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,