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.