Shell-shock and other neuropsychiatric problems

by Elmer Ernest Southard

Would that the medical profession understood neuroses at their true value! Only too frequent is the impression on the part of the profession that imaginary symptoms are by the same token non-existent! I have even heard a physician well-trained in somatic lines say that Shell-shock did not exist because Shell-shock was nothing but neurosis, and neuroses were characterized by imaginary symptoms,—accordingly neuroses, being imaginary, do not exist! All of which reminds us that many of the profession were entirely skeptical when Charcot made his original observations. Some men here in America felt that, whereas hysteria might occur in Paris, it did not occur to any extent in America. The Shell-shock data of this war will abundantly prove to the profession the existence of the neuroses, and I feel that physicians will have to brush up their ontology to the extent of conceding that a symptom may be in a sense imaginary and yet not in any sense non-existent.

7. Babinski points out a case of hysterical paralysis of a leg which led the patient to lean so heavily upon his arm as to produce an organic crutch paralysis. It would be to no point to argue that the hysterical paralysis was here non-existent. Of course we shall have to meet the false analogies drawn from methods of cure. If a paralysis can be cured in a few minutes by the electric brush, or by hypnosis, or on emergence from chloroform, or by some other modern miracle.

8. Is it too much to ask the profession not ever to say that this rapid and seemingly miraculous cure was brought about because the disease was non-existent?

Diagnostic Delimitation Problem

9. The delimitation problem, taken up in [Section A], is not identical with the differentiation problem, taken up especially in [Section C] but passim in Sections [B] and [D]; by delimitation we may 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.