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]).