Shell-shock and other neuropsychiatric problems

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.

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.

To clear the decks for action re the differentiation problem, let us dismiss the major troubles of the delimitation problem as shown in groups I (syphilitic), III (epileptic), VI (somatic) and thereafter very briefly refer to the residue of the delimitation problem. For convenience of reference, a few out-standing remarks concerning the general relations of these divisions to war and peace conditions are inserted here. We dealt in the diagnostic order of exclusion with 190 cases, distributed as in the table below (bear in mind that the method of this book precludes attaching great statistical weight to the comparative figures, since the various authors published their cases for their special rather than their typical interest).