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La divina giustizia di qua punge

quell’ Attila che fu flagello in terra.

Divine justice here torments that Attila, who

was a scourge on earth.

Inferno, Canto xii, 133–134.

The data from all the belligerent countries, collected in this book, go far to prove that, whatever at last you elect to term Shell-shock, you must pause to consider whether your putative case is not actually:

A matter of spirochetes?

The response of a subnormal soldier?

An equivalent of epilepsy?

An alcoholic situation?

A result of neurones actually hors de combat?

A state of bodily weakness (perhaps of faiblesse irritable)?

A bit of dementia praecox?

One of the ups and downs of the emotional (affective, cyclothymic) psychoses?

An odd psychopathic reaction in which the response is abnormal not so much by reason of excessive stimulus as by reason of defective power of response?

On a simpler basis, is not our Shell-shocker just a banal example of hysteria, neurasthenia, psychasthenia; and is not this psychoneurotic more peculiar in his capacity to be shocked than are the conditions that purvey the shocks?

Put more concretely in the terms of available tests and criteria, open to the psychiatrist, does not every putative Shell-shock soldier deserve at some stage a blood test for syphilis? Should we not be reasonably sure we are not facing a man inadequate to start with, so far as mental tests avail? Should we not verify (even at considerable expense of time and money by so-called “social service” methods) the facts of epilepsy and epileptic taint? Of alcoholism? And so on? There can be no two answers to these questions.

Upon the following page is a practical grouping of mental diseases, devised in the first place, not for war psychoses, but for the initial sifting of psychopathic hospital cases. Now the psychopathic hospital group of cases constitutes in peace practice the closest analogue of the mental cases met in active military practice, because the “incipient, acute, and curable”[1] cases, for which psychopathic hospitals are built and which flock to or are sent to the wards and outdoor departments of such hospitals, are precisely the cases that early come forward in active military practice. They are precisely the cases in which that pathological event—whatever it is—we know as Shell-shock may be expected to develop. It is precisely the “incipient, acute, and curable” instances of mental disease which we hope to exclude from our American army by cis-Atlantic winnowing-out at the hands of neuropsychiatric experts—the best preventive we hope both of Shell-shock and of other worse mental conditions, if such there be. Military mental practice plainly deals, not so much with frank and committable insanity, as with mental diseases of a medically milder but a militarily far more insidious nature.

[1] Official phrase for the scope of the Psychopathic Hospital, Boston, Massachusetts.

A further inspection of this grouping of mental diseases shows not only that it contains many conditions not usually termed “insanity” (such as, e.g., feeblemindedness, epilepsy, alcoholism, sundry somatic diseases, psychoneuroses), but that these conditions are presented for practical purposes in a certain seemingly arbitrary order. Without attempting to justify this selection of scope (not too wide for modern psychiatry, most would readily acknowledge), I shall draw out a little further what I consider to be the virtues of the order selected. In the first place, all will concede, some order of consideration of collected data is a prime necessity to the tyro. Without an order of consideration the diagnostic tyro is but too apt to find in the best textbooks of psychiatry (even more easily the better the textbook) all he needs to prove that the case in hand is—almost anything he selects to make his case conform to! And how much more dangerous this debating-society method of diagnosis (by choice of a side and matching a textbook type) may become in the fluid and elastic conditions of psychopathic hospital practice, can readily be observed by one who contemplates the formes frustes and entity-sketches that the “incipient, acute, and curable” group of cases presents.