Shell-shock and other neuropsychiatric problems

The neuroses of war have this in common with the neuroses of peace—that they need to be distinguished from all other nervous and mental diseases. One cannot be a specialist in Shell-shock unless one is a neuropsychiatric specialist; even the neuropsychiatrist has much to learn from the internist, the orthopedist, the neurosurgeon, as well as from the psychologist.

But however wide the diagnostic field for Shell-shock, the therapeutic field is wider still. For the neuropsychiatric reconstructionist has to face the peculiarities of the military status of his ward, the difficulties of demobilization into civilian life (a canal system with very precise technic for the opening and closing of locks), the choice and timing of the proper measures of bedside occupation, of occupation therapy in a broader sense, of prevocational and vocational training—the whole complicated by the character changes that may have set in to bowl over all one’s preconceptions. The nub of the matter, after the era of the manière forte, the brusque psychotherapy, the rough jarring of the man back into approximate normality is, perhaps, this potentiality of subtle character changes defying possibly anybody’s analysis, but stimulating us all to our best endeavor, whether we are physicians, psychologists, occupation-workers, social workers, or nurses. Now that all sorts of reconstruction programs are in the air, each claiming its share, or more than its share, of attention, let us not forget that no one can stake out in any small plot the measures of refitting, readjustment, readaptation, rehabilitation—all these terms with slightly differing denotation have been used—especially when we take into account that not only must the patient be refitted to his entourage, but also not seldom the entourage to its returned Shell-shocker.

104. It is proper to place these general considerations first because the slow, patient, prosaic measures of reëducation are apt to be forgotten in our enthusiasm for the lightning-like cures of the hypnotic, the psychoelectric, the pseudo-operative, and other psychotherapeutic forms. Psychotherapy in all its forms has come into its own in Shell-shock. Miracles or their equivalents are daily wrought by men who are not prophets. Lourdes and Christian Science have their unassuming rivals. Let us remember, however, that even Lourdes and Christian Science never solved 100% of the problems placed before them, even though the votaries have the best will in the world to be cured. If the will itself is disordered, what can be done save investigate? And the mauvaise volonté is by no means absent from some of our prospective patients; witness one man, a Frenchman, who so resented being cured by torpillage, i.e., by the electric brush, that he carried his case against Clovis Vincent, who cured him of his hysteria, clear to the Academy! And, even after we have cured our cases by these modern miracles, let us not be too proud of ourselves! One soldier sent back to Australia, hysterically mute for months, got his voice back after killing a snake—a peculiar instance of occupation-therapy, not enumerated in courses on reconstruction. And remember the man who jumped the wall and got drunk, breaking back into the hospital to show his doctor how his refractory voice had at last come back.

Thus there are cures and cures (even a newspaper cure of mutism by a moving picture vision of the antics of Charlie Chaplin), and spontaneous non-medical cures as well as medical ones, and slow cures due to vis medicatrix, as well as to shrewd reëducation measures.

105. I shall not attempt to cover systematically the topic of Shell-shock therapy in this epicrisis. The reader must go through the treated cases, especially in Section D but passim elsewhere, if he is to obtain a proper conception of all the methods so far employed—and at the end he cannot know the ultimate outcome of the cases. Patrons of the miracle cures and the manière forte are having their day: on the whole, the law of sudden onset, sudden ending has much to say for itself in the hysterical (pithiatic) group. Forebodings of relapse in these torpedoed cases may indeed have some foundation: but figures are yet lacking, and relapses may be as expectantly predicted in the slow-onset, slow-cure group. The decision must be post-bellum. Nor must the fact that a few absolutely normal subjects have succumbed de novo to Shell-shock blind us to the fact that, statistically speaking, most cases are ab ovo psychopaths in whom relapses, recurrences, or new instances of neurosis may be confidently expected. For these ab ovo psychopaths, what can suffice but (a) removal of the disease by the vis medicatrix naturae; or (b) reëducation, intellectual or (c) moral (as the case may be); or else (d) some plan of environmental shielding from new occasions of disease?

106. I shall content myself with a brief survey (insisting that the details be read of at least the leading cases in each treatment subgroup) of the cases offered in Section D (Shell-shock: Treatment and Results), consisting of 117 cases (Cases 473-589). The cases are in general arranged with the spontaneous and quasi-natural cures at the outset,—a series of 11 cases (Cases 473-483). The remainder of the section deals with cures under medical conditions, although many cases naturally show an interplay of non-medical factors in the cure or persistence of one or more symptoms.

A few cases illustrative of the physical value of hydrotherapy, mechanical therapy, and drugs are given in a short series (Cases 484-489). A treatment of hysterical contractures by induced fatigue is dealt with in Cases 489-493; and the occasional value of surgery is shown by Case 494.

Pseudo-operations and suggestive operative manipulation of avail in the treatment of certain local hysterical phenomena are considered in a series of eight cases (Cases 514-521). The comparatively long hypnotic series follows: 27 cases (Cases 522-548). The above-mentioned cures by pseudo-operation and by hypnosis may be classified with those that follow, i.e., mainly rapid cures by psychoelectric methods and by suggestion on emergence from anesthesia (Cases 549-574), as modern miracles. These cases of modern miracle are followed by a briefer set of reëducative cases (Cases 575-589).

Throughout the treatment section are scattered instances in which, not a cure, but merely a modification or even a persistence of symptoms was the outcome. It is useful to bear in mind, while reading cases in the etiological and diagnostic sections, these main divisions of treatment into what might be called (1) spontaneous, (2) rapid (or “miraculous”) and (3) slow or reëducative.

107. It is beyond the scope of this book to deal systematically with the hospital and administrative side of these questions. Especially the zone question is of practical importance, that is, the question of arrangements at the front, on evacuation lines, and in the interior. Roussy and Lhermitte have particularly discussed these matters.

After thirty months’ experience in the psychiatric centers of two armies, Damaye suggested an organization of psychiatric centers in two parts,—First, a service draining patients from the firing line, rapidly give them first care and evacuate them, in charge of special attendants, to: Second, a psychiatric or neurological center in the communication zone (étapes) without danger of bombardment and at a distance from the guns. The more serious cases will then be evacuated, thirdly, into the interior from these centers along communication lines. But most will have gotten well at the front.

108. By orthopedists and mechanotherapeutists too much stress may indeed be laid on non-psychiatric measures, as Duprat hints. Yet perhaps neuropsychiatrists may need as much coaching in the opposite direction. One must remember the non-psychopathic fraction of these Shell-shock disorders and their need of diathermy (Babinski). Duprat says that the centers for physiotherapy cannot effectively do the work of all Shell-shock therapy, as the physiotherapists have their aims fixed on nerves and muscles rather than the mind. Each case requiring psychotherapy ought to be studied in an experimental psychological laboratory from a number of points of view such as mechano-motor capacity, the sensibility, emotional and intellectual sides, memory, impulses and the like. Testing apparatus should be available together with dynamometers, sphygmometers, chronoscopes, ergographs, pneumographs, cardiographs and recording apparatus.