CHAPTER V
WAR NEUROSES AS A MEDICO-MILITARY PROBLEM
War neuroses as a medico-military problem present threeimportant aspects for consideration, each of which necessitates some specialnotice.
First, there is the military aspect of the problem. Thisconcerns itself with the important fact that, in most instances, the soldierwith a war neurosis is physically intact and very often in splendid physicalcondition. His symptoms of disease are disturbances due to an intricate physicalmechanism of defense based primarily on the primitive instinct ofself-preservation. He obviously can not be classified as mentally unfit; no morecan he be regarded as physically disabled, yet he is incapable in this state ofacting the part of a soldier. The fact that at times he has only a limited powerof volition over his disability removes him from the class of malingerers. Asmany of these patients have been good soldiers, judgment as to their potentialability for further military life must be suspended. Where to place such anindividual, and what to do with him, are questions that present themselvesimmediately. A soldier physically fit, mentally not affected, in every outwardaspect a good fighting type, not a coward, often wanting to get back to thelines but held in the grip of a mechanism which negatives his soldierlyimpulses, presents a problem that again and again has mystified an officer whohas at heart the best interests of the men under his command. Where the numberof such cases increases to such an extent as to seriously threaten man power,then more than ever do the war neuroses assume the dignity of militaryimportance. Therefore, no statement of the problem of the war neuroses can bemade without considering from the very beginning its military significance. Manyof the errors made in attempting to solve the problems of the war neuroses amongsoldiers might have been avoided if at all times the military point of view hadbeen kept in mind. This point of view might be expressed as the effort towardreturning such a patient to his former status as a soldier with the basicassumption that this is a thing possible to accomplish.
The second aspect is purely clinical. A traumatic incident ora series of them acting on the human organism, causes that organism to respondfunctionally by sets of abnormal reactions which, becoming fixed, stereotyped,and organized as symptoms, gives the picture of disease called war neurosis.Obviously, the thing to do is to classify these appearances into types, todesignate them in some way, differentiate them from similar types seen in otherconditions, and to devise some adequate means by which they can be treated andmanaged. The significant thing is that the war neuroses are essentiallyreactions to the varying incidents of war and that usually there is present aknown set of etiologic factors. There is, further, a varying effect from theetiologic incident, and a therapeutic aim, which has as its chief incentive thereturn of the subject of war neurosis back to the conditions which, in the firstinstance, caused them to appear.
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The third phase of the statement of the problem is thedefinition of mechanism. For it is necessary to know something of the processeswhich activate the clinical syndrome, as the surface symptoms are more a resultof this deeper-lying, but not readily understood process. These must first beappreciated before anything really tangible can be done for the victims of warneurosis. Incidentally, it is this emphasis upon the underlying mechanism andnot on symptomatic expressions, this apparent indifference, in fact, to specificsymptomatology, which differentiates war neurosis from almost every otherclinical problem.
MECHANISM AND CLINICAL EXPRESSIONS
The conception of war neurosis as a defensive mechanism oras a part of a system of physiologic or bodily conservation may be approachedwith less difficulty if it is made clear just what is implied by these terms. Itis necessary, also, to appreciate the fact that the defense meant here is notconscious, but automatic and probably altogether outside of volition.
There exist in all living organisms, sets of factors whichwork toward saving them from destruction. There exists, likewise, in eachimportant function of that organism, a mechanism for preventing the functionfrom becoming excessive and for preventing injury to it as a whole or to itsrespective elements. Living would be impossible if this did not exist. Theprotection may be purely automatic and adjustable to mechanical factors, as, forinstance, the hypertrophy of the heart. It may be chemical, as in the immunitydefense. It may be various combinations and mixtures in which polyglandularactivities come into play. It may be physiologic in respect to functionaladjustments and physical when deeper and more intricate activities ofconsciousness are at work. The latter may be termed physiologic, but forconvenience it is better to consider it a definite psychogenic mechanism.
This principle of organic defense appears to be fundamental,touching on the innermost principles of living things. Naturally this principlehas long been recognized and, by whatever term it has been designated, it hasbeen an admitted fact to be considered always in the attempts to understand thephenomena of life. When the mechanism of defense, whatever its nature is,becomes inactive or less efficient, the living organism may be said to approachdestruction, or, if it fails completely, the organism dies. It is possible,perhaps, to divide the defense mechanism into two classes, one acting to preventthe mechanical using up of the living tissue-the wear and tear of themachinery of life-the other acting to resist and modify the exogenous factorsof a destructive kind to which every living thing is ceaselessly exposed. It isobvious that, even if no sharp line of demarkation can be said to separate thesetwo, yet the adjustability of the defense shows, in either instance, adifference in the quality of promptness and speed with which it can be put intoaction. The mechanically incited defensive organization is apt to be slow andcumbersome, taking place gradually according to the progress which the changedconditions of the mechanism itself necessitates, while the other must be capableof meeting quickly and decisively the immediacy of an oncoming event. Therefore,the latter type of defense must possess a certain power of selection oradaptability, because events or experiences are in their very nature dissimilar
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and varied. This seems to be true of the neuroses in general,and of the war neuroses in particular. If they are studied from such point ofview as this they show the characteristics of an exquisitely adjustable andoften complicated piece of psychical machinery, adequately and, in a sense,personally fulfilling the purpose of protecting the individual againstreexperiencing a series of destructive events to which he recently has beenexposed. The analogy between the organically activated or sensitized probablygoes no further than this, and the comparison has served its purpose if the facthas been made clear that the neuroses defensively considered are a part of amechanism so fundamental for the preservation of life, as a physical phenomenon,that their existence can not well be doubted. There is nothing new in thisconception. Freud long ago, and others before him, had seen in the neurosessomething more than a collection of symptoms simulating organic diseases. Manystudents of the neuroses have been impressed with the apparent needlessoveremphasis of symptoms in face of slight degrees of possible determiningfactors, and they must have seen in this, or dimly felt at any rate, that someother incentive was at work than merely processes of reaction on the part of theorganism. It was in this zone of overresponse that the explanation was to befound.
With the appearance, in the early nineties, of Freud's Abwehr-Neurosen,the conception of the neuroses as defense mechanisms began to make slowheadway among the neurologists. To many of them the rest of the Freudianpsychology was not convincing. That conception, however, was so helpful andclarifying that it gained the support and belief of many to whom anything elsecoming from that school would not have been acceptable.
The war neuroses have given the opportunity to test out thisaspect of the Freudian psychology by furnishing thousands of cases in which awell known, and more or less constant, etiology was always to be found, and inwhich the resulting reactions might be studied, divorced completely from thecloud of etiologic sexual entanglements which so confuse the attempt tounderstand the peace neuroses.
With this conception of the neuroses in mind there remains tostudy them as they show themselves clinically in varied disease pictures, and toattempt to understand what these pictures mean and how they came about. The testof the accuracy of this conception is to be found in the light that it can throwon origins and mechanisms and the use that can be made of it in appreciating whythe thing has happened. A further test will be shown if the facility by whichsymptoms can be treated and the patient restored to the condition he was inbefore is increased. The war neuroses show themselves clinically in a variety ofconfusing types. Classification seems almost impossible because the samesymptoms are represented by types that are obviously distinct. In a group of ahundred acute cases, for example, there will be many symptomatic types, such asfrank hysterias, anxiety groups, pure sensory disassociation forms, individualover-reactions, concussion forms, episodal and transient mental states.
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Two ways are open in facing so complex a clinicaldemonstration. The first is to regard classification as of little consequence,but merely to find some few labels grossly descriptive of large groups and thento think of them as a whole and approach the therapeutic task by some mass formof treatment. The other way is to attempt a grouping, not based on clinicalappearances alone, but on mechanism and the most immediate of the etiologicfactors concerned. The former method has been adopted by most of the English andFrench neurologists. It has a certain advantage, chiefly in the avoidance ofintimate study of individual types, and in supplying a ready means of avoidingdifficult and controversial questions in regard to terminology. For example, itwould be perfectly feasible to say that all war neuroses belong to one of twogroups-neurasthenia or hysteria-implying that those showing primary fatigueelements belong to the former, those showing paralyses, sensory anomalies,convulsions, etc., to the latter. A third group might be made up of theconcussion types. Some of the very best therapeutic results have been obtainedby those to whom a further effort seemed useless. It should by no means beinferred because no effort is made to classify or carefully group cases, thatthe work is unworthy of praise.
It seemed, however, in our own experience, that in the longrun the more minutely the cases were studied the more effective the therapeuticmethods became. The first and essential step was to disintegrate the mass intogroups. The smaller groups made easier an intensive study of mechanisms forming,by comparison with other groups, a standard of measurement. Furthermore, thevarious groups which sprang up almost automatically as a result of this tendencyto analyze the material, became centers about which clustered speciallydeveloped therapeutic methods, prognostic experiences, disability classificationquestions and characteristic sets of mechanisms. All of this lent to their studya surprisingly increased amount of interest. A common differential diagnosticlanguage grew up, at first limited to the staff at Base Hospital No. 117, whichlater spread to the forward areas and became, in a measure at any rate, themeans by which neuropsychiatrists could communicate with others about theircases.
Therefore, the attempt to classify or group the war neurosesseems to be justified by the use which was made of the grouping and by theimpulse it gave to a closer scrutiny of individual cases as they fittedthemselves into this or that class. It must be understood that a grouping ofthis kind is of value only if it fulfils the test of utility. If it does not, itdeserves to be given up without further argument. That it did seem to stand thistest, at least in the experience of Base Hospital No. 117, is the reason for itsdescription here.
The following groups were recognized as diagnostic entitiesat Base Hospital No. 117: 1, neurasthenia; 2, psychasthenia; 3, hypochondriasis;4, hysteria; 5, anxiety neurosis; 6, anticipation neurosis; 7, effort syndrome;8, exhaustion; 9, timorousness or state of anxiety; 10, concussion-(a)syndrome, (b) neurosis; 11, gas-(a) syndrome, (b) neurosis;12, malingering.
In order that the mechanism of automatic defense may be setto work, the average soldier must undergo a series of events which tend toweaken what may be roughly and rather inexactly termed his ordinaryself-control. By
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this is meant that he must be put temporarily in a conditionwhere his normal mechanism of inhibition is seriously weakened. By inhibition inthis sense is meant the totality of his power to control the natural exhibitionof the phenomena of fear, terror, nervousness, horror, etc. To this must beadded the positive factor which strengthens the inhibitory impulses-themilitary quality which keeps alive and ever present in consciousness therecently acquired traditions and customs of a soldier. This is an element ofmorale. The mental process by which this is accomplished is suppression orrepression. Inhibition is merely a larger and more physiologic way of expressingit.
The important circumstances which tend to weaken this facultyare: Exhaustion; fatigue (the more chronic phase of exhaustion); and then, insuccession, sleeplessness, lack of food or water, worry, responsibility, andincidents of a particular, horrifying or unaccustomed kind, loneliness,strangeness, ill-treatment, etc. The list of these incidents might be endlesslymultiplied, but enough has been set down to indicate their character. Theimportance of incidents like those mentioned and others of a similar kind liesin the fact that they tend, each of them or in combination, to weaken theindividual and to prepare the way for the reception of the final traumaticincident. They create in the soldier a favoring terrain; they further tend todevelop in him a soil of receptivity, in which the neuroses, given the propersetting, can easily develop, become fixed and chronic. In opposition to these,the soldier, according to his peculiar personal make-up, struggles eitherforcibly or feebly, according to the measure to which he has surrendered himselfto his career as a soldier. Back of all this lies, no doubt, many anemotionally-tinged impulse, leading straight back to his former nonmilitaryexistence. Among these may be mentioned the mass effect of discipline, ormorale, the grip of idealism which led him to offer himself as a fighter, hisexperience with the Army as an antagonist, the memory of killed friends orcomrades, his love for his officers, the honor and reputation of his regiment;all of them or some of them are present in the make-up of every soldier. Theyform the counterflow against the onrush of factors which center about thecondition called fatigue or exhaustion. It is to be noted that in whatever stageof fatigue the soldier now happens to be, he is still in possession ofconsciousness and a knowledge of himself. In no way has he departed from thecondition of a consciously controlled human being. No matter how feebly theinhibitory impulse is asserting itself, it is still to some degree active, andto that extent the soldier is aware of himself as a soldier, perfectlyresponsible and responsive to the demands of his position. It may be argued thatin the extreme stages of fatigue, the condition of automatism may be reached,but even if this were so, its approach is too gradual to permit the neurosisstructure instinctively fortified by the necessity of self-preservation, to takecomplete hold of him. At this stage there comes into play a very important andsignificant psychologic element in fatigue. This is a very unusual and possiblysuddenly developed state of suggestibility. This extraordinary state ofreceptivity not only to outside things, but also to ideas, memories, andemotions of endogenous origin, form, perhaps, the most favoring circumstance forthe development of the neurosis which at this moment is awaiting an opportunityto enmesh the individual in its defensive system.
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From this point on two sets of things may happen. Both ofthem have a precipitating effect and both tend to act in a positive and dynamicfashion equally effective in the production of the first and necessary phase ofa war neurosis. One set of incidents has to do, in a certain proportion ofcases, with the purely mechanical results of a shell explosion in the immediateneighborhood of the soldier by which he is shocked to a greater or less degree,so that there is momentary loss of consciousness, or it may extend over somehours, as the case may be. As a rule, he either falls or is thrown to theground, or wanders about in a confused way, and immediately enters into a statein which conscious inhibition is for the time being totally in abeyance. Theother set of incidents has to do, not with a mechanically working factor, butwith the appearance on the scene of some sudden, unusual or terrifyingexperience which, emotionally overloaded, tends to produce exactly the samecondition.
The question of concussion, around which so much controversyhas arisen, was not an important cause of dispute in the early years of the war.Even as late as 1917 and up to June, 1918, the most common etiologic factor in acase of war neurosis was that of shell explosion and the resulting concussion,but, as the fighting on the Western Front began to open up, the importance ofthis factor tended to lessen, though not enough to make it take a secondaryplace in the list of causative moments. In the earlier days of the war theexplosive incident was often combined with a burial experience; that is, thesoldier was not only thrown in the air but was covered with trench d?bris of allkinds, the two forming a twin traumatic incident which often had importantconsequences in the symptomatic sequence which followed. In the experience ofthe American Expeditionary Forces burial incidents were infrequent, a fact whichdecreased by so much the emotionally laden incident, which later became one ofthe most important of the fixation mechanisms.
The very constant reports in a soldier's history, as givenby himself, of a shell explosion experience led the British Expeditionary Forcemedical service to inquire more exactly into its accuracy. For a time shellshock could be diagnosed only if there was documental evidence by witness of ashell explosion near enough to a soldier to produce a concussion effect. In someinstances the soldier's recollection of what happened was not supported by thereports that came from the front. How large the error finally turned out to beis not known, but that the doubt was sufficiently important to warrant theeffort of investigation is of importance here. No attempt, as far as is known,was made in the American Expeditionary Forces to obtain exact statistics on thissubject, and all that can be relied on is the account given by the soldier asfar as he could remember, and on the symptomatic sequence of events which hepresented. These, as a rule, are unmistakable and can scarcely be imagined bythe average soldier. Whatever may be the percentage of shell concussionexperiences in cases of war neuroses, concussion still remains, in a largeseries of cases, the most important of the immediately working traumaticincidents. It was so important a factor that at one time concussion and itsresultant neuroses became from a percentage point of view a very important,perhaps, all things considered, the most important group in the entireclassification.
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Whatever the immediate factor may be, a period ofunconsciousness, confusion, or a dazed condition appears to be one of the mostsignificant and almost necessary preliminary states favoring the development ofa neurosis. Such a condition offers to the protective mechanism the opportunityto work, unaffected by the ordinary control of the touch with reality, which isimplied when consciousness remains undisturbed. It is true that a neurosis candevelop without an intermediary state, but in these instances the mechanism atwork is of a much slower and more complicated kind, leading to approximately theidentical condition through endogenous processes largely activated by emotionalhyperreactions, breaking through consciously acting repression.
Considered as a process, and nothing else, evidently a stateis reached by the soldier going into a neurosis when, for the time being, hisconscious control is weakened or lost; at that period the instinctive reactiontakes possession of him, and, uncontrolled by anything that he can at thatmoment interpose to counteract it, opens the way for the self-preservationinstinct to obtain its fullest influence. At any rate, he remains under itscontrol until one of two things happens: One leads back directly to therestoration of himself in his soldier capacity, in which instance no neurosisdevelops; the other, further and further away from his normal soldier self intosomething totally unlike and alien to the thing that he was, and then he beginsto show one of the many types of the war neurosis.
In the course of this process another important element inthe mechanism comes into play, especially during the period of transportation toa hospital and in the early days of the soldier's stay there. The process bywhich the initial symptoms become either temporarily fixed or tend to furtherelaboration has been described by various terms, none of them very satisfying.What happens is that there is given an opportunity for more completeconcentration and introspection, so that the individual removed from contactwith his accustomed environment and away from the external influences ofmilitary discipline, easily surrenders himself to his neurosis, whichautomatically tends to further elaboration and intensification of symptoms. Ifthis is not counteracted by intensive medical intervention skillfully planned,and, above all, promptly put into effect, the war-neurosis subject falls underthe complete sway of his neurosis and the picture becomes wholly that of awell-developed and chronic type. That there is more at work in this stage thanpure automatism and unconscious impulses must be admitted. That there graduallydevelops a fairly active desire not to get well, but to remain in the apparentlysafe grip of the neurosis instead of facing a return to conditions which led toits production, seems also evident. There are seen here also the beginnings ofanother process, that is, a struggle between the innate desire to return as asoldier and the automatic persistence of the preservative tendency previouslyalluded to. Cases left untreated, neglected, or contemptuously handled rapidlydevelop into this state, and as a result form the most difficult subjects forsubsequent treatment.
Before venturing to classify these cases, or rather to labelthem when grouped, it was necessary to redefine such terms as had been usedbefore and to define the terms that were new. This implied in some instances arather new, or at least a novel point of view, and a departure from some of thecherished
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landmarks of our old neurology. Two factors necessarilyinfluenced all the conceptions in classification. One was that the war neuroseswere essentially war-born conditions, and that etiologic incidents were allcolored by this fact. The other was the conception of the defensive orprotective character of the neuroses frequently referred to in this chapter. Aclassification which implies a theory may seem artificial and dogmatic andapplicable only to a limited series of differing conditions. This and otherobjections more vital might be advanced. For example, this classification isconfusing because three things are considered in the grouping and given unequalprominence: Etiologic traumatic incidence; symtomatic expression; and what mayappear at first sight to be an arbitrary selection of psychologic mechanisms.
It appears necessary to point out these defects for thereason that classifications are so often the objects of needless controversy andtoo much emphasis is often placed on them-an emphasis by no means justified inthis instance when the modest origin of these attempts is considered. If thisattempt at grouping, then, served the purpose of usefulness, it might take itsplace as a pragmatic constituent of the work done at Base Hospital No. 117.
There is a condition to which much that has been describedabove does not apply. It is mentioned here because it occurs very largely in theofficer class, and may or may not have as an etiologic factor the acutetraumatic incidents seen so frequently in the soldier types. The anxietyneurosis has a mechanism which is more complicated than the other neuroses andin which the defensive element is obscured by the presence of an intense andpersistent conflict. This conflict has its origin in the necessity, which anofficer at all times is conscious of, to conceal from the men under him and fromhimself too, every evidence of emotional stress he may be passing through. Thishe does by the use of repression. The repressed material of his experiences,notably those in which emotional loading is strongly present, activate theconflict between his desire to maintain and follow the tradition and training ofan officer and the strongly intrenched but completely unacknowledged instinct tosave himself. The essential difference between his reaction to the sequence oftraumatizing events, just described, and that existing in the case of thesoldier, lies chiefly in the fact that there is an ethical element at work whichintensifies the conflict and causes him, in many instances, a great degree ofmental distress, suffering, and self-accusation. This produces the state ofanxiousness which is sometimes the chief and often the only evidence, externallyat least, of his neurosis.
It is not to be inferred from this that only the officerclass can be afflicted with this type of neurosis. Any soldier, especially oneof some education or in whom there exists a well-developed ethical sense capableof introspective attention, may show this type of neurosis.
The anxiety type of neurosis presents a much more highlydeveloped, pure, psychologic defense than the other forms. Its relation tophysical factors is often much more difficult to demonstrate. In fact, it isoften found developing after a rather long sequence of physically acting traumasshowing markedly insidious progress and evidently originating from insignificantand not easily demonstrable beginnings. Its defensive character is chiefly inthe fact that it renders the officer incapable of positive action, reducing himto a state
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of neutrality. In this condition he becomes, one might almostsay, the prisoner of his conflict and remains inert, without energy, withoutinitiative, controlled almost wholly by the emotional stress engendered by theconflict going on within him. He is frequently unaware that such a conflict ispresent, the repressing mechanism working automatically to keep out of hiswaking consciousness all evidence of a thing of this sort. What he is aware of,and that very acutely, is his own mental distress and the physical expression ofthe emotional strain he is under. These external signs of fear, worry, etc., aredissociated in his own consciousness from the sources to which they owe theirorigin, and he is thus as much a puzzle and mystery to himself as he is often tothe neurologist under whose care he may happen to be.
Several bits of qualification must be added to much of whathas been written in this attempt to state the clinical problem of the neurosisfrom the point of view of its underlying mechanisms. It is necessary toappreciate the fact that in trying to trace the sequence of happenings which asoldier passes through on his way to a neurosis an average of such experienceswas recorded, something that might be accepted as a plan of a physiologicexperiment if the soldier could be made into a laboratory problem. There is nothought of making this entirely applicable to every case of war neuroses, or, infact, is it certain that anyone ever passes through just the things that weredescribed. Of all things in the world the war neurosis lends itself least todogmatic statements, but what has been set down appears to be a reasonableexplanation based on an analysis of many hundreds of cases.
The expression "his neurosis" has been usedfrequently in this chapter. The purpose of this was to hint at the very personalcharacter of these defense systems, and any serious study of such cases willshow the interesting fact that to each war neurosis subject the symptoms dobecome personalized, unique, and individual. Thus in attempting to describe themexpressions having the touch of ownership appear to be warranted.
The clinical problem of war neuroses, then, may be summarizedin some such way as this: There is a set of determining factors sensitizing theindividual to one of or the set of direct causative incidents. These, as awhole, are capable of being set down in the order of their assumed importance.The immediately determining factor has a definite traumatic quality, eithermechanical, as in the case of shell explosions, or emotionally directive, as inthe case of unusual or terrifying experiences. A certain degree of initialdisturbance of consciousness appears to be either necessary or a very favoringcircumstance for the development of the neurosis structure itself. Thedisturbance may be anything from a slightly dazed condition, associated withsome degree of confusion, to complete loss of consciousness lasting severalhours. Associated with the disturbance of consciousness there develops somedegree of automatism, or a stage in which conscious inhibition is so lost orweakened that the individual becomes a primitive organism reacting to theprimitive processes of instincts. In this state the instinct ofself-preservation asserts itself. Instead of instinctive flight or concealmenttaking place, a manifestly impossible condition in most instances, theredevelops the manifestation of various forms of the neuroses which replace them.These take such form as may be modified
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by the peculiar circumstances in which the individual findshimself at that time and also according to his make-up. From the temporaryfixation of symptoms the rest of the clinical manifestations of the neurosistend to unroll themselves, influenced by the peculiar mechanism which was thenset in action. The neurosis tends to elaborate, become fixed and stereotypedafter the initial stage according to the individual experience of the soldier,his surroundings, the kind of hospital he may be in, the character of hismedical treatment, the attitude of his nurses and doctors toward him, and othercircumstances of a similar kind. At first the neurosis is entirely automatic,the product of a mechanism entirely out of the control of the individual. Later,there enters into the problem some measure of responsibility for the furthermaintenance of the neuroses. At this place in its development a cure must beeffected, if the patient is to be restored to his former condition.
As was previously stated, the attempt to classify such casesas came to Base Hospital No. 117-and their number amounted to 3,000-was madefor the purpose of so grouping them that more exact study would be possible, andthat the mechanism underlying their production could be more effectivelyinquired into preparatory to a more direct method of treating them. It wasapparent almost from the start that there were cases that seemed to correspondalmost exactly to types met with in civilian neuroses and to these the termscommonly used there could be applied.
What appeared to be necessary, however, was a new definitionto meet the conditions which the stress and strain of war implied so that thedesignation, war neuroses, might be justified.
NEURASTHENIA
There was a group of cases in which the chief evidence ofdisease was a manifest and intense condition of fatigue, the chief neurosiselement of which was a marked subjective sensation of tiredness. Fatigue was anessential accompaniment of all muscular and mental effort, as it was of allspecial sense activities. In such cases it was possible to demonstrate thepresence of a fatigue reaction, which can briefly be described as anoverresponse to a minimal stimulus, or rather an overeffect to the resultant ofa minimal stimulus. To such cases it seemed that the designation neurastheniamight be given. In this group, a very small one by the way, all the presentingsymptoms were interpreted and analyzed as depending on the factor of fatigue,and this factor was amplified further by its subjective incidence. In otherwords, the primary experience was carried over into the neuroses as a fixed andpowerfully acting preventive toward any moderate muscular or mental effort. Theemotional background secondarily produced was that of a state of simpledepression, with a concomitant fact of irritability.
The protective quality of a state such as this is clearlyevident and needs no further emphasis. Such patients presented all thesymptomatic evidences of a typical neurasthenic of civilian life, with thisdifference-they did not show the physical appearances so commonly met with inthe usual neurasthenic types. When they did it was certain they were not warneuroses alone, but the development of war neuroses on conditions that hadexisted prior to enlistment.
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Two types could then be recognized: (1) A neurastheniadiffering in no important way from the neurasthenia of civil life, and (2) anacute, acquired neurasthenia-that is, a definite clinical variety of warneurosis. The distinction became the more obvious when it was noted that theacute cases presented few, if any, of the organic characteristics of the oldneurasthenia, very few of the vasomotor disturbances, such as sleeplessness andcardiac irritability. Some of the extreme cases eventually did, but as a rulethe evidence of neurasthenia was centered rather about the subjective sensationand its controlling power on the patient's activities than on the physicalreaction due to disturbances of an internal kind.
What appeared to determine the presence of the neurasthenictype of war neurosis was the effect of a previous state of exhaustion, an acuteexperience which led to its further elaboration as a neurosis. That out of thiscould and did develop the typical neurasthenia was likewise true. Of all typesof neuroses, perhaps the neurasthenia cases gave the poorest prognosis andresisted treatment most stubbornly. The absence of previous symptoms ofneurasthenia in many of these cases, except the congenital type, led to theattempt to place them in a special class and very quickly they came to berecognized as characteristic but not common clinical pictures. Another part ofthis picture was the fact that there was nothing mysterious to the patient abouthis symptoms, their cause or their significance. No conflict of any kind seemedto develop. Its mechanism was automatic but wholly and completely conscious. Atypical case follows:
A., L. J., pvt., Co. L., 30th Inf. Born inMassachusetts; age, 20 years; race, white; date of admission, August 8, 1918;source, Base Hospital No. 13; occupation, worked in woolen mill, common laborer;alcohol, moderate. Family history: Mother dead-growth on neck; father,alcoholic, quick tempered. Schooling, first year high school. Always in goodhealth; enlisted in August, 1917, at Syracuse until October, Camp Greene, N. C.,until March, 1918; did well in camp. (Started to get dizzy when in a mill, gaveit up and worked on farm, but it did not do any good.) Venereal disease denied.
History of present condition: Arrived inFrance, in April, 1918; to the front in May, 1918. Chateau Thierry, June 6; notunder shell fire until July 14, and was able to carry on for about 11 daysafterwards. Shells at first only made him a little nervous, but he keptconstantly getting worse. Had been working pretty hard, and states had little toeat and drink. Finally while "digging in" amidst heavy barrage lostconsciousness and remembers "coming to" in hospital about five hourslater; here felt weak, dizzy, very shaky, and had pains in eyes.
Subjective symptoms: Condition on admission,heavy headache all the time; gets dizzy; sleeps well, eats well; "getswinded quick." "Not very strong." Not much energy-neurasthenictype?
Objective symptoms: Condition on admission,body clean; temperature and pulse rate normal; weight, normal, 144; present,144. General condition-good; left ear not as good as right; three scars, pale,over left shoulder. Glandular system: Very slight enlargement of thyroid. Heart:No murmurs. Station good; tremors very slight.
Report of disability board, August 20, 1918:Disability did not exist prior to entry into service. Nature of duty recommended-dutyin the line of communications.
Disposition: Duty, Class C-2, August 22, 1918.
Final diagnosis: Psychoneurosis, neurasthenia,L. O. D.
Condition on completion of case: Improved.
Postwar history: In 1919-20, he was working athis old job and was getting along very well. The work was done in a large airyroom and he found it very agreeable. It was the same work he did before the war.
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In August, 1924, he wrote: "Since I camehome, the firm I worked before the service, they havepromoted me to examiner on cloth, which was not my position before entering theservice. I feel nervous at times, but not as much as when I returned. I thinkthat probably my work does it as I am responsible for everything that goesthrough my hands. No diseases or operations since discharge, or before enteringservice. Weight 170 pounds when I returned home; after three months reduced to120 pounds. Stopped work for a while and felt better; weight now is 165 poundsand feeling pretty good."
PSYCHASTHENIA
The second group of cases which early differentiatedthemselves were those in which doubt was a prominent symptom. In such instancesthere was little evidence of fatigue, or not at all after a short period ofrest, or indeed, without it. Such patients were capable of considerable mentaland physical effort, but they complained chiefly of doubt, hesitation, and analmost complete incapacity of choice. To this group, not a very large one, theterm psychasthenia was given, chiefly because the symptoms correspondedaccurately to the psychastenic condition of civilian neuroses. Here two typesbegan to show themselves; one, the typical psychasthenia of other days-thecongenital scrupulous type, the exaggerator of small differences, the individualincapable of making decisions owing to the conflict of differences; fear as aconsequence of choice preventing decision. The type is too well known to warrantany further description in this place. The other was an acquired state similarto this without a previous history of this kind.
If the condition of psychasthenia is reduced to its simplestexpression, incapacity of the function of choice appears to be its primarydeparture from the normal. It is the fear of the consequence of choice throughexperience or through the anticipation of what the choice may bring about, thatcreates the static condition which is the chief characteristic of thepsychasthenic's attitude toward events which tend to focus on him.
The term in Janet's sense seems to have too broad anapplication for the type which develops among the war neuroses. Here it is seenmore as an evidence of the peculiar twist which the neurosis in its defensiveadaptation causes. Perhaps, as is often the case, the type that the neurosisfinally develops into depends on some congenital peculiarity of the individualor on some experiences in his past life, which are awakened and are set againinto activity by the more recent emotionally-tinged traumatic incidents. Anattempt to connect up the acute psychasthenic symptoms in war neuroses withevents long past and forgotten with the purpose of proving this point was notsuccessful.
A case history of a psychasthenic patient is the following:
D. E. R., pvt., Co. D, 101 Ammunition Train,26th Div. Born in Maine; age, 25; race, white; date ofadmission, April 6, 1918, transferred from Base Hospital No. 15; motorman;alcohol, moderate. Family history: Father 45, living and well, moderatelyalcoholic; patient's grandmother 85, had some sort of nervous trouble; uncle,suicide by hanging at 55; father had one attack of nervous trouble at 35; goodrecovery; nature of trouble not known, not nervous now. Left school at 16-2years in high school, good progress; five years motorman at Lynn, Mass.; hadrheumatism at 23, back and legs; pretty healthy; was struck by lightning (orrather schoolhouse was) at 12; scared of thunderstorm since; pretty eventempered; sociable; no especial fears. Was overcome with heat, July, 1917, justafter being called out in Massachusetts; sick 2 weeks; no loss of consciousness.Always easily startled, especially after a hard stretch of work-"jumpy."Always dreamed scary dreams, mostly of fire.
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History of present condition: Enlisted May, 1917; had heatprostration in July (see personal history); came to France October, 1917; wellup to present illness and efficient; present illness, went up the line with the26th Division the beginning of February and carried on normally till March 23 atSoissons; nerves all right till then. Town was shelled and shells were strikingall around; one fell about 50 yards away; patient was not knocked down; he wasscared and commenced to shake all over; after this, appetite and sleep poor;patient was jumpy and trembling and weak. He was accidentally hit on the headwith a rifle about 10 days before and after this shelling his head ached on thehit (left) side of his head; headache better now; easily startled, any noisemakes him jump; spontaneous, jumpy movements came on a day or so later,movements not localized. No change; has been at Base Hospital No. 15 three days;condition about the same. No work from March 23 (date of shelling) up toadmission to Base Hospital No. 15.
Subjective symptoms: 1. "Jumping"-"any noisestartles me and makes me jump." 2. Not much sleep (average 4 to 5 hours). Dreams much ofbombardments (one recurring dream especially, being bombarded in a cellar,patient not hit). Difficulty is in getting to sleep and then wakes with a start.3. Legs getting weak from lack of exercise. 4. Occasional headaches (chieflyleft-sided). Cooperates well in examination, talks in rather quick jerky way.Jumps with small noises. No mood disturbance or outstanding anxiety features.
Objective symptoms: Big chap, 6 feet 2, weight 250 pounds atenlistment, 185 pounds now. Well developed and nourished. Mucous membranes faircolor. He has several dime-sized skin infections on his face and some hairfollicle pimples over his body. Special senses normal. There are frequent,usually several per minute, involuntary twitching movements, small excursion,more marked in neck and shoulder muscles, occasionally in face and legs.Bilateral and tielike. Glands not enlarged; throat clear. Heart not enlarged,sounds normal, pulse 76 regular. Lungs normal, genito-urinary system normal.Pupils active, no especial tremor. Deep reflexes hyperactive. No Babinski. Gait,station, sensation normal.
Diagnosis on transfer card: Psychoneurosis, psychasthenia.
Progress: April 11, patient is easily disturbed by whistlingand chimes; get trembling and jerky; excited last night by excitement of anotherpatient, made threats to "get the ward men." Calmed down and sleptfairly. April 22, loud-mouthed and easily startled. Works fitfully, but gets afair amount done. May 11, 1918, returned to labor duty, class C, to-day. On thewhole, in practically same state as on admission. Works fairly and will beuseful. May get a grip on himself later on, but it is doubtful. Doubtful stufffor the front in any case.
Report of disability board, May 10, 1918: Unfit for full dutybecause of psychoneurosis, psychasthenia. Disability did not exist prior toenlistment and did not originate in the line of duty. Nature of dutyrecommended: That he be placed in class C and used for general labor. Condition,unimproved.
On September 22, 1919, he wrote that he was not working atformer employment. Unable to do anything at present. Feels "prettyrocky." Present condition poor. On July 24, 1924, he wrote that he was sickin bed and under a doctor's care and receiving compensation from theGovernment. He had not worked since his discharge.
HYPOCHONDRIASIS
The next group is the third of the consciously produced neuroses, and to thisthe term hypochondriasis was given because it so exactly fulfilled the conditionon which such a diagnosis would have been made in neuroses in civil practice.This group was also a small one, having the smallest percentage of incidence ofany of the groups. Indeed, it is questionable whether a pure hypochondriasis candevelop de novo from war experiences alone. In almost all cases in which thisdiagnosis was made a previous history of this condition could be discovered.Hypochondriasis is perhaps the most perfect type of a
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defensive neurosis because it touches a fundamental andprimitive tendency found among all peoples; that is, the automatic release fromduty, responsibility, and work in the presence of disability or sickness.
The mechanism consists of two intimately related things.First, there is evidently present in these patients an abnormally low level toreceptive impressions from the external world; that is, the skin and specialsense mechanisms are capable of transmitting a greater bulk and variety ofsensory impressions and having them perceived as impressions, than is foundamong normal individuals. This lowering of the sensory level is also found inthe receptive mechanism having to do with sensations arising from within thebody, probably through the autonomic system. This intensification of the sensorymargin has its chief effect in developing an increased capacity of attention-thehypochondriacal individual has not only a capacity to become aware of a flood ofunusual and strange sensations arising externally and internally, but also hashis capacity of attention sharpened to their perception when received. By thatvery sharpening of attention the facility of final interpretation of suchsensations is increased. He thus becomes aware of a constant inrush of sensoryimpressions which tend more and more to occupy his field of consciousness. Thismass of wrongly interpreted and wholly new and strange sensations is the crudematerial out of which the neurosis is fabricated. This fabrication takes on thepicture of disease which becomes more and more definitely personalized as theprocess goes on. Naturally the experience with, or knowledge of, disease,together with the suggestions obtained from observation, rumor, andsurroundings, influences the variety and dramatic quality of the particulardisease in question. The collection of ideas concerning disease tends to occupymore and more the patient's field of active consciousness so that he livespractically controlled by them. When he responds to a constellation of this kindmore than he can possibly do to the world about him, when his mental life spinseternally about this or that picture of disease, which at all times fills hisfield of consciousness, the complete picture of hypochondriasis may be said tohave developed.
This completed picture should be sharply differentiated fromwhat may be called a hypochondriacal attitude. This latter is very common amongsoldiers, but only as a temporary state which quickly disappears with rest andimprovement. The true case of hypochondriasis shows no change under eithercondition and apparently is uninfluenced by treatment of any kind. It has beensaid that true hypochondriasis is rarely found as an acute or acquired type ofthe war neuroses. This is in a measure true, but it is quite possible for aclinical state closely resembling this to develop on the foundation of a slightand often insignificant or passing trauma or condition, insignificant inproportion to the more dramatic kinds of traumas so frequently mentioned in thischapter. For example, it was sometimes found that a soldier who had beenoperated on previously for appendicitis, under the influence of a series oftraumatizing events, would develop a neurosis of this hypochondriacal type whichappeared to center about the operation or the scar remaining as an evidence ofit. Previous to such an experience the whole appendicitis incident had beencompletely forgotten, but suddenly there developed a complete picture ofpostoperative adhesions, pains, and a widespread area of scar tenderness. Fromsuch a
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beginning the whole picture tended to spread, involvingneighboring organs, until the patient was entirely in the grip of aneverspreading collection of disease ideas. It is of some significance that insuch cases the therapeutic outlook was more encouraging than in the typepreviously mentioned.
It is necessary to emphasize once more that thehypochondriacal tendency is often found entirely dissociated from the trueneurosis, but even in its partly developed form, the essential mechanism asdescribed could easily be demonstrated; that is, the increased capacity forautomatic attention and the lowered threshold of sensory receptivity. Inhypochondriasis, again, the neurosis is consciously determined and thus belongsto the group of which neurasthenia and psychasthenia are members. These three,then, form the first subdivision, the consciously originating neuroses. Thisdoes not at all imply that they are either willfully or designedly produced, butthat they play themselves out in the upper zones of consciousness and awareness.
A case history of this type is the following:
D., H., pvt., Co. K, 109 Inf. Born,Pennsylvania; age, 25; race, white; date of admission, August 11, 1918; service,4 months; team driver, shipyard. Alcohol, total abstainer. Family history:Mother died, cancer of breast; father living and well; 1 brother, stomachtrouble, constipation; maternal aunt, nervous. Previous personal history:Indigestion (chronic constipation).
History of present condition: Inducted, March10; France, April 2; front, July 15; left, July 16. "We were getting readyto make a counterattack. I asked for a drink of water, they handed me a canteen;as I made to get it I fell flat. We were in woods, shells flying prettythick." One burst about 20 feet away, one hit apple tree and knockedpatient down, and dirt flew all around; patient up all right as runner forcaptain. Another man tells of shell exploding right in back of him when hefainted away. This observer says patient was all blue and they thought him dead.Taken to regimental infirmary, then evacuation 6-to Base Hospital No. 30-here.
Subjective symptoms evacuation hospital: 1.Pains in head, also across back and in legs; 2, patient was shaky, legs andarms; 3, sleepless. Now: 1, stomach, gas, belching; constipation; 2, head; 3,can't lie on broad of back or left side because of smothering or punching ofheart; 4, shortness of breath at night; 5, spells of vomiting; patient hadstomach trouble previous to war-probably a severe ease of concussion, delayedseveral hours before overcoming. C., of patient's platoon, says company hadn'teaten for 14 days, been under severe bombardment, patient asked for drink, shelllanded 20 feet away, patient "keeled over," French Red Cross man fixedhim up and C. took him to first-aid station, 100 yards away. Patient wouldn'tlet himself be carried, was in a pretty bad fix; "shell might have scaredhim; he just fainted."
Objective symptoms: Ambulatory. Weight,normal, 133; present, 128. General condition, good; skin and mucous membranes,healthy; blood pressure, 110. Heart: Loud systolic murmur over base.
Diagnosis: Hypochondriasis. Report ofdisability board, September 26, 1918: Disability did not exist prior to entryinto service. L. O. D. Nature of duty recommended: Returnto ordinary duty. Classification A. Condition: Improved.
On December 8, 1919, patient reported thatsince returning from France he had worked for two months but could not keep itup. Not working at present. Has pains in back and chest. Had not put any claimin for disability as yet. A letter received on July 31, 1924, indicated thatthis man had been receiving vocational training ($100 a month) from December,1921, and studying to be a stationary engineer. In January, 1921, he wasoperated upon for gastric ulcer at the Philadelphia Navy Yard. He said that hewas not feeling very well.
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HYSTERIA
By far the most striking of all the war neuroses, clinically,at any rate, is hysteria, as anxiety neurosis is the most subtle and intangible.These two are taken together, in so far as etiology and primary reaction areconcerned, because both represent unconsciously produced neuroses, and both aretypes of a dissociation process. The one shows itself by dissociation of motor,sensory, special sense functions, and in some instances of the function ofmemory; the other, by purely psychical forms. The one-hysteria-showing noevidence of conflict; the other-anxiety neurosis-arising out of a conflictwith a strong moral or ethical component. Hysteria was regarded as being in asense a type of cortical dissociation, very often almost anatomic in itsdemonstration; the other has to do with much deeper and more illusive qualitiesof consciousness touching more closely on the factors concerned in personality.Another striking difference lies in the reaction to therapy. Hysteria was themost easily cured of all the neuroses, anxiety the most difficult. A curious andinteresting point of difference was found in the fact that in hysteria there waslittle relation to pre-war conditions or experiences. In the anxiety neurosisanalysis often led back directly to pre-war conflicts in which the same orsimilar elements could be demonstrated. They did not necessarily give rise to aneurosis then because the repressive mechanism sufficed to tide the patientover, but it was often easy to appreciate how definitely the stage was set, byvirtue of the patient's former experience with conflict processes of lessintense form.
Hysteria, then, is to be considered as a type of war neurosiscaused by the mechanism of dissociation, by which functional activity in eitherits motor, sensory, or physical capacity is blocked from consciousness andconscious control. If an organ of special sense is involved the dissociationprocess tends to separate out one or more of its coordinating functions from thecontrol of the complete mechanism. The part, or parts, in either instancedivorced from consciousness can maintain itself in one of three ways. It cancease to act at all; it can act abnormally, that is, in a qualitative sense; orit can hyperact, that is, in a quantitative sense. In other words, there can beparalysis, uncoordinated or perverse forms of action or convulsive-likemovement. This same thing is found naturally in the sensory and special sensefields. The dissociation process is most frequently set in activity by asomewhat sudden emotional or physical shock and, if in the latter instance, theprecipitating factor is most often the effect of a shell explosion or some typeof trauma associated with some degree of violence. The type of reaction inhysteria in respect to both localization and function bears a definite relationto the local effect of the trauma. Blindness is often the result of the acuteblinding sensation of an explosion, deafness due to momentary loss of hearing.For the same reason, sensory disturbances are due to numbing of areas of skinfollowing disturbance of atmospheric pressure in the zone of an exploding shell,etc. The emotional precipitating factors have the same curious localizingtendency, with the exception that here suggestion or imitation seem to show amore active influence. It is necessary to point out that in hysteria,particularly the acutely established types, is shown less clearly thecharacteristic protective defense than in some other types of neuroses, and itmust be admitted that in some instances it is
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only after the primary disturbance has manifested itself,whatever its nature may be, that the defensive mechanism is set to work and thenchiefly in the direction of fixing it and making it more permanent.
A sudden shock having a positive degree of physical incidencemay throw out of activity a certain function or a part of it, certainly toorapidly for any kind of physical mechanism to be set going. In such instancesthe instinctive action of self-preservation arises later, automatically makingthat loss of function fixed, thus establishing it as a neurosis of the war type.
Such a conception of hysteria is a departure from the usualthinking on this subject and naturally differs essentially from the theory ofBabinski so much in vogue in the literature on war neuroses, but it seemsimpossible to escape from some notion of this sort, in the face of the almostinstant appearance of symptoms after an explosion incident and the tendency tofixation and elaboration of the symptoms following the slow return ofconsciousness. Whatever r?le suggestion plays, it surely can be regarded asonly part of a much more complicated mechanism and not the only factor at work.Among the most interesting phases of hysteria in its war neurosis coloring arethe amnesias, which may be regarded as pure types of dissociation in the purelypsychical sphere, and they obey apparently the same sequential rule as thecruder forms of response. The single and most reliable diagnostic evidence ofhysteria is found in the presence of the dissociation process. When the symptomis capable of being described as due to that, and if it meets the necessaryrequirements of a hysterical symptom, not necessary to mention here, thediagnosis of one of the many forms of hysteria found in the war neuroses can bemade.
Another characteristic of a hysterical symptom is that in itsdisappearance it may pass through any one or a combination of the three formswhich have been described. Complete paralysis often recovering through thephases of tremors, exaggerated movements, etc., aphonias recovering through thephase of stammering, etc. The synthesis with consciousness very often is notdirect and immediate, but indirect and incomplete. Two cases of this group arethe following.
O. C., sgt. Co. F., 362 Inf. Born, Illinois;age, 25; race, white; date of admission, September 10, 1918; source BaseHospital No. 75; farmer; alcohol, moderate. Family history: Father died, Bright's.Mother, stomach trouble; 1 sister, nervous breakdown, 7 years ago. Influenza,1917. Pyemia. Always nervous.
History of present condition: DraftedSeptember, 1917. Overseas, July 5, 1918. Has never been to front. April, 1918,while in hospital for influenza had hysterical attacks occurring 3 to 4 a dayfor 3 to 4 days. No more attacks until rifle practice, after a few strenuousdays again developed and then after coming to France during hand grenadepractice a man in patient's platoon pulled the pin from grenade but became tooexcited to throw it and let it drop, he warned his men and they managed to getaway unhurt. But he became much excited and that night after taps had an attackin which his whole body shook, was nervous and had queer numb sensations overbody, profuse perspiration, was not unconscious, no tongue biting, noincontinence, did not fall.
Subjective symptoms: Complains of pains aroundheart, trembling of entire body. (Soldiers call him ''shakes".) Poorstuff. Hysteria. Class C.
Objective symptoms: Ambulatory. Generalcondition, good; skin and mucous membranes, healthy.
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Diagnosis: Psychoneurosis, hysteria. Report ofdisability board, October 4, 1918: Disability did notexist prior to entry into service. Disability is in line of duty. Nature of dutyrecommended: Labor in the line of communication.
Disposition: Class C-1.
Final diagnosis: Psychoneurosis, hysteria.
On December 13, 1919, he wrote that he hadimproved wonderfully in the last three weeks. Not working as yet, as he wasdischarged only a short time ago, but plans to do so in a short time. Is to begiven a chance at his old work. Feeling quite well and has had a very good rest.Just came back from farm where he got back into shape. In the summer of 1924, hewrote that he was still nervous in time of excitement or exertion, but otherwise,normal except for "pains around the heart at times." He was working asan indexer of crankshafts and making 50 cents per hour. He received compensationof $20 a month for eight months. This was cut to $8 for three months.
B., F. E., corpl., Co. I, 102 Inf. Age, 19years; race, white; born, Connecticut; date of admission, June 15, 1918;transferred from Base Hospital No. 1. Accountant; alcohol, moderate. Familyhistory: Father, 42, gets tired very easily; very nervous temperament;excitable; two paternal aunts nervous; one has St. Vitus's dance; another wasparalyzed in an arm and again in a leg-all cleared up. Previous personalhistory: Left school, 17; had two years at high school and two years atagricultural school; pneumonia, twice; grip, likely; last attack, 1916; followedby 3 weeks of pain in back, similar to present; no neuropathic history; variablemood.
History of present disease: Came to FranceOctober, 1917. Was not up in Soissons in February. Was in hospital with pains inright abdomen. (Old appendix, 1915, operation.) Went up to Toul with 26thDivision, April 1. "Not at all nervous." Was on duty until April 21;all right except for diarrhea, which was getting worse (began in January). Wassent down from the line because of "exhaustion"-poor sleep; stomachupset because of diarrhea, and he couldn't eat. Says he was knocked down by ashell on the above date, but he kept on running; was paralyzed after; shakinessdeveloped later in hospital; weakness was most striking thing; feels better now;pain in back came on in bed at Base Hospital No. 18.
Subjective symptoms: Present complaints-1,diarrhea, 1 to 5 times a day; some abdominal pain before stool; bowels loose; noblood; bowels apt to move at any time during day; 2, pain in back-comes andgoes; 3, some pains around old appendix operation; 4, flat feet; sleeps allright; appetite all right; composed. Tells glibly how his abdominal adhesionswere turned down by the S. C. D. Board. Says he wants to rejoin his outfit.Possible class A. Rather juvenile, bumptious type. " Will it be long beforeI can go back to duty?" (hopefully).
Objective symptoms: Body, clean; weight,normal, 165; present, normal. General condition: Well nourished and husky.Glandular system: Slight exopthalmos; positive von Graefe. Vascular system:Pulse 88, regular. Good looking appendix operation scar; nothing objective madeout of abdomen. Nervous system: Coarse finger tremor not marked. Diagnosis-transfercard: 1, psychasthenia; 2, spondylitis, chronic, 8th and 9th dorsal vertebr?.
Diagnosis of ward surgeon: 1, psychoneurosis,hysteria, line of duty; 2, spondylitis, chronic, 8th and 9th dorsal vertebr?,existed prior to entry into service, not L. O. D.
Progress: July 3, 1918, apparently recovered,except a slight recurrent pain in back.
Disposition: Returned to duty, class A, July,1918.
Final diagnosis: Psychoneurosis, hysteria,line of duty; 2, spondylitis chronic, 8th and 9th dorsal vertebr?, existedprior to entry into service, not in line of duty.
Condition on completion of case, cured.
On September 20, 1919, he stated that he was acost accountant before enlisting. Expects to take position in same work. Hishealth is excellent but exceptional loud noises, such as a band, a blast, afactory whistle, a passing train, or particularly a thunderstorm will set hisnerves aquiver for periods ranging from five minutes to three hours. Is tryinggradually to gain control of himself and thinks he will succeed.
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On July 22, 1924, he wrote:
I am feeling fair only. I am very nervous butthrough power of will am able to keep it in check with the exception of organictrouble. For several months I have been troubled with stomach trouble and myphysician lays the blame to nervousness wholly. Of the old troubles, my worstday of the year is the 4th of July and secondly those in which thunderstormsoccur.
I am very strong physically, being 5 feet 7inches in height and weighing 180 pounds, but this does not keep me from tiringeasily. I can stand only a small amount of manual labor and my other labors mustnot be too monotonous if I am to work the whole day at the same job. Exercise inthe form of games does not tire me and gives me the sleep which I would not getotherwise.
ANXIETY NEUROSIS
It is in anxiety neurosis that the most complete example ofpsychical dissociation is met with, that is, a dissociation unaccompanied byanatomically expressed loss of function. Anxiety neurosis has to do with a moregeneral process and reaches down more deeply into personality than the moresuperficially located mechanism seen in hysteria. Something of the etiology andthe primary reaction has already been touched on in the consideration ofhysteria above. There remains to describe progress and final clinical results.The subject of an anxiety neurosis must be thought of as an individual in whomthe repression faculty is well developed. This may come about as a personalcharacteristic, or it may be due to the position of authority given by hismilitary status. Naturally the officer falls most easily into this class and itis in the officer class that the majority of instances of anxiety neurosis arefound. Next would come certain types of the noncommissioned officers, chieflysuch as have received their commissions recently, and then soldiers who byvirtue of education and the development of higher standards are inclined toreact easily to ethical considerations. While this may be the general type whichdevelops this form of neurosis, there are always found exceptions whichapparently do not fit into the conditions as set down. Such exceptions areprobably insufficiently studied or understood.
In the typical case-for the purposes and necessary limitsof this discussion only such can be considered-there is present, almost fromthe beginning, the essential elements of the mechanism of an anxiety neurosis.These are conflict, repression, not only of the memory of the experiencesthemselves, but also of the expression of the emotional reaction associated withthem, and a certain degree of what may be called the ethical point of view inthe presence of the antagonism between what is regarded as the right thing to doand the natural innate tendency toward self-preservation. These, of course, formonly the basic groundwork of the process, indicating enough of the mechanism towarrant grouping these cases in a class by themselves.
In almost all instances an officer very early in his career,very likely even in the training camp, feels the necessity of repressing hisdislike or objections to discipline, obedience, authority, and many of the otheressential phases of military life. His repressive mechanism not only has to dowith the ideas themselves, but also with the external evidence of his attitudetoward them; that is, his conduct must depart in no way from the correctmilitary form. For these, and indeed for most of the experiences associated withactual combat duty, the repressive function is amply sufficient to keep theofficer from ever approaching the territory of the neuroses.
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The repression faculty has a well-known tendency to becomeautomatic and to act entirely without the intention of the individual. As theofficer advances in his training as military life grips him more and moreintensely, and as military discipline forms him into a silent part of the bigarmy machine, he is less and less in need of any active manifestation on hispart of this faculty or repression which was so much a part of the mentaldiscipline of the earlier days of his training. It must not be forgotten that inthe American Expeditionary Forces the professional class of officers wasnecessarily a small one and that most of the nonprofessional officers were takenout of civilian pursuits of various kinds in which no trace of militaryatmosphere, and certainly none of active combatant duty, were to be found.Therefore, there was no important set of military or officer traditions to whichthe future officer had long ago accustomed himself.
Therefore, it should be appreciated that in our Army thetraditions of of conduct in general, and particularly those associated withactive military life, had been very recently acquired, so recently that theywere only superficially grafted on the officer's personality. There was need,then, to exercise, whether consciously or not, that form of inhibition calledrepression in order to maintain such traditions under circumstances ofdifficulty. This was especially necessary when the officer met front-lineconditions, for the first time, when he had not only himself to keep in hand,but also the added responsibility of men under him for whose fortunes in thestress of trench or open warfare he held himself in a measure responsible. Inaddition to this he realized that the technical side of his profession, a mostdifficult and intricate thing, was also but recently and often most laboriouslyacquired and had now to withstand the actual and often bitter test of realcombatant conditions. Notwithstanding these heavy burdens, very few officers, itmust be acknowledged, even under the adverse conditions associated withfront-line duty, developed neuroses. Those who did had to face peculiar sets ofcircumstances which tended to break down the inhibitory processes which heldthem together in their capacity as leaders of men. Under the strain of fatigue,exhaustion, worry, and some of the many incidents that have been before alludedto, and as a result of shell explosion with a concussion sequence, the facultyof conscious inhibition was temporarily lost and the officer acted for the timebeing as a primitive instinctive piece of human machinery and during the periodof semi-automatism, confusion, or haze, the beginning of the neurosis of theanxiety type was laid. If some of these things did not happen in an acutemanner, then a series of smaller and less important incidents brought theofficer in exactly the same condition.
From this time on, the conflict began to assert itself,coupled with the dormant repressive tendencies, which again came into activityas the reality of the situation became more and more apparent. It is thisantagonistic relation of conflict to repression that tends toward the separationof emotion from experience. This supplies the mechanism of dissociation alludedto before. There results then the clinical picture of a state of intense anxietywith the external evidences in the way of facial expression, depression, apathy,loss of sleep, dreams, and even the objective appearance of fear, tremor, rapidpulse, vasomotor reactions, in the face of the complete unawareness and lack ofunderstanding on the part of the patient, of what really is at the basis of hisdiscomfort.
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The battle experiences repressed and in a sense partiallyforgotten, tend to express themselves by freeing their emotional content or byspinning themselves out in dramatic and terrifying dreams. There is present,then, the evidence of fear, and even terror, without being related to eitheractual experiences themselves or even to the actual memories of suchexperiences. In this state there develops a series of conflicts which must beregarded as being hardly conscious in some instances and wholly so in others.These seem to have been the more usual: (1) The conflict between the desire togo back to the front and the negative desire or wish for self-preservation. (2)The conflict arising between tradition and training of an officer and the desireto escape front line conditions. (3) The conflict between the desire to avoidthe dangers and discomforts of the front, and previous ideas of duty, valor,etc., and family, social, personal, and class standards. (4) Conflict betweenthe desire to escape and the feeling of inadequacy, in a military sense, of theresponsibility of an officer in command of men. (5) Conflict between the impulseto go forward and the wish, expressed or not, to go back to former conditions inthe United States. (6) Conflicts which had reference to events or similar typesof conflict in pre-war experience.
Naturally there are many other kinds of conflicts, but thesewere so common in the cases seen in Base Hospital No. 117, that some of themwere predicted in certain individuals and were actually found to be present.
Enough has been said of anxiety neurosis to indicate at leastwhat is believed to be its fundamental mechanism, and to establish the fact thatsuch a group of cases exists characterized by this mechanism. A case historyillustrating this condition follows:
A. P., pvt., Co. 95, 6th U. S. M. C. Age, 19;race, white; service, 1 year; date of admission, July 11, 1918; source ofadmission, transfer Base Hospital No. 17; born, New York; mechanic; abstainer.Family history: Mother and sister had had "nervous breakdowns." Noalcoholism; paternal uncle insane. Exanthemata. High school: Normal progress.Had headaches relieved by glasses; formerly somnambulist; afraid ofthunderstorms until 14.
History of present disease: Enlisted June,1917; France September, 1917. While in training camp did not like theinstructors, but was not unhappy and not sorry he enlisted. After coming toFrance he liked it. Went into front line during March and April. Shelling didnot bother him. Shelling was constant, "but it didn't amount to muchbecause we had dugouts." During May was in rear. Became rather disgustedwith excessive drilling; thought his outfit should have been given rest. Wentinto front lines at Chateau Thierry in June and welcomed the opportunity ofgetting some open warfare. For first four days he rather enjoyed it and althoughunder shell fire and seeing a goodly number of casualties, he was not consciousof any fear, merely wondered whether one of the shells would "gethim." June 5, his company advanced under fire to relieve French. He sawmany French dead, with heads shot off and others staring at him. He was detailedto assist in burial. This disgusted and horrified him because he never couldbear to touch a corpse. He then began to realize for the first time what shellfire was. For several nights he could not sleep because the dead Frenchmen wouldbe constantly before him. At the same time shells began to terrify him. He beganto tremble under fire but tried to conceal his fear and to carry on. Hiscondition was exaggerated by the fact that his own artillery was not workingvery efficiently. June 14, while under heavy shelling in open, and afterposition of company had been changed several times, he began to tremble, becameweak and had to go to dressing station. He quieted down as soon as he was inquiet hospital. For first few weeks had terrifying dreams. Dreams have beenabsent for weeks.
Subjective symptoms: Condition on admission-Sayshe feels fine now. Knows that he will not continue to feel so well if kept inhospital. Other patients make him nervous.
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They shake and jump at every little noise. He says he wasalways unable to look at people who were shaking, or to listen to people whowere stammering. Does not think that he is unusually susceptible just atpresent. Wants to go back to company.
Objective symptoms: Condition on admission-Good.Weight, normal, 150. General condition good. Diagnosis on transfer card: Anxietyneurosis. Diagnosis of ward surgeon: Anxiety neurosis (mild). Any duty in line ofcommunication for at least two months.
Disposition: Class B-1.
Final diagnosis: Psychoneurosis, anxiety form,mild, L. O. D.
Condition: Improved.
On October 1, 1919, he stated he was notworking at all at present. Upon discharge he started to drive a truck but couldnot continue to do so. He saw a doctor who ordered him to be quiet and do nowork until he gave him permission. He says he is all right mentally.
On January 5, 1920, he wrote that he hadreceived $7.50 a month compensation, and that he was in the same condition hewas in except rheumatism bothers him more and more.
In the summer of 1924 he wrote that he was ateacher of industrial subjects receiving $2,200 for 10 months. He said:
I feel pretty good but can not stand anysudden and loud noises as on July 4. My breathing bothers me quite a bit.
The United States Government gave me atwo-year teacher training course at Buffalo State Normal under the Veterans'Rehabilitation Board; also compensation at $13.50 per month at present.
ANTICIPATION NEUROSES
The anticipation neuroses were so named because theyrepresented reactions not to actual experiences in battle but to theanticipation of such experiences. The neuroses, therefore, acted not asprotections against the repetition of events already lived through, but asprotection against initially experiencing them. As a whole, they probably werepatients who had shown symptoms of the neuroses in training camps at home, themanifestation of which had most completely developed. On the way over or afterthey reached the concentration camps in France, the symptoms became manifestagain, and under the spur of immediacy rapidly took on the characteristics of awell-defined neurosis picture. The anticipation group was never a very large oneand rapidly declined after active fighting began. Since they formed less than 10per cent of the total material, evidently most of them were excluded by theneurological examinations made in the home training camps. Any of the clinicaltypes of neurosis could be found in the anticipation group. This appeared toshow that the memory of a past experience, imitation, suggestion, rumor-ifemotionally intensified sufficiently-could arouse, in given instances, thedefensive instincts to take the form of a neurosis, in the presence of asufficient degree of receptivity and expectancy on the part of the individual.
The anticipation neuroses are not war neuroses in the narrowmeaning of the term, but it was found necessary to include it in aclassification and to place in it such cases as had never been at the front, aswell as a few patients who developed the attitude of anticipation towardreexperiencing former experiences. They reacted similarly to the group for whomthe anticipation neuroses were at first devised. The history of such a case, asfell automatically in the latter group, is as follows:
G., A. F., pvt., Co. 2, Trench M. B. Born,Illinois; age, 23 years; race, white; date of admission, July 25, 1918; source,Base Hospital No. 6; drove mule in mine, $3.19 per day; alcohol, moderate;finished fifth grade at 14; at 15 began working in mines and has continued eversince. Always healthy. Enlisted March 29, 1916, Jefferson Barracks; went to ElPaso (15 months), then to Gettysburg, Pa., 7 months.
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History of present condition: Came to France January 8, 1918.Went to the front March 12, 1918, Verdun, then to Chateau Thierry in May. Wasnever afraid when shells broke around him, but rather enjoyed them; had neverbeen in hospital. On June 29, 1918, at 11.30 p. m., several shells burst near,and finally one burst and killed two men and wounded two others. Jumped up andstarted running toward woods and fell in ravine. Began to shake all over; kneweverything that was going on around him, but couldn't control his nerves. Fromfield hospital went to Base Hospital No. 6, July 3, 1918, until coming here.
Subjective symptoms: 1. "Nervous, shake all over, anylittle noise, can't stand it." 2. "Never afraid of anything, but nowwhenever anything drops I jump." 3. "Short of breath, sometimes I can'tbreathe." 4. "Can't sleep well, the least little noise wakes meup." Appetite good.
Objective symptoms: Body clean; weight, normal, 168, present,158; general condition good; blood pressure, systolic 125, diastolic 95; hearttachycardia 94; abdomen, slight protrusions due to muscle weakness over eachinguinal region; nervous system, quite marked general bodily tremors; pupils,regular, good reaction; knee jerks, slightly increased; osseous system, slightlateral curvature of spine to left about 10-12. Diagnosis on transfer card:Psychoneurosis of war.
Report of disability board, August 24, 1918: Nature ofdisability-psychoneurosis, anticipation neurosis; disability did not existprior to enlistment in service; disability is in line of duty; classificationB-2; condition, improved; nature of duty recommended, labor in the lines ofcommunication.
On September 20, 1919, he wrote that he was back at home andat work as a salesman. He was feeling fine and doing well. On July 22, 1924, hewrote that he was working in a paper mill, salary 40 cents per hour. He wasfeeling fairly well, though a little nervous sometimes. He was receivingcompensation at the rate of $9 per months at the time of writing.
EFFORT SYNDROME
Very little will be said about the effort syndrome in thisplace. So much has been written about this condition and there is still so muchcontroversy on the subject that nothing can be added toward clearing it up fromthe point of view of its place in a list of war neurosis types. It was commonenough in the material at Base Hospital No. 117, and formed so distinct apicture that it was one of the most easily classified. From the point of view ofits defensive quality it is a typical neurosis, associated with the exhaustiontypes, but has a more definite localizing quality. It frequently followed gaspoisoning, being the most persistent perhaps of its after effects. Its closeassociation with emotion and the emotional reactions of the cardiac andrespiratory functions seems to justify its position among groups of a functionaldefense system. Clinically, it is too well known to describe here, and it ismentioned because, mechanistically considered, it ought to have a place in anyclassification of the neuroses. The following case illustrates this condition:
D. P., pvt., Co. G, 104 Inf. Age, 26 years;race, white; born, Michigan; date of admission, July 27, 1918; source, BaseHospital No. 30; rubber-tire salesman and repairman; alcohol, moderate. Familyhistory: Father, 50, neurosis-invalid type; rheumatism. Previous personalhistory: Left school at 14, seventh grade; at 8, in bed six months, infected,broken ribs below left axilla. "Heart trouble right along," alwaysshort of wind; easily startled; nervous with excitement.
History of present disease: Came to FranceOctober, 1917; up to the line February, 1918. Had hard times sometimes keepingup on account of shortness of breath. Carried on till July, 1918. Going overtop, first time, dropped from exhaustion. As he arose a shell exploded near byand he remembers no more till he woke up at the dressing station. Shaky; blinded(not gassed). "My lungs have been weaker than they ever were." Feels alittle better; not much.
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Subjective symptoms: Present complaints-1. "Heart andlung trouble "-"nervous." "I seem to get all my breath onthe right side. At night I have to jump out of bed sometimes to get my breathand on a hike I have to drop out to get my breath. Nervous; body shakes. When Iam walking I get weak-kneed." Headache for two days; appetite fair; tastessometimes after eating.
Ward surgeon's note: Rather hypochondriacal attitude andmanner. Some grandstand rapid breathing. General tremor, moderate.
Objective symptoms: Condition on admission-body, clean;weight, normal, 158, general conditions, fair; two scars of old rib operationsin lower axilla-left. Pulse, 100; regular; variable rate. Too much muscletenseness. Nervous system: General tremor, moderate. Deep reflex is difficult toget because of muscle rigidity. Diagnosis on transfer card: Psychoneurosis,hysteria. Diagnosis of ward surgeon: Psychoneurosis, effort syndrome. Progress:September 10-hard time breathing when doing strenuous work; difficult to takelong breath; always been short-winded; pain in side and in heart; cough;head-shake tic; some stammer; appears quite neurotic; says always been somenervous; when in camp seemed like he couldn't last out in hikes. Gets upset inexcitement. Does little detail work. Many hypochondriacal complaints. Pulse from80 to 156; tremors of fingers; flushing of face; cough; respiration rapid.Probable Class C. Desires work in garage.
Report of disability board, October 9, 1918: Psychoneurosis,effort syndrome. Disability did not exist prior to entry into service.Classification, B-2. Nature of duty recommended: Labor in line of communication.
On September 29, 1919, he was in the U. S. P. H. S. Hospital,Waukesha, Wis., and not doing very well.
On July 28, 1924, he wrote that he was feeling fairly welland after receiving vocational training had obtained a satisfactory position.
EXHAUSTION
Exhaustion has its place in a classification of war neurosesbecause it connotes defense of a chemical or polyglandular kind. These patientscame into the hospital in some numbers at first, but with the establishment ofthe forward-area hospitals fewer were seen. They represented a large percentageof the material seen in the triages and a considerable number of those seen inthe advanced hospitals. In the earlier months of fighting they were oftenmistaken for and designated as war neuroses. As forming the foundation on whichthe neurasthenia type of war neurosis often developed, they deserve some mentionhere.
TIMOROUSNESS, OR STATE OF ANXIETY
Timorousness, or a state of anxiety, was a term given to asmall group of individuals who frankly admitted that they were afraid to faceconditions at the front, and deliberately gave way to this fear, refusing toaccept or develop any compromise between themselves and what they had to do assoldiers. These are the true and only types of cowards. In them no repression ofthe kind mentioned here exists. This is not a neurosis, of course, as the wholemechanism is entirely too open and frank. At first sight such cases ought to bedealt with outside of a hospital, but in the case of a soldier the condition wasso strange and departed so much from the usual conduct of a soldier that such anindividual was not considered normal enough to be handled from the military sidealone. They would belong probably in the same class as conscientious objectors,the difference being in respect to the kind of thing that interfered with theirwillingness to act the part of a soldier. The following is a case history ofthis condition:
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B., W. C., pvt., Co. B, 12th R. R. Engrs. Age24 years; race, white; service, 1 year; born, Montana; date of admission,October 18, 1918; transferred from Neurological No. 1; railroad machinist;alcohol, moderate. Family history: Father and mother living and well; sister hadepilepsy. Previous personal history: Went two years to high school; never wassick. Venereal, none.
History of present disease: Enlisted October17, 1917; France, May 14, 1918; front July 17, 1918. July 18, on Chateau Thierryfront was wounded by shrapnel in left thigh; was in hospital five or six weeks.Returned to front September 9; became nervous over shells and airplanes; couldnot work at his railroad work on account of shells making him nervous. Droppedtools or whatever he had in hand when explosion came. Asked for work fartherback, as could not stand shells. Present complaint: Complains of weakness andnervousness. Soreness in old wound in thigh; noise causes him to become nervousand to have headache; dreams some of shells and airplanes.
Impression: A man of fair intelligence, but ofrather weak, neurotic tendencies; was wounded by shrapnel and when returned tofront was afraid of noises; is able to do all kinds of railroad machine work.Recommended for work in railroad shops in S. O. S.-not combatant stuff.
Objective symptoms: Nervous; weakness; weakleg. Weight, normal, 114; present, 130. General condition, fair. Vascular system: Pulse 80; after slight exercise, 92; full andregular. Knee-jerks active; pupils react normally; coarse generalized tremors.Diagnosis of ward surgeon: Psychoneurosis, state of anxiety. Progress (laterreport): Very much improved; still has little tachycardia; says feels good butnot as strong as formerly. Composed. Fearful of returning to shell fire. Sure hewould go to pieces again. Complains of cough sometimes at night; pulmonaryexamination negative. O. K. for duty Class A sincearmistice.
Report of disability board: Disability did notexist prior to entry into service. Return to duty, Class A.
Diagnosis: Psychoneurosis, state of anxiety,November 16, 1918.
On December 16, 1919, he was back at home andclaimed to be bothered by a wound received July 18, 1918. Was working at oldtrade as machinist but could not do the work. Is doing much more inferior work.
On July 22, 1924, he wrote: "At present Iam taking a degree course in mechanical engineering under Section No. 2Training. Not nervous at present time. When I first got back I was somewhatnervous but I am not bothered with it at present or none within the last threeand one-half years."
GAS AND CONCUSSIONS
Under gas and concussion were included cases in which theprimary symptoms of a concussion or gas experience were elaborated into thestructure of a neurosis by the mechanism of fixation and defense. In theconcussion neurosis the headache, vertigo, amnesia, temporary blindness, insteadof passing away in a few days, as they normally do, begin after a comparativelyfree interval, to become apparent again, with a definite degree of persistenceand exaggeration which had all the characteristics of a definite neurosis. Inthe gas neuroses the hoarseness, difficulty in breathing, pain in swallowing ortalking, pressure sensation in the chest, dyspnea, etc., show exactly the sametendency until there develops a chronic picture of gas poisoning long after theacute symptoms have any right to be present. In gas, too, the actual pain of askin burn persists as a widely spread burning and parasthesia, long after theprimary burn has healed and all trace of it has completely disappeared. Thesyndrome of these types is included here, because at times such patients weresent down to the hospital either through a mistake in diagnosis or on account oftransportation necessities.
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The following cases illustrate these conditions. The first two are gassyndrome and gas neurosis; the third and fourth, concussion syndrome andconcussion neurosis:
A., O. E., pvt., Co. A, 6th Engineers. Age, 41 years; race,white; born, Washington; source of admission, Cas. Off. Dept. Blois; carpenter;alcohol, very little. Family history: Negative, except that one son has aparalysis, subsequent to "grip." Previous history: Common-schooleducation. No neurotic irregularities in make-up or history. No gunshot woundsor other casualties. Gassed, October 16, 1918. Venereal denied.
History of present disease: Enlisted, April 8, 1917. France,June 28, 1918. Front, Chateau Thierry, July 14, 1918. Carried on very well untilgassed (Verdun) on October 16; mustard and chlorine, he was told; carried onanyway until sent out by his officer on October 21; in hospitals until sent toBlois, November 24. Sent from there here, December 3, 1918, forreclassification. No history suggestive of a neurosis; possibly an exhaustionwith a rather persistent bronchitis following gassing. He had night sweats andloss of weight. Patient does not appear at all a neurotic type.
Subjective symptoms, conditions on admission: Complains ofcough and pain in front of chest and easy fatigability.
Impression: Some exhaustion, associated with chronicbronchitis following gassing.
Objective symptoms, condition on admission: Ambulatory.Weight, normal, 156; present, about 140. General condition: Rather tall andspare; looks a little emaciated, but has a good color. Skins and mucousmembranes, as above; also a little tendency to hyperidrosis. Vascular system:Radials a little thickened; rate, 100. Blood pressure: Subnormal by palpation.Lungs: Right upper chest in back rather duller and percussion and breath soundsless clear than right; but no persistent r?les. Pupils: Left a littleirregular, larger than right, but both react normally. Deep reflexes allincreased, equally on the two sides. Right face a little weaker than left.Otherwise regular.
Disability board, December 9, 1918. Diagnosis: Gas neurosis.Disability did not exist prior to entry into service. Nature of dutyrecommended, return to United States.
January 6, 1920, he was getting along pretty well, although hehad a hard time of it at first. Is doing well at present.
On July 25, 1924, he reported that he was in vocationaltraining studying to be a shoe repair man. He had worked as a carpenter forabout one year, but had suffered from tuberculosis. He had been sent to Arizona,where he was at Whipple Barracks, Prescott. At the present time he is feelingwell, though occasionally suffering from nervous troubles.
S., J. C., pvt., 1st Cl. Co. 2, M. P. Born, Pennsylvania; age,20 years; race, white; date of admission, October 2, 1918; source, NeurologicalHospital No. 1; millwright helper; alcohol, very moderate. Family history:Father, 56, alive and well (except for rheumatism); mother, 48, alive and well,one sister and two brothers, alive and well; one brother nervous; left school at16-8th grade; always healthy, usual diseases of childhood; "had spasmsuntil 6 years old." Well ever since; rheumatism two years ago; nevernervous.
History of present case: Enlisted April, 1917. France, May,1918; went to front July 14, Chateau Thierry. Under heavy shell fire for aboutthree days, becoming more and more nervous. A shell broke about 12 feet away,and he remembers nothing until waking up in a field hospital. Says other mentold him he was gassed with chlorine and a little mustard gas. Very nervous andshaky; went to various base hospitals and finally put on M. P. duty at Nixville.Sent to Verdun front. Didn't mind the barrage, but couldn't stand the shellsbursting near him. Stayed two days; got more and more nervous and fell down.Awoke in Neurological Hospital No. 1 and hence here. Dreams continually ofbattle, hears the whizzing of the shells, but "they never light."Sleeps very poorly. Says he is all right here, but couldn't stand the shellsat the front.
Subjective symptoms: Insomnia-battle dreams. Very goodmaterial, somewhat nervous in make-up. Talks freely and frankly of condition anddoesn't think he will be able to stand shells again. Probably Class B-2.
Objective symptoms: Good-rather nervous. General condition:Good. Glandular system: Small maxillary gland palpable. Vascular system:Impalpable. Heart: Normal in size and position; no murmur heard. Lungs: Nothingof note.
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Diagnosis: Psychoneurosis, gas syndrome.Report of disability board, October 23, 1918: Disability did not exist prior toentry into service. Disability is in line of duty. Nature of duty recommended:Labor in the line of communications.
Dispositions: Class B-1. October 29, 1918.
Final diagnosis: Psychoneurosis, gas syndrome.
On August 8, 1919, he wrote that he was doingdifferent work from his pre-war occupation; working in a steel factory. It istoo hot there for him, as he works with hot steel. Gets a pain over his heartevery day at work and feels as if he would fall over any minute. On July 18,1924, he wrote that he was earning $175 a month as a bottom maker-had receivedno compensation from the Government and was feeling fine.
A., A., pvt., Co. L, 102d Infantry. Age, 21years; race, white; born, Massachusetts; date of admission, May 31, 1918; sourceof admission, transfer Base Hospital 18; machinist; alcohol, moderate; familyhistory negative. Previous personal history: Good health; left school at 14-9thgrade; steady worker; no neuropathic history.
History of present condition: Came to FranceOctober, 1917. Was at Soissons with division in March, 1918. Nerves all right;went up to Toul, beginning of April, all right till about April 15, when he wason his way up to join his company. A shell landed about 6 feet away. Didn'thear it. First he knew the explosion lifted him off the ground. Partly buried.Stunned-not unconscious. While he lay there a second one rolled him overagain. He got up and was helped to aid station; he felt nervous and weak andwas shaking all over. Was at Field Hospital No. 101 about 10 days; felt allright and returned to duty about May 1. Upset by a thunderstorm, and thebatteries near him would keep him awake. Became jumpy. Could not sleep;headaches. Stayed on duty about two weeks. Came to hospital about the middle ofMay.
Subjective symptoms: Present complaints: Weakspells and headaches. "I'll be feeling fine and all of a sudden I getdizzy. I have to sit down." Last an hour. Headaches come and go-sharp,frontal; dreams a great deal-war coloring; sleep broken. "When there is alot of noise I get nervous." Appetite and bowels fair. Patient is oflimited intelligence; speaks in a low, rather quick, tense voice; restless withhands. Slight nodding, jerking of the head; feels quite a bit better; may be fitfor line duty again.
Objective symptoms, condition on admission:Very slight generalized tremulousness more marked in hands, variable; bodyclean; weight, normal, 140; present, slightly underweight; general conditionsfair; eye grounds normal; skin and mucous membranes: on forehead, pea-sizedreddish area; some pustular and some scab covered. Acne. Vascular system: Pulse100; regular. Blood pressure: Systolic 110, diastolic 75. Nervous system:No sign of organic lesion; finger and lip tremor; no ataxia.Diagnosis on transfer card: Psychoneurosis, anxiety form.
Findings in this case at Base Hospital No. 18,neurological examination: Early development fairly normal; never very bright,but has gotten along well. Was doing well in his company until he was blown up,April 15, 1918. Sent to Field Hospital No. 101. Neurological status: Negative,except for coarse, jerky tremor. Diagnosis: Psychoneurosis, anxiety form.Recommendation: Transfer to Base Hospital No. 117 for further treatment.
Summary of case at Base Hospital No. 117:Admitted May 31, 1918. April 15, 1918, was blown up by a shell explosion,stunned, weak and shaky. After 10 days in the hospital he returned to duty, andabout May 1, 1918, was upset by a thunderstorm and a barrage; became jumpy anddeveloped sleeplessness and headaches. He came to the hospital about the middleof May. His chief complaint on admissions here were weak spells, headaches, andbeing easily startled. He was a little tense and restless and had a slightnodding head tremor. He was negative physically aside from a bad facial acne. Heshowed good improvement while in the hospital.
Dispositions: Return to duty B-1. July 3,1918.
Final diagnosis: Psychoneurosis (concussionneurosis).
Postwar history, 1919-20: Present condition,poor. Is bothered with slight headaches and at times has dizzy spells. Hasreturned to his old work but does not like it, as it is in a cotton mill and hecan not stand it. Is a yarn boy now; was formerly a fixer of machines. Has notworked a week steadily since his return.
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In the summer of 1924 the patient wrote:
I feel fair. I still am nervous. I do notsleep well. The least bit of excitement makes me feel faint. I get tired quickat night but can not sleep sound. At present I am working one week and loafing aweek. While out in the air I feel good, but while working inside I am all in atnight. If I had a job outside I would feel a lot better. I have had three yearsof vocational training and it was a failure in my case, as I was knocked aboutand did not have a chance to learn enough to make a living at it. It is a longstory and if you so desire I will write you later about my training career. Ifit is so in your power, I would like a hearing on my case. I had one hearing,but the persons involved did not have the least interest in the hearing.
The American Red Cross sent this report underdate of March 12, 1925:
Mr. A. filed his claim on December 15, 1919,claiming as his disability shell shock. He was discharged from service on May 9,1919, and was examined on January 19, 1920, and was given a diagnosis ofneurosis, traumatic. He was considered to be disabled to a degree of 5 per centwith regard to vocational handicap. The report from the office of The AdjutantGeneral of the Army shows treatment April 15, 1918, for psychosis, traumaticacute due to exhaustion of concussion of high explosives in action in line ofduty May 19 to July 3, 1918.
He was given training on May 10, 1920, for oneyear as a cabinet maker. On May 12, 1920, he entered training at the LowellVocational School, Lowell, Mass. On August 16, 1921, he changed from training inthe vocational school to placement training in cabinet making. On December 6,1921, he was examined by the bureau doctor, and at that time he wanted to changehis training from cabinet making to either telegraphy or plumbing. There wassome question at that time whether the man would succeed in any work whichrequired the skillful use of tools. The requirements for telegraphy were beyondhis limited educational background.
On May 15, 1923, he was rehabilitated as acabinet maker, and was examined by the bureau examiner in the Veterans' Bureauon May 7, 1923. The diagnosis was traumatic neurosis mild. His case was rated onJune 7, 1923, and he was given a 10 per cent rating on this neuropsychiatriccondition and was considered competent.
A follow-up visit was made by the EmploymentService and it was found on March 21, 1924, that the man was employed at the-- Textile Co., assisting in the packing room and inspecting cloth. He wasgetting $21.26 a week. He has been working for this concern since the date ofrehabilitation with the exception of one week and his work was consideredsatisfactory, although there was no future as far as promotions was concerned.It is interesting to note that he has never worked as a cabinet maker, althoughrehabilitated as such.
He was examined again by the Veterans'Bureau on May 28, 1924, and his disability was considered of a noncompensabledegree due to service.
B., J. H., pvt., Co., M, 168 Inf. Born, Iowa;date of admission, July 25, 1918; source of admissions, Base Hospital No. 66.Drug store clerk; alcohol, abstainer. Previous personal history: No neuropathichistory; left school at 17; third year high school; good health; operation forundescended testicle July, 1917. ''When I take a long hike it leaves mepretty stiff the next day."
History of present disease: Came to FranceDecember, 1917; up the line in March, 1918; got on all right until July 14,1918; was in trenches fixing an automatic rifle; doesn't remember anything,unconscious for about three hours; came to an infirmary; gradual emergence. Wasn'thimself until next day; had bad headache; "not so shaky at any time."Was gassed at time; "lungs were sore"; short windedness is better now;headache some better; upset by air raid and thunderstorm July 15, the night hearrived at C. H. 13.
Subjective symptoms: Present complaints: 1."Dull headache all the time. I don't shake much but I am a littlenervous." Easily startled; shooting pains in forehead and back of head. 2."My wind isn't what it always has been." "Takes a long time toget to sleep." Some war dreams; dizzy on stooping; feels fairly strong;appetite and bowels all right. Composed-good stuff; anxious to return to duty.
Objective symptoms: Conditions on admission-bodyclean; weight, normal 130; present, normal. Wax in ears. Pulse, 88, regular.Right testicle half descended. Moderate fine finger tremor. Diagnosis ontransfer card, shell shock. Diagnosis of ward surgeon, psychoneurosis(concussions syndrome).
Report of disability board: Did not existprior to entry into service. Duty in line of communications.
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Disposition: Returned to duty B-2, August 14,1918.
Final diagnosis: Psychoneurosis, concussionsyndrome. Line of duty.
Condition on completion of case: Improved.
Post-war condition: September 29, 1919,"Back at work and feeling fine. Keeping books at present."
On July 23, 1924, he wrote:
My conditions at the present time is a greatdeal better than when discharged and the only time that I can notice any traceof nervous trouble is upon being excited over some happening or some loud noiseat an unexpected time. I can see no reason why my compensation should have beendiscontinued, as I have one bad lung at the present time which gives me sometrouble. I really think if the proper authorities were advised that I would begiven a just examination and no doubt would be entitled to some adjustment. Ifanything can be done it would be greatly appreciated.
I drew compensation from the time I wasdischarged in 1919 until the fall of 1922, when it was discontinued. Don't knowjust why it was dropped as the disability which I had besides the nervoustrouble still exists and have been unable to get any satisfaction from thebureau at this time.
I was in the Samaritan Hospital in Sioux City,Iowa, in 1920, I think. Also the Veterans' Bureau in Des Moines, Iowa, anumber of times the dates I can not remember. In the spring of 1923 I was inthe Veterans' Hospital at Jefferson Barracks in St. Louis for about five weeksand discharged from that place with a discharge marked "conditionunchanged."
GENERAL SYMPTOMS COMMON TO WAR NEUROSES
The classification or grouping has shown that the differenttypes depend rather on certain sets of distinctive mechanisms and on certainalmost specific traumatizing experiences than on symptomatology or on the finalclinical picture. It is, therefore, necessary now to describe some of the moregeneral symptoms common to many of these types and then to touch on some of themore general of the mechanisms.
Three are selected for description under the latter head,noting (1) what may be called, by analogy with general medical description, thereactions of the organism as a whole; (2) the fixation process, especially inits initial stage; and (3) the convalescent conflict.
There are certain symptomatic reactions of the organism toemotionally effective traumas, which represent its protective response as awhole and furnish the symptomatic background of the neurosis. As has been shown,such symptoms are capable of elaboration, fixation, and stereotype, according tothe type of mechanism set in activity. For this reason some or all of thoseabout to be mentioned may he found in any of the groups which have just beendescribed. They may be regarded either as instantaneous reactions taking placeat the moment of traumatic impact, or arising afterwards as a result of theemotional responses accompanying the traumatizing incident. These are, in themain, primary fear reactions, such as tremor, dyspnea, tachycardia, sweating,and sense of muscular weakness, and the resultant condition of headache,restlessness, and insomnia. All of these may be regarded as vasomotor in originand purely physiologic in expression. They appear to be so closely associatedwith hyperemotional states seen in other than war experiences that they must belooked on as very general types of reaction with no specific war incidence atall. For this reason they are found as a kind of symptomatic background toalmost all of the severer types of neuroses. The majority of the cases showedheadache, and considerably more than one-half had insomnia. In most of thelatter the insomnia was of brief duration, the headache was often verypersistent. The headache in cases of concussion is somewhat differ-
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ent, approaching closer to a specific symptom. Even in thedevelopment of the neurosis out of the concussion experience the headache had amore persistent character, a more definite localization, and appeared to producemore discomfort than those found in the other conditions. The characteristicheadache was one of the most insignificant items in the diagnosis of concussionneurosis.
It is apparent, then, that there are in the war neuroses,more or less sharply defined clinical groups, sufficiently characteristic towarrant giving to them separate neurological designations. The first six of themhave a more or less characteristic mechanism; the gas and concussion neurosesare separated out because of a definite etiologic sequence, the others arequestionable neuroses but should be included in a classification in use at aneurological hospital in the war zone.
TREATMENT
No adequate statement of the treatment developed in aspecial hospital such as Base Hospital No. 117, can be given without describingthe history and growth of the place, its spirit and purpose, and the individualscomposing its staff. Therefore, the merest outline of methods used can bementioned here. Each staff member was encouraged to work out and develop his ownparticular notion as to the best way to treat these cases; in this way, whilemany personal therapeutic technical methods were developed, often to aremarkably high pitch of efficiency, nothing new or original can be said to havebeen discovered. Whatever unusual facility there might have been developed inthe handling of these cases came more from the importance attached to the studyof the mechanism than to emphasis on symptoms.
The cases at Base Hospital No. 117 represented, on the whole,the very severe types of war neuroses, particularly so in the earlier and latermonths of its activity. In the beginning, evacuations were made indirectly toBase Hospital No. 117. After the St. Mihiel operation the forward screening wasperfected enough to keep all but severe cases from reaching the rear areas. Thetherapy found effective in the acute cases (it was from these that the techniquewas developed) was found effective in the chronic types. But it took longer forthe symptoms to disappear. The result with chronic cases was not as good as inthe acute cases.
The first principle of the hospital was to cure the soldierand send him forward. If this was not possible he was to be fitted for militaryservice in the Services of Supply with the hope that he would soon reach thefront-line status. Very few cases were to be sent to the United States;therefore, recommendation to this effect was permitted only in the absolutelyhopeless cases, and these chiefly on account of some undercurrent organic maladyor previously undiscovered organic lesion of the nervous system. After thearmistice began, however, the hospital received a great many cases from otherplaces. These were chronic, defective, and other types, representing theunsuccessfully treated residue of hospitals, camps, and division back areas. Asan offset to this the percentage of higher classification during the armisticeincreased likewise, so that the balance was maintained and perhaps ran to morecured cases than at any other time in the hospital's history. Very few casesof war neuroses devel-
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oped de novo after November 11. The therapeuticproblem after that time became much simpler and required much less effort andtime.
The second general therapeutic principle was that a patient'sstay at the hospital was to be as short as possible-the average in the wholehospital was slightly above three weeks. This included the officer materialwhich required long treatment, and also included delays in getting patients outdue to transportation difficulties and all other sources of block incident to ahospital operating at the time of active fighting.
The third general therapeutic principle was that all attemptsmade to cure a patient should be instituted as promptly as possible-within 48hours if it could be arranged. Associated with this was the idea, also, thatwhen the attempt was made it should be followed through to a finish at onesitting. This, of course, refers only to the hysterical symptoms.
The fourth principle was that the war neuroses were caused bya mechanism not under the patient's control in its initial phases, butsubsequent to that, in two to four weeks, there might be a contributing factorin the retention of symptoms through the desire or wish of the patient to remainprotected by his neurosis. At least this possibility was kept in mind, so thatif a cure was not effected within that time the question of the patient'scooperation was brought up.
The fifth principle was that work of some kind was one of themost important aids in effecting symptomatic cures, so that always more than 80per cent of the patients were engaged in work of some sort. This work was of avaried sort, work in the fields in season, road making, wood chopping, and workin a special shop-a therapeutic workshop carried on by reconstruction aides.The only novel feature in this was that it was carried on in a hospital to meetwar conditions within a comparatively short distance from the front areas.
Of the more general and usual methods of treatment of casesof this kind nothing will be said, such as rest for exhausted cases andisolation for excited or markedly tremulous cases. Such things form a necessarypart of every hospital, and it will be taken for granted that such methods werecarried out as effectively as they could be in a hospital equipped under thehandicaps existing in France at that time.
Such methods as presented an individual therapeutic view wereto be found naturally in the hysterias and in the anxiety neuroses, and adescription of what was tried out and found of value will be set down, rather toindicate the general trend of therapeutic effort than completely to describethem.
The point in view in hysteria was that the symptoms were theresult of a promptly acting shock-dissociation process, either materially oremotionally produced. If in the former it was not in any sense due to definiteorganic changes in the brain but to some sort of preorganic thing, possibly of amolecular or circulatory sort-anything which does not preclude the possibilityof an equally prompt restoration to the normal. It was further appreciated thatthere was a mechanism of fixation of symptoms from which the neurosis tended todevelop and become elaborated, so that if the emotionally fixed objectivesymptom could be removed thoroughly, the rest of the neurosis structure wouldrapidly disintegrate.
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Inasmuch as hysteria was thought of as a mechanism ofunconscious origin, coming into activity without the patient's awareness andoften without his subsequent knowledge, its symptoms were regarded by thepatient as being mysterious and strange. He himself, then, neither understoodwhat they were, why he had them, nor to what they were due. The first logicalstep, therefore, was to attempt to explain to the patient something about themechanism that had been at work in making of him an hysterical type of warneurosis. The second was to assure him both of its unconsciousness and of thepossibility of rapid disappearance provided he gave his cooperation, chiefly bydeveloping a condition of receptivity as far as he was able to do so. The nextstep was the acquirement of an attitude of expectancy. Then followed the use ofthe many methods of suggestive symptomatic treatment designed to remove asquickly and thoroughly as possible, symptoms in the order of their importance tothe patient. This, in turn, was followed by after-treatment aimed to emphasizethe fact that the symptoms had disappeared, and furthermore, to fix the notionof the mechanism originating the symptoms and then to fix the mechanism oftheir disappearance. The last step was an attempt to so increase automaticinhibition that the symptoms could not reappear. This last was still in processof development when the war ended.
In the phase of explanation only very simple methods wereused, depending much on the intelligence and understanding of the patient. Withan understanding and belief in a definite mechanistic production of hysteria, itwas not difficult to impart such belief to the patient. Without such belief andknowledge it would have presented great difficulties. The attitude ofreceptivity and expectancy grew up in the patient's mind automatically, ashis belief and faith in his physician took hold of him, or it arose from hiseagerness to get rid of an embarrassing or handicapping group of symptoms. Itwas possible in many instances to increase the attitude by maneuvers designed tostimulate his desire for treatment. The use of apparent indifference, delay,etc., often caused an increased state of eagerness in the patient to get well.There were developed many devices to increase these essential preparatoryqualities to the attack on the symptoms themselves. Some of the staffdeveloped, to a high degree, what was called ward morale. This meant theinfluence of the cured cases and cases cured of a similar set of symptoms, onthe individual about to be treated. It also had reference to a rather mysteriousthing called ward atmosphere. This was a reflection of the attitude of thenurse, physician, and patients to a patient who showed neither aptitude norinclination to meet the cooperative demands which his case warranted. It israther difficult to describe in a few words. In certain wards patients werecured quickly and remained so. It was not customary in these wards for patientsto show symptoms for more than a little while after admission. It is of interestthat this aspect of ward morale did not simply happen, but was consciously andcarefully worked out by the physician and nurse.
The immediate attack on the symptoms was carried out by meansof one or more of the suggestive methods in vogue throughout all theneurological services in all the armies. The suggestive treatment was eitherintensive-in which case, as a rule, the faradic current was used-or it wasgradual, being
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given at intervals. In some instances the battery was notused at all, persuasion and command, argument and reasoning being all that wasrequired. In other instances, again, some other material type of suggestion wasemployed, as tuning forks or stethescopes in deafness, and tongue depressors inaphonias. Whatever method was used, great care was always taken to convince thepatient that the results attained were only intensifications of what he wasperfectly able to do himself. The faradic current, for instance, used tostimulate a muscle in a case of paralysis, was only a means of demonstratingthe functional capacity of the muscle, so that the idea of its paralysis,engendered by the process dissociating it for the time being out ofconsciousness, was negatived.
The personal modifications of the technique of intensivesuggestion, developed by members of the staff at Base Hospital No. 117, was usedin every type of hysteria and in all its various manifestations. It was verygenerally effective in causing these symptoms to disappear. Tremors of allkinds, choreiform movements, fixed position, all types of paralysis, blindness,aphonias, deafness, etc., were daily cured, often in a few minutes, seldomtaking as much as an hour. There is nothing surprising in this, especially ifone considers that a certain percentage of these disappeared of themselves. Ofmore importance and of greater interest was the surprising degree of individualtechnique which grew up about each of the more expert therapeutists of thestaff.
The hysterical amnesias as a rule were treated differently,although in some instances much of the same technique as the above was followed.More often, however, these cases were treated by various associative exercisesleading back to the event for which the amnesia existed and for which itexercised its protective influence. By bringing into full consciousness thisevent and forcing the patient to face, and square himself with it, the path ofreassociative memory was found, and the amnesic block gradually grew less andfinally disappeared. It was either complete, leaving the thread of memorywithout a break, or some small remnant of block still persisted. In the latterinstance it might be left as a perfectly harmless amnesic islet, as it wastermed, or dissipated by putting the patient under a very mild degree ofhypnosis. In this condition, no great difficulty was found in reestablishing theflow of consciousness again. A small series of amnesias was treated from thestart by hypnosis.
The therapy of the anxiety neuroses was a much more difficult thing to develop and apply. The condition itself presents a much morecomplicated form of neuroses than the cruder reactions of hysteria. The anxietyneurosis, as has been said, dips down deeply into the personality and touches onfactors that are associated with the make-up of the individual. It has astrongly ethical character, presenting conflicts of various kinds. Thisdissociation has very little direct material expression and presents, for thisreason, little opportunity for a direct therapeutic attack. An anxiety neurosiscase takes a great deal more time both to develop and to treat, and theindividual who is capable of having it has reacted to it much more deeply than ahysteria case ever does.
Besides this, he is apt to be more intelligent, therefore,more suspicious and very much less suggestible than the hysteria case. A certainamount of study must be given to past experiences, to his former life, to hiscareer in the
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Army, and to the succession of events which brought him intothe hospital. It is necessary to acquaint the patient at first-hand with thecauses that led to the condition, the nature of the condition. He must beinstructed as to the nature of conflict, his in particular, and as to thefunction of repression. Above all, he must be taught to face the whole matter asa section of experience which has come into his life, and which will remain as apart of himself as long as he lives or until the memory of it becomes fainterwith the piling up of those of more recent origin.
The therapeutic aim in the anxiety neuroses had formerly beento encourage the patient to forget his experiences and to aid by his own effortthe automatic repressive tendency already existing. The new point of view was toattempt to train the patient to face, and to face daily as a matter of course,the experiences he had been through, no matter how uncomfortable or terrifyingthey happen to have been. It was in a sense a modified psychoanalytic procedureadapted to a war-born condition, divorced from a good deal of the technicalcomplications of the method used in peace times.
A patient was encouraged to talk about his experiences, to goover the emotional states which accompanied them, and to examine himself ascritically as he could in reference to them. It is one thing to face a pastevent and to measure oneself in the light of that event; it is quite a differentthing to try to forget an event and thus allow the criticism, so to say, to goon unconsciously and the resulting emotion to remain as the only consciousevidence of the conflict going on sublimated and beyond reach. The former stateof mind was encouraged in the patient, the latter was to be avoided.
The chief conflicts found in the anxiety neuroses wereanalyzed out in some such manner as this. The technique differed according tothe individual therapeutists. None found it necessary, however, to employ anymore complicated technique than that of question and answer. A perfectly frankaccount of experiences, with the proper narrative sequence of events, togetherwith the critical comments of the physician, was all that was required in manyinstances to prepare the way for a successful therapy. The knowledge of suchcases acquired by the therapeutists led to the proper emphasis of the points hewas trying to make, much in the way that a trained psychoanalyst in the Freudiansense indicates to his patient the line of associative events he desires tobring up into active consciousness. In the peace neuroses this is frequently amatter of great difficulty on account of the patient's unwillingness to facethe embarrassing nature of the conflict from his point of view. In the warneuroses the conflict is formed out of simpler elements and, since the wholething is more recent, the repressive function has had much less opportunity tobury them deeply in the lower levels of consciousness. Furthermore, theconflicts were so frequently conventionalized and so often found repeated indifferent individuals that it was an easy matter to present them to the patientwith only a little assistance from him. In this way the rapport betweenpatient and physician was not difficult to establish, because it was found thatthere was little to conceal and less possibility of deception. The favoringelement therapeutically was, of course, the central motive underlying allefforts of treatment, that is, the duty and necessity of fulfilling hisobligation as a soldier-the return to duty. Only
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in exceptional cases was this ever a matter of argument oreven of doubt. There could be little weighing of contending motives in such asituation. The duty of a citizen may present many points of conflictinginterests, that of a soldier none. That is, none, if the point is reached, whenhe is brought face to face with the definite reality of his military position.
Although the methods of treatment and the general therapeuticattitude toward a patient with anxiety neurosis can be set down in so simple amanner as this, the implication does not follow that the procedure was an easyone or that it was always successful. Such certainly was not the case, for noconditions in the war neuroses were so difficult to handle or required so mucheffort. Comparatively few men ever acquired the knowledge, patience, tact,insight and firmness to treat such cases adequately. In Base Hospital No. 117,and no doubt in other places, too, there developed among the staff a few men whobecame in a way anxiety neurosis specialists. The contrast to hysteria in thisrespect was marked. Almost anyone after a little instruction could treat theordinary hysterical case successfully, whereas only a few ever qualified as goodtherapeutists for the anxiety cases.
The therapeutic methods in use in the other types of the warneuroses need scarcely be mentioned in detail. Apart from the usual symptomatictreatment, the conventional hospital manner of handling the daily discomforts ofa ward full of patients, there was little to distinguish this hospital from anyother. Drugs were given as seldom as possible, and then only to meet the simplecomplications of an average patient in a hospital. Bromides, hypnotics, andanalgesics were given with the greatest reluctance, and for the most part thepatient did better without them. It was necessary at all times to combat thenatural desire of a patient for some more tangible evidence of treatment, butthis the nurses were for the most part able to do.
Therapeutic use was made of many other agencies not usuallymentioned in describing methods of treatment. All of them had to do withstrengthening the patient's morale, and forcing on his attention at all times,the necessity of getting out of the hospital and back to duty.
The hospital chaplain, approached this through wisely andcleverly designed sermons touching on the spiritual phase of courage, loyalty,devotion, and patriotism. The sermons and religious exercises were planned inpart toward this end, as were the weekly talks by members of the staff andsometimes by visitors to the hospital. In other ways the military atmosphere waskept alive by every means possible. The decorations in the recreation huts wereall planned to keep the military atmosphere in the minds of the soldiers throughstirring posters and scenes of actual war conditions. The walls were covered bysketches drawn for the most part by patients, of men going over the top,artillery going into action, airplane fights, etc.
Sympathy in the ordinary meaning of the term had little placein this hospital; intelligent insight and appreciation of the mechanism of thewar neuroses in a measure took its place. The military necessity was accentuatedand kept constantly in mind, but notwithstanding a certain grimness in thehospital's attitude to its patients, not the slightest suggestion of harshnessor
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severity was ever permitted. The war neuroses were regardedas temporary conditions into which a soldier might fall and thus become asubject for medical treatment. The treatment was found to fail unless theefforts made to help him met with the cooperation of the patient and a desire onhis part to get well. The hospital was planned and equipped for the purpose ofreturning him to duty and, given his support, in most cases, this wasaccomplished. If expressing his recent experiences by talking, writing, or even,as was done in some cases, by the most lurid drawings, was an aid to this end,such efforts were encouraged by whoever might happen to be at the time helpingon his case, be it chaplain, civilian aid, nurse, or some other speciallyqualified member of the hospital personnel.
