOHOLISM

SHELL
SHOCK
NEUROSES

NEUROSYPHILIS
EPILEPSY
SOMATOPATHY

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 ORGANO- PSYCHOPATHIC	Hysteria e.g. DYNAMO- PSYCHOPATHIC
ORGANO- NEUROPATHIC e.g. neurosyphilis tabetica	DYNAMO- NEUROPATHIC Babinski’s “reflex” 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.

(d) Functional neural (subcortical), e.g., “reflex” disorders.