Table of Contents

CHAPTER IX

A POSTWAR STUDY OF A TYPICAL GROUP OF WARNEUROSES CASES IN 1919-20 AND1924-25

THE 1919-20 STUDY

Reference was made in the beginning of the preceding chapter to the fact thatin 1919 and 1924 studies were carried on, in the United States, of the postwarcondition of certain of the war neurotic patients of Base Hospital No. 117, A.E. F. Plans for these studies were begun shortly after the armistice was signed,when the statistical work on clinical records at Base Hospital No. 117, A. E.F., was extended to include other purposes besides the definition of the natureof war neuroses and the make-up of patients. The preparation of an address listand the tabulation of supplementary data were undertaken to make possible alater study of these typical cases following their return to the United States.

The purpose of the study made in 1919-20 was to determine the condition of atypical group of bona fide war neurosis cases after their return to civilianlife in America. Basically it was a search for tendency data concerning the warneurotic's readaptation to the condition of civilian life. Though adequateclinical conclusions for a medical definition of war neurosis or its aftermathcould not be drawn from these data, because they are social rather than medicalin bias, they nevertheless furnish certain practical insights into the problemof neurosis which may prove of value in directing attitudes toward the problemsand difficulties which confronted the war neurotic in his attempts atreadaptation.

The point of view used in organizing the data for purposes of summary isentirely a practical one. The former patients of the hospital are classifiedherein according to the type of civilian readjustment they have made and theextent to which they were able to be self-supporting. This point of view issimilar to that underlying the military classifications used by the Army inFrance as definitive of the man's future military usefulness at the time ofhis discharge from the hospital.^a Theproblem was to find out how well or poorly these men were getting along incivilian life; whether they were working or not, or how much, if they were;whether ill or well, etc.; and to attempt to relate these facts to such data aswere available about them individually and as a group.

As a matter of fact, neuroticism seems to be best defined in terms of thetotal situation-the patient and his environment. Especially is this important

^aAll individuals in the American Expeditionary Forces were in one or another of the following physical classifications: Class A, all officers and enlisted men fit for combat service; class B, officers and enlisted men temporarily unfit for combat service but physically fit for other duty and restorable to a class A status within a period of six months after classification as B; class C, officers and enlisted men permanently unfit for combat service but capable of performing service in the Services of Supply; class D, officers and men unfit for any duty within the American Expeditionary Forces.

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in cases where the persistence of the symptoms depends solargely upon environmental factors of the patient's life. A war neurotic whoshortly after his discharge tries his old work in a machine shop and "goesto pieces," and who later leaves the city, works on a farm, and gets rid ofhis symptoms, would be considered finally cured, in so far as present purposesare concerned. Many of the men of the Base Hospital No. 117 group gave just sucha history upon returning to America. Though a return to their old work doubtlesswould bring on a recurrence of their former troubles, judged from this moreinclusive social viewpoint the men are now cured and are listed below in ourclassification as "normal."

In discussing the neurotic the dual fact of personality andenvironment must be considered, for, according to Southard,¹ not onlymust the patient be refitted to his entourage, but the entourage must berefitted to a returned "shell-shocker." So likewise in discussing thereadaptation of the Base Hospital No. 117 group in 1919-20 and in a laterfollow-up group, 1924-25, considered more at length below, categories are usedin terms of social status and ability to work and be self-supporting, as thefollowing discussion attempts to bring out.

EXPLANATION OF THE CATEGORIES FOR PRESENT CONDITION OF THE WAR NEUROTIC GROUP

NORMAL

The first category to be used in discussing these cases is"normal." Under this come those men who, upon return home, went backto work and readjusted themselves to civilian life, or have been able to supportthemselves and their families. Many of them note certain novel tendencies inthemselves, such as tendencies to become angry or excited easily, some littlenervousness, restlessness, forgetfulness, and occasional slight headaches ordizziness (seldom enough to incapacitate them from work), and other like mild,neurotic symptoms. Yet the general health of these men is good; they are able tobe self-supporting and are normally happy.

NEUROTIC

The second group, called "neurotic," consists ofthose who made partial readjustments to their old way of living, yet continuedto suffer from one or more rather severe nervous difficulties. Most of these menwere under a physician's care, or else had at least consulted one about theircondition. They were able to work fairly well, but their own personal lives wereunhappy because of these neurotic troubles. Some were assigned to lighter andeasier work in their old places and were very sensitive about their loweredstatus. One finds among them the residue of symptoms shown in France-occasionally,fine tremors and tics, more often speech defects, weakness, insomnia, jumpiness,distressing inability to concentrate, memory disorders, and "spells"of all sorts. One case, that of a man with combined concussion and gas neurosis,working

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as an express helper, fainted in a railroad station when a nearby locomotivepuffed suddenly. A great many minor injuries and several serious accidents werereported by men in this group as the result of their nervous condition. The menof this group tended also to lose considerably in weight upon working hard,especially during the summer. In all men who carried over symptoms to civilianlife there was a marked reaction to changes of weather, especially damp weather,which called out moods and depression, seriously handicapping them. In this"neurotic" group there were many men who upon return home tried theirformer work in machine shops or factories but could not control themselves andbecame nervous and tired. As one man put it: "I used to work a pneumaticdrill but I can not any longer; the constancy of action is so much like amachine gun. I tried my best but could not stick it out. I had a semibreakdown"In the cases of some of the men when gas or ideas of gas were involved, indoorwork was difficult. Many of these men, especially during the warm summer months,took positions as salesmen, farmers, sailors, laborers-any position whichwould give them outdoor work. This change in many cases was the basis of cure,for some later wrote that their new work agreed with them and they weregradually getting back to themselves. With difficulty in standing indoor workcame the same inability to remain in noisy places, especially machine shops orfactories. Also some men who were in school or college reported that they foundit very difficult to concentrate upon their work and that their memories werebad.

FATIGUED

Third comes the group called "fatigued." Most of these men can notwork regularly without suffering and being confined to bed. The symptoms hereare ready fatigability, severe headaches, lack of ambition and depression(general neurasthenic coloring). Whereas the "neurotic group" are ableto work, though with much discomfort, this group can work only on the averageabout one-half of the time. Some of them are fortunate in having easy jobs orconsiderate employers and so manage to support themselves after a fashion. Insome cases where the men are married, their wives also are working to meet theexpenses of living.

DISABLED

The fourth group consists of those at the time of the follow up (1919-20)actually rehospitalized for psychoneurosis or reporting a "nervousbreakdown" or some incapacitating medical disease, such as tuberculosis.One would anticipate many physical disorders occurring as an aftermath of theconditions to which the men were exposed in France, and indeed, many of the menhave had some difficulty as a result of these experiences. There may also besome men in the "fatigued" group outlined above who have disabilitiesof an organic nature. A study like the present one made by correspondencenaturally can not make adequate clinical differentiations.

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PSYCHOTICS

Fifth is the psychotic group, including such conditions as dementia pr?cox,psychopathic personality, and epilepsy. An interesting commentary is theinfrequency of psychotic outworkings among the former patients of Base HospitalNo. 117 as a group. In the 1919-20 study, only one suicide was reported-a man of poor stock and make-up, never at the front, who entered thehospital after the armistice was signed and was evacuated with the diagnosis"neurasthenia." Otherwise there were relatively few men (10, or about1 per cent) whose condition had changed by 1920 from the psychoneurosisdiagnosed at the hospital to a psychosis. By 1925 four deaths had been reportedas suicides. Twelve were definitely psychotic, 14 were returned as either"in hospital; parents uncertain of address," or "lost" witha psychopathic coloring attaching to their disappearance. For instance, one manenlisted in the Navy under his brother's name, causing the family considerabletrouble when he later deserted. The outside total of possible psychotics was 28cases diagnosed psychoneurotic in France, or 3.4 per cent of the group. This isstriking evidence favoring the psychological conception of war neuroses, for themere possibility of insanity developing in 830 men over a period of seven yearswould probably not be less than this total.

In viewing the 1919-20 civilian status of these men in relation to theirphysical classification in France, when discharged from Base Hospital No. 117,several significant considerations arise. First of all, the AmericanExpeditionary Forces physical classification was a practical estimate of futureArmy usefulness. It took into consideration such matters as health, strength,and endurance. Obviously these are factors which would be of significance inboth Army and civilian life. Therefore, if the classifications were adequatelymade, then some positive correlation should exist between them and the 1919-20conditions of the men. Second, it should likewise be appreciated that theability of a man to return to the front calls upon factors in him differing fromthose that would be called forth in his attempting to get back, for example, toclerking or to farming in civilian life. Military conditions facing the man inFrance were obviously very different from civilian circumstances upon his returnhome. It is quite possible for Army misfits to be normal and even verysuccessful in civil life. Third, the Army estimate of the value of a man beforethe armistice, when further battle service was under consideration, and duringthe armistice would be based on different factors; the latter would more nearlyaccord with the criteria of civilian usefulness. Consequently, throughout thisdiscussion figures are given separately for the two groups of cases, thosedischarged from Base Hospital No. 117 before the armistice and those dischargedduring the armistice. The total figures are likewise used when the group as awhole is under consideration. The data on military classification are presentedin several tables, and the conclusions from each of them are given in order.

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TABLE 7.-Comparisonof the 1919-20 follow-up group and the total Base Hospital No. 117service in regard to physical classification

Physical classification	Column 1	Column 2	Column 3	Column 4
	Totals for follow up	Totals for hospital	Percentage of follow up	Percentage of all cases at B.H. No. 117
A	36	142	8.2	9.7
	152	366	47.6	32.6
	188	508	24.8	19.6
B	210	696	47.9	47.4
	68	316	21.0	28.1
	278	1,012	36.6	39.2
C	171	548	39.0	37.4
	51	276	15.9	24.6
	222	824	29.3	31.8
D	11	32	2.5	2.2
	46	139	14.4	12.4
	57	171	7.5	6.6
Tb	10	48	2.3	3.3
	3	27	1.0	2.4
	13	75	1.8	2.9
Total	438 (57.8)	1,466 (56.7)	100.0	100.0
	320 (42.2)	1,124 (43.3)	100.0	100.0
	758 (100.0)	2,590 (100.0)	100.0	100.0

^aIn each group of figures, theupper figure indicates cases discharged before the armistice; the second, casesdischarged during the armistice; and the third (below the line) the total numberor per cent.
^bTransferred to another hospital, unclassified.

Table 7 is concerned with the problem of the adequacy of sampling of thefollow-up group as compared with the total hospital group from the standpoint ofphysical classification. The selection of cases used in this study is a goodone, especially in reference to the proportions before and during the armistice,i. e., 57.8 per cent compared to 56.3 per cent and 42.2 per cent to 43.3per cent (see totals in columns 1 and 2). Furthermore, the percentages of eachclass of the follow-up group and of each class of the total hospital group arealso indicative of a good sampling (see the figures below the line, lowestfigures of each group of three in columns 3 and 4; i. e., 24.6 per cent comparedto 19.6 per cent, 36.6 per cent to 39.2 per cent; 29.3 per cent to 31.8 per cent; 7.5 per cent to 6.6 per cent; 1.8 per cent to 2.9 per cent). Likewise, thepercentages of each class in the pre-armistice group of the follow up and of thehospital service (given on the top line in each grouping in columns 3 and 4) arenearly identical, i. e., 8.2 per cent compared to 9.7 per cent; 47.9 per cent to47.4 per cent; 39.0 per cent to 37.4 per cent; 2.5 per cent to 2.2 per cent; 2.3per cent to 3.3 per cent. There is more variation in the armistice figures(given in the middle of three in columns 3 and 4) than in the others; but it is,however, a fair sampling from the standpoint of the proportions of each class inthe total hospital group (i. e., 47.6 per cent compared to 32.6 per cent; 21.0per cent to 28.1 per cent; 15.9 per cent to 24.6 per cent; 14.4 per cent to 12.4per cent; 1.0 per cent to 2.4 per cent).

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Several other facts are to be ascertained upon inspection of the data onTable 7. First, the military fact is apparent from the totals at the bottom ofcolumn 2 that there were almost as many cases discharged from the hospitalduring the armistice as before it. The sudden ending of the war just after theUnited States had thrown our great Army into it, the population of Base HospitalNo. 117 at the time of the signing of the armistice, the use of Base HospitalNo. 117 as a reclassification center for war neurosis cases after the armisticewas signed-these facts are the explanation for the nearly equal figures fordischarges before and after the armistice began. Second, another military fact,it is notable that there was considerable difference in the percentage usage ofthe different classes before and during the armistice; namely, in class A thedifference between its use in 10 per cent of the cases before the armistice and33 per cent after the armistice had begun. The infrequency before the armisticeof the physical classification A indicates that the members of the hospitalpersonnel were only willing to send back to the front immediately 1 man in 10 ofthe discharged psychoneuroses cases, whereas during the armistice one in threewere sent out class A to full duty in an army at peace.

From Table No. 8 we are able to get some idea of the actual prognostic valueof military classification for readjustment in civilian life. The differencebetween the two tests of fitness, that of civil life and earning a living, thatof army life and withstanding the hardships of battle conditions, are obvious.Yet there are enough similarities to justify an expectation of a positivecorrelation between the facts. Reviewing the figures, we find in the column forclass A that 68.1 per cent of the patients reached were carrying on in civilianlife in 1919-20; i. e., 45.2 per cent were "normal" according toour categories and 22.9 per cent "neurotic." Of those given class B,64.8 per cent were carrying on, of whom 41.8 per cent were "normal"and 23 per cent were "neurotic." Of those given class C, 55.4 per centwere carrying on, 33.3 per cent were "normal," and 22.1 per cent"neurotic." Of those given class D, 40.3 per cent were carrying on, ofwhom 21 per cent were "normal" and 19.3 per cent were"neurotic." The T group is too small and indefinite for drawinginferences; usually the neurotic condition was complicated by other medicalconsiderations.

The class B men of before the armistice are as a group readjusting themselves better to civilian life than the prearmistice class A group. Of course,some of the class A group got back to the front again (several were wounded, afew killed in action), others had "relapses" and were returned to BaseHospital No. 117, whereas, since the war ended so soon, few of the B classpatients were used again in battle. There is a corollary to this last in thatalthough about 1 in 2 of thedischarged psychoneurosis cases were sent out before the armistice as class B,only 3 in 10 were so classed after the armistice began. The 47 per cent in classB before the armistice indicated a general optimism that a short time out of thehospital and back among other soldiers would cause these men to become suitableas members of combat units.

The 37 per cent class C before the armistice indicates that it was notpractical with three-eighths of the men to try to so groom them for front-lineduty. The C class discharges dropped from 37 per cent before the armistice

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to 21 per cent afterwards. The increase in class D after the armistice hadbegun is due to clearing out uncured cases and sending them to hospitals at theports for further treatment or for return to the United States.

TABLE 8.-American ExpeditionaryForces, physical classification of 1919-20 follow-up groupin relation to condition in 1919-20

	Class A		Class B		Class C		Class D		Class Tb		Total
	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage
Normal	15	41.7	94	44.9	55	32.2	2	18.2	5	50.0	171	39.0
	70	46.1	22	32.8	19	37.3	10	21.7	3	100.0	124	38.7
	85	45.2	116	41.8	74	33.3	12	21.0	8	61.5	295	38.9
Neurotic	8	22.2	47	22.4	41	23.9	2	18.2	---	---	98	22.4
	35	23.0	17	25.0	8	15.7	9	19.6	---	---	69	21.5
	43	22.9	64	23.0	49	22.1	11	19.3	---	---	167	22.0
Fatigued	4	11.1	32	15.1	29	17.0	2	18.2	---	---	67	15.3
	28	18.4	13	19.4	12	23.5	11	23.9	---	---	64	20.0
	32	17.0	45	16.2	41	18.5	13	22.8	---	---	131	17.3
Disabled	8	22.2	37	17.6	42	24.6	5	45.5	3	30.0	95	21.7
	19	12.5	16	23.8	10	19.6	15	32.6	---	---	60	18.6
	27	14.3	53	19.1	52	23.4	20	35.1	3	23.1	155	20.4
Psychotic	1	2.8	---	---	4	2.3	---	---	2	20.0	7	1.6
	---	---	---	---	2	3.9	1	2.2	---	---	3	.9
Total	1	.5	---	---	6	2.7	1	2.2	2	15.4	10	1.3
	36	100.0	210	100.0	171	100.0	11	100.0	10	100.0	438	100.0
	152	100.0	68	100.0	51	100.0	46	100.0	3	100.0	320	100.0
	188	100.0	278	100.0	222	100.0	57	100.0	13	100.0	758	100.0

^aThe upper number in each groupindicates cases discharged from Base Hospital No. 117 before the armistice; thesecond number, cases discharged during the armistice; and the number below theline, total.
^bTransferred to another hospital, unclassified.

Lastly, Table 8 shows (figures in the "Totals" column) that therecoveries or nonrecoveries from war neuroses of the group studied in relationto military classification gives percentages about the same for those dischargedbefore and those discharged during the armistice. In the two largest groups, i.e., "normal" and "neurotic," the percentages before andduring the armistice are nearly identical (39 per cent and 38.7 per cent and22.4 per cent and 21.5 per cent, respectively). The chances that a mandischarged in class A, for instance, would be normal in 1919-20 were aboutequal for him whether he was discharged before or during the armistice. In otherwords, the prognostic value of military classification for the group of mendischarged from Base Hospital No. 117 before and during the armistice is aboutthe same in terms of civilian readjustment.

By way of conclusion it may be said that the data on 1919-20 condition area verification of the military classification. If the data were to run otherwisethan as they do above, it might reflect seriously upon the categories ofpotential value used by the hospital personnel. The tendency of the dataindicates that the medical staff in France gave a good practical consideration

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of the make-up and potential value of a soldier beforelaunching him forth with a physical classification to the replacement centersfor further utilization of his services by the army.

DIAGNOSIS IN FRANCE IN RELATION TO 1919-20 CONDITION

Diagnosis in mental disease, especially with thepsychoneuroses, is less absolute and clean-cut than in many of the physicaldiseases. At Base Hospital No. 117 there were 12 possible diagnoses under thegeneral head of psychoneurosis. It is obvious that in making a diagnosis amongthese categories there would be found considerable overlapping of symptoms andmany difficulties in accurately differentiating symptom groupings. The list ofthese diagnoses is given above in Chapter V, page 372.

It must be appreciated that the diagnoses referred to, whichwere devised for the psychoneurosis cases at Base Hospital No. 117, were notused with entire uniformity by the medical officers. Hysteria might be given asthe diagnosis by one, whereas the same symptoms drew the diagnosis concussionneurosis from another. These variations were chiefly attributable to officersassigned to the hospital for temporary duty or for training. On the whole,however, the diagnoses were similarly used, for the majority of the cases werediagnosed by a small group of men, the original staff (or others under theirsupervision), whose notions of the different types of neuroses for the most partcoincided. Thus, the great majority of the diagnoses follow the scheme ofclassification used at the hospital, and the error, above mentioned, though itdoes enter, plays but a minor part.

Our first inquiry into the question of diagnosis and itsrelation to present condition is in regard to the selection of cases in thefollow up. Table 9 gives the frequency of usage of the various diagnoses at BaseHospital No. 117 in France; Table 10 gives the frequency of their occurrence inthe follow-up group compared with the total hospital group. Inspection of thepercentages for totals in Table 10 for each diagnosis (given below the lines)shows that the follow up is a good sampling of the total hospital group. Forinstance, hysteria occurs in 27.6 per cent of the cases in the hospital serviceand 25.9 per cent in the follow up; concussion neurosis occurs in the relativeproportions 22.1 per cent and 22.9 per cent; neurasthenia 12.1 per cent ascompared to 14.4 per cent; others run 2.8 per cent to 3.8 per cent; 5.1 per centto 5.4 per cent; 2.1 per cent to 2.2 per cent; 8 per cent to 6.7 per cent; etc.

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TABLE 9.-Frequencyof usage of diagnoses and physical classifications of psychoneurosiscases discharged from Base Hospital No.177

Diagnoses	Physical classification					Totals
	A	B	C	D	Tb
Hysteria	30	119	208	19	3	379
	93	92	98	49	6	338
	123	211	306	68	9	717
Concussion neurosis	17	236	64	0	9	326
	112	79	38	17	1	247
	129	315	102	17	10	573
Neurasthenia	14	69	95	0	9	187
	15	18	56	37	1	127
	29	87	151	37	10	314
Hypochondriasis	2	10	41	5	0	58
	4	1	18	16	0	39
	6	11	59	21	0	97
Exhaustion	13	49	7	1	2	72
	28	30	9	0	0	67
	41	79	16	1	2	139
Effort syndrome	3	17	7	0	1	28
	3	8	12	3	3	29
	6	25	19	3	4	57
Anxiety neurosis	4	55	55	2	2	118
	14	24	15	3	0	56
	18	79	70	5	2	174
Concussion syndrome	42	112	11	1	15	181
	37	30	7	0	3	77
	79	142	18	1	18	258
Psychasthenia	3	4	18	2	1	28
	2	2	2	6	0	12
	5	6	20	8	1	40
Timorousness (state of anxiety)	1	3	11	2	3	20
	11	6	15	1	0	33
	12	9	26	3	3	53
Anticipation neurosis	0	4	18	0	0	22
	1	0	2	2	2	7
	1	4	20	2	2	29
Gas neurosis	2	11	8	0	0	21
	11	13	3	3	0	30
	13	24	11	3	0	51
Gas syndrome	0	2	1	0	---	3
	1	6	0	1	---	8
	1	8	1	1	---	11
Traumatic neurosis	1	1	1	0	1	4
Gastric neurosis	0	0	0	1	0	1
Post-operative neurosis	1	1	1	1	1	5
No disease found	10	4	3	---	2	19
	34	7	1	---	11	53
	44	11	4	---	13	72
Totals	142	696	548	32	48	1,466
	366	316	276	139	27	1,124
	508	1,012	824	171	75	2,590

^aThe upper number in each groupindicates the cases discharged from Base Hospital No. 117 before the armistice;the second, cases discharged during the armistice; and the number below theline, the total.
^bTransferred to another hospital, unclassified.

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TABLE 10.-Comparison of the 1919-20follow-up group and the total population of Base HospitalNo. 117 in regard todiagnosis^a

Diagnosis	Totals for follow up	Totals for hospital group	Percentage of follow up	Percentage of hospital group
Hysteria	101	379	23.1	25.9
	95	338	29.7	30.1
	196	717	25.9	27.6
Concussion neurosis	98	326	22.4	22.2
	76	247	23.7	22.0
	174	573	22.9	22.1
Neurasthenia	63	187	14.4	17.8
	46	127	14.4	11.3
	109	314	14.4	12.1
Hypochondriasis	12	58	2.8	3.9
	9	39	2.8	3.4
	21	97	2.8	3.8
Exhaustion	21	72	4.8	4.9
	17	67	5.3	5.9
	38	139	5.1	5.4
Effort syndrome	10	28	2.3	1.9
	6	29	1.7	2.6
	16	57	2.1	2.2
Anxiety neurosis	40	118	9.1	8.1
	21	56	6.7	4.9
	61	174	8.0	6.7
Concussion syndrome	53	181	12.1	12.4
	19	77	5.9	6.9
	72	258	9.5	10.0
Psychasthenia	8	28	1.8	1.9
	7	12	2.2	1.1
	15	40	2.0	1.6
Timorousness (state of anxiety)	13	20	2.9	1.4
	4	33	1.3	2.9
	17	53	2.2	2.0
Anticipation neurosis	12	22	2.8	1.5
	0	7	0.0	0.6
	12	29	1.6	1.1
Gas neurosis	5	21	1.1	1.4
	10	30	3.1	2.7
	15	51	1.9	1.9
Gas syndrome	1	3	0.2	0.2
	0	8	0.0	0.7
	1	11	0.1	0.4
Traumatic neurosis	0	4	0.0	0.3
Gastric neurosis	0	1	0.0	0.1
	0	5	0.0	0.2
Post-operative neurosis	1	19	0.2	1.2
No disease found	10	53	3.1	4.7
	11	72	1.4	2.8
Total	438	1,466	100.0	100.0
	320	1,124	100.0	100.0
	758	2,590	100.0	100.0

^aThe upper number in each group indicates the cases dischargedfrom Base Hospital No. 117 before the armistice; the second, cases discharged during the armistice; and the number below the line, the total.

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Table 11 gives the relationship of diagnoses to condition in1919-20. The psychotics are combined with the organic group; individualstatistics for those classed psychotics here are to be found in Table 12. Someof the diagnostic groups are very small. They are included in part for the sakeof completeness, for, since they are a representative sampling of the totalhospital service, their proportionate size is a just index of their frequency ofoccurrence in Base Hospital No. 117 in France.

TABLE 11.-Condition in 1919-20 in relation todiagnosis in France

	Normal		Neurotic		Fatigued		Disabled and psychotic		Total
	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage
Hysteria	26	25.7	29	28.8	20	19.8	26	25.7	101	23.1
	34	35.8	18	18.9	20	21.1	23	24.2	95	29.7
	60	30.6	47	24.0	40	20.4	49	25.0	196	25.9
Concussion neurosis	44	44.9	28	28.6	8	08.2	18	18.4	98	22.4
	29	38.1	17	22.3	18	23.7	12	15.8	76	23.7
	73	41.9	45	25.9	26	14.9	30	17.2	174	22.9
Neurasthenia	27	42.8	10	15.9	15	23.8	11	17.4	63	14.4
	9	19.6	9	19.6	15	32.6	13	28.2	46	14.4
	36	33.0	19	17.4	30	27.5	24	22.0	109	14.4
Concussion syndrome	29	54.7	6	11.3	9	17.0	9	17.0	53	12.1
	9	47.3	6	31.6	1	5.3	3	15.8	19	5.9
	38	52.8	12	16.7	10	13.8	12	16.7	72	9.5
Anxiety neurosis	17	42.5	13	32.5	4	1.0	6	15.0	40	9.1
	9	42.9	7	33.3	4	19.0	1	4.8	21	6.7
	26	42.6	20	32.9	8	13.1	7	11.4	61	8.0
Exhaustion neurosis	11	52.4	0	0.0	4	18.6	6	28.6	21	4.8
	8	47.0	4	23.5	1	5.9	4	23.5	17	5.3
	19	50.0	4	10.5	5	13.2	10	26.3	38	5.1
Hypochondriasis	3	25.0	1	8.3	2	16.6	6	50.0	12	2.8
	4	44.4	2	22.2	0	0.0	3	33.3	9	2.8
	7	33.3	3	14.3	2	9.5	9	42.8	21	2.8
Psychasthenia	3	37.5	0	0.0	1	12.5	4	50.0	8	1.8
	2	28.6	2	28.6	2	28.6	1	14.2	7	2.2
	5	33.3	2	13.3	3	20.0	5	33.5	15	2.0
Gas neurosis	1	20.0	2	40.0	1	20.0	1	20.0	5	1.1
	6	60.0	2	20.0	1	10.0	1	10.0	10	3.1
	7	46.8	4	26.6	2	13.3	2	13.3	15	1.9
Anticipation neurosis	4	33.3	4	33.3	1	8.3	3	25.0	12	2.8
	0	0.0	0	0.0	0	0.0	0	0.0	0	0.0
	4	33.3	4	33.3	1	8.3	3	25.0	12	1.6
Effort syndrome	1	10.0	3	30.0	0	0.0	6	60.0	10	2.3
	4	66.7	1	16.7	1	16.7	0	0.0	6	1.7
	5	31.2	4	25.0	1	6.2	6	37.5	16	2.1
Timorousness	5	38.5	2	15.4	1	7.7	5	38.5	13	2.9
	3	75.0	0	0.0	0	0.0	1	25.0	4	1.3
	8	47.1	2	11.8	1	5.9	6	35.3	17	2.2
Gas syndrome	---	---	---	---	1	100.0	---	---	1	0.2
	---	---	---	---	0	0.0	---	---	0	0.0
	---	---	---	---	1	100.0	---	---	1	0.1
No disease found	0	0.0	0	0.0	0	0.0	1	100.0	1	0.2
	7	71.0	1	10.0	1	10.0	1	10.0	10	3.1
	7	63.7	1	9.1	1	9.1	2	18.2	11	1.4

^aThe upper number in each groupindicates the cases discharged from Base Hospital No. 117 before the armistice;the second, cases discharged during the armistice; and the number below theline, the total.

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TABLE 12.-Condition in 1919-20 in relationto diagnosis and physical classification

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If we combine for each diagnosis the normal and neuroticgroups, that is, the patients of the hospital who were engaged in some pursuitin civilian life in 1919-20, and compare the various diagnoses on the basis ofpercentage working and percentage disabled (fatigued, disabled, or psychotic)some interesting data come to the surface. For instance, if we rank the variousdiagnoses on the basis of the percentage of those reached in 1919-20 who wereworking in civilian life we get the following figures:

TABLE 13.-Rank order of diagnoseson the basis of the percentage of thosecarrying on in civilian life in 1919-20

Diagnosis	Per cent	Diagnosis	Per cent
1. Anxiety neurosis	75.5 (N-61)	8. Timorousness	58.8 (N-17)
2. Anticipation neurosis	75.0 (N-12)	9. Effort syndrome	56.2 (N-16)
3. Gas neurosis	73.4 (N-15)	10. Hysteria	54.6 (N-196)
4. No disease	72.5 (N-11)	11. Psychasthenia	53.3 (N-15)
5. Concussion syndrome	69.5 (N-72)	12. Neurasthenia	50.4 (N-109)
6. Concussion neurosis	67.8 (N-174)	13. Hypochondriasis	47.6 (N-21)
7. Exhaustion neurosis	60.5 (N-38)

Thus it is seen that the typical war neuroses-notably theconcussion, gas, and anxiety types-rank very high in percentage of successfulreadaptation, while the more pronounced constitutional types rank lower. Acommentary of no little interest here is that the conclusions offered by thesedata approach very nearly the prognoses made by the medical staff of thehospital, while the men were still in France, as to the future well-being of thevarious types of these cases. The exhaustion, concussion, and anxiety cases weregiven the best prognosis, the effort syndrome cases, the cases of neurasthenia,psychasthenia, and hypochondriasis the worst. Hysteria was placed in betweenthese groups. And no one predicted any marked number of psychotic outworkingsfrom these symptoms. These facts are in the most part borne out by the abovefigures. The fact that the true battle neuroses-the concussion cases, forinstance-are readjusting themselves better proportionately than the timorous,neurasthenic, or hypochondriacal types is interesting, showing, as it does, howincorrect are the popular notions of war neuroses. Men who developed nervoussymptoms in the cantonments at home are usually viewed with suspicion byordinary persons and regarded almost as malingerers by many. The facts hereindicate that the hypochondriasis, psychasthenia, neurasthenia, and timorousnessgroups, due perhaps to the long continued nervous state before the onset ofsymptoms, often playing upon constitutional susceptibility, do not readjustthemselves nearly so well as the actual concussion cases; in other words, manymen who never saw action have a more serious aftermath in symptoms than thosewho were actually in the thick of it, and were concussed by exploding shells ordriven into an anxiety state by the fearful conditions and terrible sights atthe front.

Among the cases of hysteria, the majority are havingdifficulty getting along in civil life, and, though earning their own living andseemingly carrying on their work, still they are constantly unhappy because ofneurotic residues in the form of headache, insomnia, jumpiness, speechdisorders, and often tics. On the whole, the men who had hysteria retain enoughof their old condition

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to handicap them seriously in their personal lives, thoughnot always directly in their business activities. A little more than one-half ofthem are able to earn their living and ask financial aid of no one, but thegreat majority are nevertheless constantly seeking advice from physicians. Thesymptoms in France were usually so gross and vivid that one may believe theyprobably tended to lay stronger habit foundations than any of the other symptomgroupings. An interesting point in reference to neurosis aftermath applicable tonearly all neurosis types, is derived from a physiological truism to which Mott²refers in discussing psychoneurosis: "Consciousness of the existenceof an organ or structure interferes with its normal automatic or habitualaction." War neurotics, who were sensitive for months to every change intheir bodily feelings, who were keenly introspective and analytic of theexistence of the various organs and structures of the body, are guilty ofcontinuing even now this search for symptoms in themselves. And it is rareindeed that this search is unrewarded; for example, anyone can produce aheadache by introspection of the contents of the cranium continued over severalminutes. These men are slow to recognize the feeling of well being, quick tonote any signs of possible ill being. This morbid practice may be the basis ofmany of their present difficulties.

The effort syndrome cases also tend to be seriously andpermanently affected by their symptoms. The great cause for the persistence ofsymptoms among these cases is that the facilities for treating the men in Francewere not adequate for the needs. Time and special care, both vital factors inthese cases, could not be offered at a hospital where beds were constantly indemand and where there was no room for chronic cases requiring lengthytreatment. The result was that these patients were for the most part sent tolight duty in the Services of Supply. Unfortunately, the officers assigning mento duty at replacement camps as a rule did not consider the mental condition ofthe men so much as their physical appearance. Many men, not only in this groupbut in all groups, were sent to duty too soon.

The group diagnosed as state of anxiety or timorousness showa great number as being permanently affected by their condition in France. Theexplanation in this case, as in some of those diagnosed hypochondriasis, restsin the make-up of the individuals. These were men who as a group were ofinferior intelligence, dull normals, or even morons. The cure of a neurosis inan intellectually inferior person is usually very difficult.

The men diagnosed as "Psychoneurosis, no diseasefound," were an anomalous group, and generally some other medical diagnosisfollowed this one. Base Hospital No. 117 being only for psychoneurosis cases,that diagnosis in some form had to be given on the patient's discharge slipwhen transferred to another hospital for treatment. The percentage of successfulreadjustment among members of this group represents cures from diseases otherthan psychoneurosis.

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PHYSICAL AND MENTAL CONSIDERATIONS IN RELATION TO CONDITION IN 1919-20

AGE AT TIME OF HOSPITALIZATION

The follow-up group under consideration is a good sampling ofthe entire group of patients at Base Hospital No. 117 in the matter of age. Thisis shown by the fact that the median age for the follow-up group is 24.46 years,while that for the total hospital population is 24.66 years. The numbers foreach age are given in Table 14.

TABLE 14.-Ages athospitalization in France of follow-up group in relation to condition in 1919-20

Age	Normal	Neurotic	Fatigued	Disabled	Psychotic	Totals
16	0	1	0	0	0	1
17	0	0	0	0	0	0
18	2	2	2	2	0	8
19	13	10	7	8	3	41
20	15	7	10	6	0	38
21	28	13	2	8	1	52
22	37	19	15	15	0	86
23	37	26	16	15	0	94
24	40	13	16	24	1	94
25	22	16	14	12	0	64
26	27	13	9	12	0	61
27	12	9	5	6	0	32
28	15	6	10	3	2	36
29	9	6	4	2	1	22
30	3	5	6	8	1	23
31	9	8	3	8	0	28
32	3	4	3	6	0	16
33	3	1	0	1	0	5
34	2	1	0	0	0	3
35	1	0	1	0	1	3
36	0	1	0	0	0	1
37	---	1	---	1	---	2
38	---	---	---	1	---	1
39	---	2	---	---	---	2
40	---	---	1	1	---	2
41	1	---	---	---	---	1
42	---	---	---	---	---	0
43	---	---	---	---	---	0
44	2	---	---	---	---	2
45	1	---	1	1	---	3
46	---	1	---	---	---	1
47	---	---	---	---	---	0
48	---	---	---	---	---	0
49	---	---	---	---	---	0
50 plus	1	---	---	---	---	1
N	=283	165	125	140	10	723
Medians	=24.25	24.38	23.69	24.69	26	24.46
Q	=2.125		2.625		2.32

(Median for total hospital group, 24.66 years.)

In so far as these data are significant, the factor of ageenters but little in relation to the type of social readjustment of the BaseHospital No. 117 group of war neurotics in 1919-20. The median of the"fatigued" group is a little over one-half a year less than that ofthe "normal" group, and the median for the "disabled" groupalmost one-half a year above the "normal" group median. The median is24.47 years for the combined "normal" and "neurotic" groups(that is, for those who were carrying on in civilian life in 1919-20) and 24.68 years for the combined "fatigued" and "disabled"groups. Thus, a comparison of medians indicates a slight tendency for youngermen to be doing better in civil pursuits than the older men. When distributionsfor the groups are studied

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from the standpoint of dispersion on the basis of thepercentage of men 21 years of age and under, and the percentage of men 36 yearsof age and over in the various groupings of present condition, as Tables 15 and16 show, there is also indication of a slight tendency for the younger men to bereadapting themselves better than the older men.

TABLE 15.-Distribution of cases within the normal, neurotic, fatigued, and disabled groups according to age

Age	Normal		Neurotic		Fatigued		Disabled
	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent
21 years and younger	58	20.5	33	18.2	21	16.8	24	17.1
22 to 35 years (inclusive)	220	77.8	127	78.8	102	81.6	112	80.7
36 years and older	5	1.7	5	3.0	2	1.6	4	2.2
Total	283	100	165	100	125	100	140	100

TABLE 16.-Distribution of cases within each age group according to condition in 1919-20

Condition	21 years and younger		22 to 35 years (inclusive)		36 years and older
	Number	Per cent	Number	Per cent	Number	Per cent
Normal	58	42.7	220	39.2	5	31.25
Neurotic	33	24.3	127	22.7	5	31.25
Fatigued	21	15.4	102	18.2	2	12.5
Disabled	24	17.6	112	19.9	4	25
Total	136	100	561	100	16	100

PERSONAL AND FAMILY HISTORY (SEPARATELY AND COMBINED), PRIOR TO HOSPITALIZATION, RELATED TO CONDITION IN 1919-20

Often the opinion is expressed that those who, after the war,were not fully recovered from war neuroses were for the most part men ofinferior stock and make-up. In other words, persistence of symptoms is supposedto be related primarily to neuropathic make-up. The accompanying data tend toconfirm this opinion. In the matter of personal history prior to hospitalizationas shown in Table 17, there are 56.4 per cent of those who are now normal whogave a negative history; 47.5 per cent of the neurotic group and 47.6 per centof the fatigued group who were negative; and 45.4 per cent of the disabledgroup. For family history, likewise, the normal group has the highest percentageof negative cases; i. e., 52.8 per cent; the neurotic 46.8 per cent; fatigued44.8 per cent; and disabled 45.5 per cent. When family and personal history arecombined the same tendency is present; for Table 17 also shows that 42.2 percent of the normal group, 31.2 per cent of the neurotic and of the disabled,32.2 per cent of the fatigued group were negative. There is thus a definitetendency for those of good stock and make-up to readapt themselves better tocivilian life than those in whom personal or familial taint is found; still,many war neurotics are now disabled who gave a good history, and a number arenow carrying on who were of poor stock and make-up. Thus, evidently, accordingto these data, stock and make-up alone, though significant, do not afford asufficient basis for the prognosis of civilian readaptation.

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Table 18 shows that on the whole the follow-up group are anadequate sampling of the hospital group from the standpoints of family stock andpersonal make-up.

TABLE 17.-Family and personalhistories (positive and negative) in relation to condition in1919-20, numbers and percentages

	Family history				Personal history				Combined family and personal history
	Positive		Negative		Positive		Negative		Positive		Negative
	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent
Normal	127	47.2	142	52.8	117	43.6	151	56.4	159	57.8	116	42.2
Neurotic	84	53.2	74	46.8	82	52.5	74	47.5	110	68.8	50	31.2
Fatigued	69	55.2	56	44.8	65	52.4	59	47.6	84	67.8	40	32.2
Disabled	78	54.5	65	45.5	77	54.6	64	45.4	96	68.1	45	31.9
Total	358	51.5	337	48.5	341	49.5	348	50.5	449	64.1	251	35.9

^aExclusive of psychotic cases, the number of which is too few (eight) for comparative purposes.

TABLE 18.-Family and personalhistories (positive and negative) of follow-up cases comparedwith 1,000unselected cases from Base Hospital No. 117,numbers and percentages

	Family history				Personal history				Combined family and personal history
	Positive		Negative		Positive		Negative		Positive		Negative
	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent
One thousand unselected cases	508	50.2	505	49.8	527	51.9	488	48.1	643	63.5	370	36.5
Follow-up	358	51.5	337	48.5	341	49.5	348	50.5	449	64.1	251	35.9

SOCIAL STATUS IN RELATION TO PRESENT CONDITION 

PRE-WAR OCCUPATION

The first question that arises regarding occupation is theadequacy of sampling of the follow-up group when compared with the totalhospital service. Using the categories of the Bureau of the Census, the totalscolumn of Table 19 shows that a somewhat greater proportion than the expectedquota answered of those engaged in agricultural (15.5 per cent compared to 11.5per cent) and professional work (10 per cent to 7.2 per cent) and that theproportion of replies from those engaged in trade (8.6 per cent to 11.1 percent) and clerical work (12.7 per cent to 15.9 per cent) was slightly less thanquota. On the whole, the sample was a representative one, for the other itemsused in the United States census, the differences were less than 1 per cent fromexpectation in terms of the total hospital group, namely, 2.2 per cent comparedto 2.3 per cent; 33.3 per cent to 34.7 per cent; 13.5 per cent to 13.8 per cent;2.1 per cent to 2 per cent; 2.1 per cent to 2.5 per cent.

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TABLE 19.-Relation of pre-war occupation^ato condition in 1919-20

	Normal		Neurotic		Fatigued		Disabled		Psychotic		Total of follow-up		Total hospital serviceb
	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent
Agricultural	34	13.9	14	10.4	25	22.5	22	16.8	2	33.3	97	15.5	261	11.5
Mining	4	1.6	2	1.5	2	1.8	5	3.8	1	16.7	14	2.2	53	2.3
Manufacturing	79	32.3	51	37.8	35	31.5	43	32.8	1	16.7	209	33.3	789	34.7
Transportation	24	9.8	20	14.8	19	17.1	22	16.8	---	---	85	13.5	313	13.8
Trade	26	10.6	8	5.9	5	4.5	13	9.9	2	33.3	54	8.6	253	11.1
Public service	3	1.3	4	3.0	1	0.9	5	3.8	---	---	13	2.1	45	2.0
Professional	29	11.9	16	11.8	9	8.1	9	6.9	---	---	63	10.0	163	7.2
Domestic service	5	2.1	2	1.5	4	3.6	2	1.5	---	---	13	2.1	57	2.5
Clerical	41	16.5	18	13.3	11	9.9	10	7.6	---	---	80	12.7	339	15.9
Total	245	100.0	135	100.0	111	100.0	131	100.0	6	100.0	628	100.0	2,273	100.0

^aExclusive of 51 who gave occupation "labor" and 42 who gave "student" (12.9 per cent).
^bExclusive of 293 classed as "labor" and 194 as "student" (15.5 per cent).

TABLE 20.-Relation of1919-20 condition to pre-war occupation

	Agricultural		Mining		Manufacturing		Transportation		Trade
	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent
Normal	34	35.0	4	28.6	79	37.8	24	28.2	26	48.1
Neurotic	14	14.4	2	14.3	51	24.4	20	23.5	8	14.8
Fatigued	25	25.8	2	14.3	35	16.7	19	22.4	5	9.3
Disabled	22	22.7	5	35.6	43	20.6	22	25.9	13	24.1
Psychotic	2	2.1	1	7.2	1	0.5	---	---	2	3.7
Total	97	100.0	14	100.0	209	100.0	85	100.0	54	100.0

	Public service		Professional		Domestic service		Clerical
	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent
Normal	3	23.0	29	46.0	5	38.4	41	51.2
Neurotic	4	30.8	16	25.4	2	15.4	18	22.5
Fatigued	1	7.7	9	14.3	4	30.8	11	13.8
Disabled	5	38.5	9	14.3	2	15.4	10	12.5
Total	13	100.0	63	100.0	13	100.0	80	100.0

^aExclusive of 51 who gave occupation "labor" and 42 who gave "student" (12.9 per cent).

TABLE 21.-Rank order of percentage of men of each occupation of the 1919-20 follow-up group now able to work

Rank order	Occupation	Number	Per cent	Rank order	Occupation	Number	Per cent
1	Clerical	80	73.7	5?	Domestic	13	53.8
2	Professional	63	71.4	7	Transportation	85	51.7
3	Trade	54	62.9	8	Agriculture	97	49.4
4	Manufacturing	209	62.2	9	Mining	14	42.9
5?	Public service	13	53.8

^aCombined ''normal" and ''neurotic" groupsinTable 19.

Tables 19 and 20 bring out the general facts of tendency. Thesignificance of the data is conclusively shown in Table 21 which gives the rankorder of the percentages of men in various occupations now able to carry on. Theranks are arrived at by adding together the percentages of "normal"and "neurotic" for each occupational group as given in Table 20. Withthe exception of mining

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(N-14) and domestic and public service (N-13 in both),the groups are all large enough to draw significant comparisons. From thesefigures it is evident that the clerical and professional groups are making thebest readjustment of all the occupational groups. Trade and the mechanical andmanufacturing trades come next, and at the bottom are transportation,agriculture, and mining. Lastly, it is to be noted that, in general, men fromthe higher types of occupations, those requiring somewhat more intelligence forperformance, are in better shape proportionately than men from some of theseoccupations demanding less intelligence for successful participation.

COMPARATIVE FIGURES FOR THE 1919-20 CONDITION OF THE GROUP ASA WHOLE RELATED TO THEIR CONDITION AT DISCHARGE FROM BASE HOSPITAL No. 117

In comparing the civilian value of this group of men in termsof our categories of readjustment, with their military worth based upon thehospital's classification, an estimate is obtained of the social value of thegroup of men reached in the follow-up in two different social situations; first,the Army at war and during an armistice, and second, civilian life in America in1919-20. Tendencies regarding these facts may be noted by comparing thoseclassified A upon discharge with those now reporting themselves"normal," the B class with the "neurotic," C class with"fatigued," and D and T combined with "disabled" and"psychotic" combined. Furthermore, the class A and class B groups maybe combined and compared with the "normal" and "neurotic"figures.

Table 22 gives us a summary of the 1919-20 condition ofmembers of the group on whom we have data. Practically 61 per cent, thecombined "normal" and "neurotic" groups of the men locatedin 1919-20, were self-supporting in civil life or sufficiently strong and wellto be on active duty in the Army or to be attending school or college. Of this61 per cent, there were 22 per cent in the "neurotic" group who wereable to support themselves, though, from a health standpoint, they were by nomeans well. The remaining 39 per cent in the "fatigued,""disabled," and "psychotic" groups were either in hospitalswhen last heard from or were having difficulties of various sorts. The"fatigued" group were the only ones of those last mentioned who wereable to work at all, and they could work, on the average, only two or three daysa week.

Table 22 is, in effect, a comparison of the militaryclassification of usefulness to an army of a group of neurotics, as a group,with their civilian value in terms of usefulness to society and to themselves ayear or so later, after returning home. It is a striking fact to be gatheredfrom the table that whereas there are almost twice as many of the follow-upgroup proportionately who are "normal" and of full usefulness in civillife as there were those who were class A and presumably of full use to theArmy, still, when one gets the sum of percentages of those of full use (class A)and of prospective full use (class B) and compare with it the sum of those"normal" and those "neurotic," the figures are practicallyidentical (i. e., 61.4 per cent as compared to 60.9 per cent). There are aboutthe same proportions who are now (1919-20) partially or wholly disabled, anddrags on society, as there were of men who were almost, or actually, useless forcombat service.

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TABLE 22.-Comparison of physical classification in the American Expeditionary Forces and the 1919-20 condition of the follow-up group, arranged so as to show cases discharged from hospital before the armistice (upper figures of each group) and during the armistice (lower figures of each group)

Physical classification	Number	Per cent	1919-20 condition of follow-up group	Number	Per cent
A	36	8.2	Normal	171	39.0
	152	47.6		124	38.7
	188	24.8		295	38.9
B	210	47.9	Neurotic	98	22.4
	68	21.0		69	21.5
	278	36.6		167	22.0
C	171	39.0	Fatigued	67	15.3
	51	15.4		64	20.0
	222	29.3		131	17.3
D (and unclassified)	11	4.8	Disabled, psychotic	102	22.3
	46	15.4		63	19.6
	57	9.3		165	21.7

When individual items in Table 22 are compared, though thesame tendencies hold, the discrepancies are greater. For instance, theproportion of class A of theprearmistice group compared with the proportion of "normal" of theprearmistice group gives 8.2 per cent class A and39.0 per cent "normal." On the contrary, for the armistice group thereare 47.6 per cent class A and only38.7 per cent "normal." In class B, thefigures are reversed, the "neurotic" group of the prearmisticedischarge from the hospital contain 22 per cent of the cases whereas class B comprised 47.9 per cent of those discharged before thearmistice; the percentages of class B and"neurotic" are identical for the armisticegroup. And the proportions of Army and civilian disabled in the twogroups for the armistice group are practically identical.

A general conclusion which may be drawnfrom the above facts is: When the civilian status of an unselected group of 800war neurotics returned to civilian life, is estimated in 1919-20 with the fivecategories used here, "normal," "neurotic," etc.,and the proportions of each status compared with the estimates of Armyusefulness (military physical classification) made in France in 1918, we findthat although there is a tendency for a greater proportion to be first-ratecitizens (normal) than first-rate front-line material (class A), still, by and large, the group is as great a weight upon society^b asit was upon the Army in war times inFrance.

At first sight, for 39 per cent of a hospital's service tobe disabled in later life would seemto be a very high figure. And, indeed, in the case of an ordinary hospital, itwould be so. For if, of every 100adults who were in a hospital for operations and diseases during 1918,two-fifths were still to be disabled, healthy and fit men would be at a premium.These figures loom large for the

^bIn attempted explanation of the serious carry-over ofsymptoms by the men of the follow up, it is necessary to include, of course, aconsideration of the significance of the pension issue in relation to presentcondition. Psychoneurotics are liable to be seriously influenced by factorsrelated to Government compensation. An estimate of the relationship between thepresent condition of the former patients of Base Hospital No. 117 andexaggerated desire for Government aid is extremely difficult of definition andbeyond the scope of this study.

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Base Hospital No. 117 service, but small in terms of thetotal American Expeditionary Forces cases. The Base Hospital No. 117 admissionswere of two strains: First, more or less "chronic" cases sent fromother nonpsychiatric hospitals in France; and second, cases from the advancedneurological hospitals. The former cases were usually inadequately treated insome way or other, with consequent fixation of symptoms. Of the latter we havemore definite knowledge. They represent approximately 15 per cent (the severe,resistive cases) of the total neuroses so classified during the St. Mihiel andMeuse-Argonne operations. For every 100 war neurosis cases which developedduring the St. Mihiel and Meuse-Argonne operations, 15 were sent from theforward area hospitals to Base Hospital No. 117. If now, of those 15, two-fifthsare disabled, it means that at least 6 out of every 100 cases developed duringthis period referred to were unable to carry on in civil life in 1919-20.

It is a fair statement to make that the cases discharged fromthe forward area hospitals as class A, and ready to return to the front, whichamounted to 85 out of every 100, would be probably much superior in potentialcivilian well-being to the class A patients of Base Hospital No. 117. Thereforesince 67 per cent of the A cases at Base Hospital No. 117 are now carrying on incivilian life, it follows, if our premise is adequate, that at least two-thirds,or 57 of the 85 admitted to these forward-area hospitals and sent out class A,would be carrying on in civil life. Our estimates, therefore, would be that of100 cases of war neuroses which developed at the front, at least 57 of theadvanced hospital service, and 9 more of those sent from this service to BaseHospital No. 117, or 66 in all, are now carrying on in civil life. Theprobability which may be sustained by future research is that when the warneuroses were handled by specialists at the front the percentage of cure and oflater civilian readjustment is much greater than is found here to be the casefor the Base Hospital No. 117 service, where some of the men were hospitalizedelsewhere before admission, and those from the special service at the front wereespecially severe cases and evacuated to the rear for that purpose.

THE 1924-25 STUDY

The purpose of this study was identical to that of the 1919-20study described above.

Table 23 is concerned with the problem of the adequacy ofsampling of the follow-up group as compared with the total hospital group fromthe standpoint of physical classification. The selection of cases of the followup is in general a good one from the standpoint of physical classification.While there are variations in the relative size of prearmistice and armisticefigures, yet the totals of prearmistice and armistice cases for eachclassification are usually close in both sets of data. For example, the totalsof class A are 23.5 per cent for the follow-up group and 19.6 per cent for thetotal hospital group,

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for class B, 39.2 per cent and 39.1 per cent, respectively,class C, 29.3 and 31.8 percent, class D, 5.9 per cent and 6.6 per cent, etc. (Table 24.) For the totalgroups likewise the prearmistice and armistice selections are good samplings(60.5 per cent of the follow up are prearmistice, compared to 56.3 per cent ofthe total hospital group and 39.5 per cent are armistice compared with 43.3 percent of the total hospital group). Thus, the 1924-25 follow-up group are arepresentative sampling of the hospital's service from the standpoint ofphysical classification.

TABLE 23.-Comparison of the 1924-25 follow-up group and the total Base Hospital No. 117 service in regard to physical classification

Physical classification	Totals for follow up		Total for hospital		Physical classification	Totals for follow up		Total for hospital
	Number	Per cent	Number	Per cent		Number	Per cent	Number	Per cent
A	35	7.6	142	9.7	D	8	1.7	32	2.2
	154	51.1	366	32.6		36	12.0	139	12.4
	189	23.5	508	19.6		44	5.9	171	6.6
B	241	52.1	696	47.4	Tb	6	1.3	48	3.3
	58	19.2	316	28.1		2	0.7	27	2.4
	299	39.2	1,012	39.2		8	1.5	75	2.9
C	172	37.2	548	37.4	Totals	462	60.5	1,466	56.3
	51	16.9	276	24.6		301	39.5	1,124	43.7
	223	29.3	824	31.8		763	100.0	2,590	100.0

^aIn each group of figures,the upper figure indicates cases discharged before the armistice, the lower,cases discharged during the armistice, the figures below the line, total.
^bT=cases transferred to another hospital, unclassified.

From Table 24 we are able to determine the prognostic valueof physical classification for civilian readjustment in 1924-25. Although in aperiod of seven years there have been many ups and downs, fortunate events, andalso difficulties and discouragements, to change the mood and outlook of thesemen, we still find a positive correlation between physical classification andcivilian readjustment, despite all the circumstances that would enter to impairsuch a relationship. In the column for class A we now note 83 per cent carryingon (40.7 per cent normal, 42.3 per cent neurotic); of class B, 85.9 per cent arecarrying on (39.1 per cent normal, 46.8 per cent neurotic); of class C, 73.9 percent are carrying on (30 per cent normal, 43.9 per cent neurotic); of class D,72.7 per cent are carrying on (40.9 per cent normal, 31.8 per cent neurotic).Members of class B, as a group, are adjusting themselves better to civilian lifethan class A. Though a slightly smaller per cent of class B are normal, the 4.5per cent greater number of class B now neurotic makes the total of men able tocarry on (i. e., either normal or neurotic) for class B 2.9 per cent greaterthan for class A. Class C and class D are smaller in percentage of recoveriesthan class A and class B. Thus, the hospital estimates of potential militaryvalue are again found to be of some significance for the group as a whole asprophecy of future civilian readjustment.

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TABLE 24.-Physical classification of 1924-25 follow-up group in relation to condition in 1924-25

	Class A		Class B		Class C		Class D		Tb		Totals
	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent
Normal	18	51.4	94	39.0	48	27.9	2	25.0	2	33.3	164	35.5
	59	38.3	23	39.7	19	37.2	16	44.4	0	0.0	117	38.9
	77	40.7	117	39.1	67	30.0	18	40.9	2	25.0	281	36.9
Neurotic	11	31.4	113	46.9	79	45.9	3	37.5	2	33.3	208	45.0
	69	44.8	27	46.5	19	37.2	11	30.5	1	50.0	127	42.2
	80	42.3	140	46.8	98	43.9	14	31.8	3	37.5	335	43.9
Fatigued	3	8.6	20	8.2	27	15.7	1	12.5	2	33.3	53	11.5
	15	9.8	4	6.8	2	4.0	1	2.8	0	0.0	22	7.3
	18	9.5	24	8.0	29	13.0	2	4.6	2	25.0	75	9.8
Disabled	3	8.6	12	4.9	17	9.9	0	0.0	0	0.0	32	6.9
	6	3.9	3	5.2	9	17.6	8	22.2	1	50.0	27	8.9
	9	4.7	15	5.0	26	11.7	8	18.2	1	12.5	59	7.7
Psychotic	0	0.0	2	0.0	1	0.6	2	25.0	---	---	5	1.1
	5	3.2	1	1.7	2	4.0	0	0.0	---	---	8	2.7
	5	2.6	3	1.0	3	1.4	2	4.6	---	---	13	1.7
Totals	35	100.0	241	100.0	172	100.0	8	100.0	6	100.0	462	100.0
	154	100.0	58	100.0	51	100.0	36	100.0	2	100.0	301	100.0
	189	100.0	299	100.0	223	100.0	44	100.0	8	100.0	763	100.0

^aThe upper number in each group indicates cases dischargedfrom Base Hospital No. 117 before the armistice: the second number, casesdischarged during the armistice: and the number below the line, the total.
^bT=Cases transferred to another hospital, unclassified.

DIAGNOSIS IN FRANCE IN RELATION TO CONDITION IN 1924-25

In attempting to learn what relationships prevailed in 1924-25between the various diagnostic groups and civilian readjustment, our firstquestion again is concerned with the selection of cases. Table 25 gives thefrequency of usage of the various diagnoses in the total hospital service, withtheir occurrence in the follow-up of 1924-25. It shows that the follow-upgroup is a good sampling of the total hospital service from the standpoint ofdiagnosis; for example, the percentage of cases of hysteria in the follow-up is27 and in the total hospital group 27.6. Concussion neurosis is even closer toexactness, 22.2 per cent of the follow up and 22.1 per cent of the totalhospital group; neurasthenia is 12.5 per cent of the follow-up and 12.1 per centof the total hospital service.

Table 26 gives the relationship of diagnosis to presentcondition; the psychotics are combined with the disabled group. Some of thediagnostic groups are small, yet since this smallness is representative of theiractual proportional number, their inclusion is desirable. If we combine for eachdiagnosis the normal and neurotic groups (that is, the patients who wereself-supporting in civilian life in 1924-25) and compare the various diagnoseson the basis of percentage carrying on and percentage unable to carry on(fatigued, disabled, or psychotic) significant features of the data are broughtto light. In Table 27 the various diagnoses are ranked on the basis of thepercentage of those reached in 1924-25 who were carrying on in civilian life.

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TABLE 25.-Comparison of the 1924-25 follow-up group and the total population of Base Hospital No. 117 in regard to diagnosis

Diagnosis	Totals for follow-up	Totals for hospital group	Per cent of follow-up	Per cent of hospital group	Diagnosis	Totals for follow-up	Totals for hospital group	Per cent of follow-up	Per cent of hospital group
Hysteria	119	379	25.8	25.9	Psychasthenia	7	28	1.5	1.9
	87	338	28.9	30.1		3	12	1.0	1.1
	206	717	27.0	27.6		10	40	1.3	1.6
Concussion neurosis	93	326	20.2	22.2	Timorousness (state of anxiety)	10	20	2.1	1.4
	77	247	25.6	22.0		5	33	1.6	2.9
	170	573	22.2	22.1		15	53	1.9	2.0
Neurasthenia	56	187	12.1	12.8	Anticipation neurosis	6	22	1.3	1.5
	39	127	13.0	11.3		0	7	0.0	0.6
	95	314	12.5	12.1		6	29	0.8	1.1
Hypochondriasis	10	58	2.1	3.9	Gas neurosis	10	21	2.1	1.4
	12	39	4.0	3.4		9	30	3.0	2.7
	22	97	2.9	3.8		19	51	2.5	1.9
Exhaustion	31	72	6.7	4.9	Gas syndromea	5	3	1.1	0.2
	19	67	6.3	5.9		2	8	0.7	0.7
	50	139	6.6	5.4		7	11	0.9	0.4
Effort syndrome	9	28	1.9	1.9	Traumatic neurosis	3	4	0.7	0.3
	2	29	0.7	2.6	Gastric neurosis, postoperative	1	1	0.3	0.1
	11	57	1.4	2.2		4	5	0.5	0.2
Anxiety neurosis	40	118	8.7	8.1	No disease	2	19	0.4	1.2
	12	56	4.0	4.9		13	53	4.3	4.7
	52	174	6.9	6.7		15	72	1.9	2.8
Concussion syndrome	61	181	13.2	12.4	Totals	462	1,466	100.0	100.0
	20	77	6.6	6.9		301	1,124	100.0	100.0
	81	258	10.6	10.0		763	2,590	100.0	100.0

(The upper number in each group indicates the casesdischarged from Base Hospital No. 117 before the armistice, the second, casesdischarged during the armistice, and the number below the line, the total.)
^aThe discrepancy intotal hospital and follow-up statistics is due to the fact that gas syndrome wasused a few times as subsidiary diagnosis.

Again the typical war neurosis, such as gas syndrome,exhaustion, concussion, anxiety, show the best recovery, except for gas neurosis(N-19); whereas the more pronounced constitutional types (neurasthenia,psychasthenia, effort syndrome) rank lower. There are, as one might expect, somesignificant changes in rank among the 1924-25 group as compared with the 1919-20group (given in Table 13); for example, exhaustion neurosis goes from rank 7 torank 2, with 48 of the 50 men, or 96 per cent, carrying on. In this connection,it is surprising, in view of the nature of their difficulties in France, thatthey did not rank higher in 1919-20; however, the fact that by now 48 out of 50 of them have been able to return to theposition of being self-supporting is a significant proof of diagnosis exactitudein the hospital service. Likewise, that the concussion and anxiety cases havemade a good readaptation is a justification of their diagnosis and the generalopinion of their condition held by the Base Hospital No. 117 staff in France. Onthe other hand, that the effort syndrome group is still in difficulty was wellnigh predictable, as functional heart conditions are liable to chronicity.Hypochondriasis, neurasthenia, psychasthenia, are about at the relative rankpredicted by the

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medical experts of the hospital. The best insight into themeaning of war-time diagnosis is found by comparing the percentage of recoveryin 1924-25 from Table 27 with the same facts for 1919-20 in Table 13. Atonce it is apparent that practically all of the diagnostic groups show a higherpercentage of readaptation at the later date. Gas neurosis, no disease, andeffort syndrome have not shown an improvement from a percentage standpoint. Onlyanticipation neurosis (which forms a small group of six cases) has shown adecrease in percentage of men with that diagnosis able to carry on.

TABLE 26.-Condition in 1924-25in relation to diagnosis in France

	Normal		Neurotic		Fatigued		Disabled and psychotic		Totals
	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent
Hysteria	32	19.6	60	29.0	15	28.9	12	32.4	119	25.9
	33	28.1	33	25.9	8	36.4	13	38.2	87	29.0
	65	23.2	93	27.9	23	31.1	25	35.2	206	27.1
Concussion neurosis	42	25.8	39	18.9	10	19.2	2	5.4	93	20.3
	31	26.4	35	27.8	6	27.3	5	14.7	77	25.7
	73	26.0	74	22.1	16	21.6	7	9.8	170	22.4
Neurasthenia	16	9.8	26	12.6	8	15.4	6	16.2	56	12.2
	13	11.1	18	14.1	2	9.1	6	17.7	39	13.0
	29	10.4	44	13.2	10	13.5	12	16.9	95	12.5
Concussion syndrome	20	12.3	28	13.5	9	17.3	4	10.8	61	13.4
	6	5.1	12	9.4	0	0.0	2	5.9	20	6.7
	26	9.3	40	11.9	9	12.2	6	8.3	81	10.7
Anxiety neurosis	19	11.5	17	8.2	1	1.9	3	8.1	40	8.3
	5	4.2	3	2.3	2	9.1	2	5.9	12	4.0
	24	8.6	20	6.0	3	4.1	5	7.0	52	6.9
Exhaustion neurosis	16	9.8	13	6.3	2	3.9	---	---	31	6.8
	11	9.3	8	6.3	0	0.0	---	---	19	6.3
	27	9.6	21	6.3	2	2.7	---	---	50	6.6
Hypochondriasis	0	0.0	8	3.0	---	---	2	5.4	10	2.2
	3	2.5	6	4.7	---	---	3	8.8	12	4.0
	3	1.1	14	4.2	---	---	5	7.0	22	2.9
Psychasthenia	3	1.8	1	.5	1	1.9	2	5.4	7	1.5
	2	1.6	1	.8	0	0.0	0	0.0	3	1.0
	5	1.8	2	.6	1	1.3	2	2.9	10	1.3
Gas neurosis	3	1.8	4	1.9	1	1.9	2	5.4	10	2.2
	4	3.3	3	2.3	0	0.0	2	5.9	9	3.0
	7	2.5	7	2.1	1	1.3	4	5.8	19	2.5
Anticipation neurosis	3	1.8	1	.5	1	1.9	1	2.7	6	1.3
	0	0.9	0	0.0	0	0.0	0	0.0	0	0.0
	3	1.1	1	0.3	1	1.3	1	1.4	6	0.8
Effort syndrome	2	1.2	3	1.4	1	1.9	3	8.2	9	1.9
	1	2.5	0	0.0	1	4.5	0	0.0	2	0.7
	3	1.1	3	0.9	2	2.7	3	4.3	11	1.5
Timorousness	5	3.1	3	1.4	2	3.8	0	0.0	10	2.2
	3	1.7	1	0.8	0	0.0	1	5.9	5	1.7
	8	2.8	4	1.2	2	2.7	1	1.4	15	1.9
Gas syndrome	2	1.2	3	1.4	---	---	---	---	5	1.1
	1	0.9	1	0.8	---	---	---	---	2	0.7
	3	1.1	4	1.2	---	---	---	---	7	0.9
No disease	0	0.0	1	.5	1	1.9	---	---	2	0.4
	4	3.4	6	4.7	3	13.6	---	---	13	4.3
	4	1.4	7	2.1	4	5.5	---	---	15	1.9

(The upper number in each group indicates the cases discharged from Base Hospital No. 117 before the armistice, the lower, cases discharged during the armistice, and the number below the line, the total.)

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TABLE 27.-Rank order of diagnoses on the basis of the percentage of those carrying on"^a in civilian life in 1924-25

Rank	Diagnosis	Per cent	Rank	Diagnosis	Per cent
1	Gas syndrome	100.0 (N-7)	8	Neurasthenia	76.8 (N-95)
2	Exhaustion neurosis	96.0 (N-50)	9	Hysteria	76.7 (N-206)
3	Concussion neurosis	86.5 (N-170)	10	Gas neurosis	73.6 (N-19)
4	Anxiety neurosis	84.6 (N-52)	11	No disease	73.3 (N-15)
5	Concussion syndrome	81.5 (N-81)	12	Psychasthenia	70.0 (N-10)
6	Timorousness	80.0 (N-15)	13	Anticipation	66.7 (N-6)
7	Hypochondriasis	77.2 (N-22)	14	Effort syndrome	54.4 (N-11)

^aSee p. 456 forcomparative figures of 1919 follow-up group.

PHYSICAL AND MENTAL CONSIDERATIONS IN RELATION TO CONDITIONS IN 1924-25

AGE

In getting data on age, the men were asked for their agesdirectly in the questionnaire sent to each, instead of using the age at time ofhospitalization. Thus the median age at the time of hospitalization would haveto be increased by six years to make it comparable with the median for the ageof the group reached in the summer of 1924, which is on the average six yearsafter hospitalization. The two medians are then quite similar-30.66 years fortotal hospital group, 30.39 years for this follow-up. (Table 28.)

As far as the factor of age enters toexplain readjustment in 1924-25, there does seem to be a tendency for theextremes of the distribution to be less well readapted than the more centralgroups. In Table 29, the figures show that there is a higher percentage of casesin the fatigued and disabled groups at the extreme ages than in the middleranges. Likewise, in Table 30, the percentages of cases having difficulties ishigher at the extreme ages than in the middle range of ages, i. e., from 28 to35. There is thus a tendency for the extreme age groups, the younger and theolder men, to be making poorer readaptations than the men of the middle range ofages.

TABLE 28.-Ages of follow-up groups in relation to condition in 1924-25

Age	Normal	Neurotic	Fatigued	Disabled	Psychotic	Totals
22	1	1	---	1	---	3
23	1	2	1	---	---	4
24	7	12	1	---	---	20
25	9	18	5	6	---	38
26	21	20	9	6	1	57
27	21	21	7	4	---	53
28	33	52	8	3	1	97
29	34	46	20	9	2	111
30	35	34	8	6	3	86
31	21	26	4	5	---	56
32	24	34	6	3	---	67
33	19	19	4	3	1	46
34	8	20	4	4	1	37
35	11	12	2	2	1	28
36	14	8	7	4	---	33
37	5	9	2	2	---	18
38	2	2	2	2	1	9
39	2	2	---	1	---	5
40	---	2	1	1	---	4
41	4	1	---	---	---	5
42	1	---	1	---	---	2
43	---	1	---	---	---	1
44	---	1	---	---	---	1
45	---	1	1	---	---	2
46	---	---	---	---	---	---
47	2	---	---	---	---	2
48	---	---	---	---	---	---
49	---	---	---	---	---	---
50 and over	5	3	---	---	---	8
N	280	347	93	62	11	793
Median	30.39	39.06	29.80	30.58	30.67	30.93

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TABLE 29.-Distribution of cases within thenormal, neurotic, fatigued, and disabled groups, according to age

Age	Normal		Neurotic		Fatigued		Disabled
	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent
27 years and younger	60	21.4	74	21.3	23	24.7	17	27.4
28 to 35 years (inclusive)	185	66.1	243	70.0	56	60.2	35	56.3
36 years and older	35	12.5	30	8.7	14	15.1	10	16.3
Totals	280	100.0	347	100.0	93	100.0	62	100.0

TABLE 30.-Distribution of cases within each age group according to condition in 1924-25

Condition	27 years and younger		28 to 35 years (inclusive)		36 years and older
	Number	Per cent	Number	Per cent	Number	Per cent
Normal	60	34.5	185	35.7	35	39.2
Neurotic	74	42.5	243	46.8	30	33.7
Fatigued	23	13.2	56	10.8	14	15.7
Disabled	17	9.8	35	6.7	10	11.3
Total	174	100.0	519	100.0	89	100.0

FAMILY AND PERSONAL HISTORY (SEPARATELY AND COMBINED), PRIOR TO HOSPITALIZATION, RELATED TO CONDITION IN 1924-25

The data in Table 31 indicate that, in so far as they applyto this group, previous familyand personal histories are not in themselves very significant determiners forpresent condition. In fact the group now classed as normal herein gives a poorerpersonal history than the neurotics, and a poorer combined personal and familyhistory than the neurotics and fatigued. Of course, not all the cases areincluded, as the data were missing on some cases from the clinical historieswritten in France. Furthermore, all data on family and personal history are aptto be unreliable unless collected for specific purposes and under definitedirections, which is in many cases not true of these data. But from the dataavailable family and personal histories, as previously shown in the 1919-20study, are not very significant in themselves in relation to civilianreadaptation. Whereas in the 1919-20 group a slight tendency existed for abetter readjustment to be made by those giving negative histories, by 1924, thistendency has decreased almost to insignificance.

Table 32 shows that on the whole the follow-up group are anadequate sampling of the hospital group from the standpoint of family stock andpersonal make-up.

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TABLE 31.-Family and personal histories in relation to condition in 1924-25

	Family history				Personal history				Combined family and personal history
	Positive		Negative		Positive		Negative		Positive		Negative
	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent
Normal	128	56.6	98	43.4	112	51.6	105	48.4	149	68.0	70	32.0
Neurotic	141	53.0	125	47.0	124	47.1	139	52.9	163	62.4	98	37.6
Fatigued	36	58.1	26	41.9	64	52.5	58	47.5	81	67.9	38	32.1
Disabled	21	42.0	29	58.0	24	52.2	22	47.8	32	68.1	15	31.9
Total	326	53.9	278	46.1	324	50.0	324	50.0	425	65.8	221	34.2

TABLE 32.-The follow-up cases (1924-25) compared with 1,000 unselected cases from Base Hospital No. 117

	Family history				Personal history				Combined family and personal history
	Positive		Negative		Positive		Negative		Positive		Negative
	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent
Total Base Hospital No. 117 patients	508	50.2	505	49.8	527	51.9	488	48.1	643	63.5	370	36.5
Follow-up group	326	53.9	278	46.1	324	50.0	324	50.0	425	65.8	221	34.2

Lastly, it is a rather interesting commentary on the wholeconception of "neuropathic" taint that there are so many men (overfour-fifths) now able to carry on in thisgroup of men, and (by comparison with the findings in 1919-20, which was aboutthree-fifths) an increasing number and proportion who give a neuropathic (i. e.,war neurotic) history. Smith and Pear³ have expressed very well the loosenessand inadequacy of all explanation of nervous or mental disease in terms ofso-called "neuropathic" taint. It is noteworthy that this group showsno very significant relationship between these factors of make-up and thecapacity of readaptation to civilian environment.

SOCIAL STATUS IN RELATION TO PRESENT CONDITION 

PRESENT OCCUPATION

Again the adequacy of sampling of the follow-up compared tothe hospital service is important. It must be realized at once that when onlythe present occupation is considered, the psychotic and disabled patients willautomatically be excluded, for they are not at work. Likewise many of thosereported at work were doing things describedin a way difficult to allocate withthe Bureau of the Censuscategories. Taking the 562 cases which remain in the 3 groups,and comparing them with the proportionsof the total hospital group, we find (in Table 33) that the samplingis a selected one in the divisions of transportation (7.7 per cent of this follow-up group instead of 13.8 percent in the total hospital figures),trade (18.1 per cent instead of 11.1 per cent), public service (5.5 percent instead of 2 per cent),clerical work (11.2 per cent insteadof 15.9 per cent), though uponinspection of the other categories(agriculture, mining, manufacturing, professional) it isnoted that the sampling is a goodone.

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TABLE 33.-Relation of occupation^a (1924-25) of follow-up group and total patients of Base Hospital No. 117 to working capacity

	Normal		Neurotic		Fatigued		Total of follow-upb		Total of hospital service
	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent
Agriculture	9	3.7	49	17.0	10	32.3	68	12.1	261	11.5
Mining	9	3.7	4	1.4	---	---	13	2.3	53	2.3
Manufacturing	79	32.5	95	32.9	10	32.3	184	32.8	789	34.7
Transportation	16	6.6	25	8.7	2	6.4	43	7.7	313	13.8
Trade	51	20.9	49	17.0	2	6.4	102	18.1	253	11.1
Public service	16	6.6	14	4.9	1	3.2	31	5.5	45	2.0
Professional	23	9.5	13	4.5	---	---	36	6.4	163	7.2
Domestic service	10	4.1	7	2.4	5	16.1	22	3.9	57	2.5
Clerical	30	12.4	132	11.1	1	3.2	63	11.2	339	15.9
Total	243	100.0	288	100.0	31	100.0	562	100.0	2,273	100.0

^aExclusive of those who were "disabled" orpsychotic at time of writing, who were by definition out of work.
^bExclusive of 293 classified as "labor" and 194 as"student" (15.50 per cent).

Tables 34, 35, and 36, give the facts of occupation relatedto present condition in the Bureau of the Census categories of general types ofwork. Again, as in the 1919-20 followup (i. e., Tables 19, 20, and 21), thoseengaged in agricultural work and those in transportation are making the poorestreadaptation. Mining is too small a group (N-13) to be significant, but thosereporting show the highest percentage as normal. The professional group aremaking the next best readaptation. Then come public service and trade, thenmanufacturing, transportation, and last of all agriculture. These facts aregiven in a rank-order presentation in Tables 35 and 36. In Table 36 the samefacts are given for those now reporting themselves as neurotic or fatigued. Thepercentages are of course the complement of those in Table 35, since the twotables include the total number of men now at work in each occupation.

TABLE 34.-Relation of condition in 1924-25 to occupation in 1924-25

	Agriculture		Mining		Manufactur- ing		Transporta- tion		Trade		Public service		Professional		Domestic service		Clerical
	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent	Number	Per cent
Normal	9	13.2	9	69.2	79	42.2	16	37.2	51	50	16	51.6	23	63.9	10	45.4	30	47.6
Neurotic	49	72.1	4	30.8	95	51.5	25	58.1	49	48	14	45.1	13	36.1	7	31.8	32	50.8
Fatigued	10	14.7	---	---	10	5.4	2	4.7	2	2	1	3.2	---	---	5	22.7	1	1.6
Total	68	100.0	13	100.0	184	100.0	43	100.0	102	100	31	100.0	36	100.0	22	100.0	63	100.0

TABLE 35.-Rank order of percentage of men of each occupation of the 1924-25 follow-up group now normal

Rank order	Occupation	Number	Per cent	Rank order	Occupation	Number	Per cent
1	Mining	13	69.2	6	Domestic service	22	45.4
2	Professional	36	63.9	7	Manufacturing	184	42.2
3	Public service	31	51.6	8	Transportation	43	37.2
4	Trade	102	50.0	9	Agriculture	68	13.2
5	Clerical	63	47.6

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TABLE 36.-Rank order of percentage of men of each occupation of the 1924-25 follow-up group now either neurotic or fatigued

Rank order	Occupation	Number	Per cent	Rank order	Occupation	Number	Per cent
1	Agriculture	68	86.8	6	Trade	102	50.0
2	Transportation	43	62.8	7	Public service	31	48.4
3	Manufacturing	184	57.8	8	Professional	36	36.1
4	Domestic service	22	54.6	9	Mining	13	30.8
5	Clerical	63	52.4

Since our comparison in Tables 35 and 36 is practicallybetween the normal and the neurotic group (there are so few cases comparativelyin the fatigued group), we also get a suggested estimate of what line of work aformer war neurotic is now able to engage in as a normal healthy person, and inwhat general kinds of work he is able to carry on though still somewhat morenervous and unhealthy than the ordinary workman in that line of work, so far aswe know. This last might suggest an answer to the question: In what lines ofwork can a psychoneurotic, still suffering from mild but quite annoyingsymptoms, be able to get along and be independent? The answer is agriculture farabove all others, then transportation, clerical work, trade and the variouslines of manufacturing. It is noteworthy in this connection that the historiesof some of the men are in line with this. Many who had difficulty working atmanufacturing trades in towns or cities have been able to make a fairlysuccessful readaptation in agricultural work. Some have even so improved as tobe entirely self-supporting and gradually losing all their symptoms.

PRESENT CONDITION OF THE GROUP AS A WHOLE

The five years intervening since 1919-20 saw thedevelopment of good improvement in the Base Hospital No. 117 group. Whereas in1919 the percentage of those reached who were able to carry on (that is, normalor neurotic), was only 60.9; by 1924-25 this had grown to 80.8 as shown inTable 37. The fatigued group who were able to work but half the time amounted to9.8 per cent as compared with 17.3 per cent in 1919-20, and the disabled orpsychotic who were practically unable to work at all, amounted to 9.4 per centinstead of 21.7 per cent in the previous study.

When further comparison is made of the military value andcivilian usefulness of these men, we find 62.7 per cent of good actual orpotential military value (classes A and B) and 80.8 per cent of good civilianusefulness (normal and neurotic). There is a greater proportion (36.9 per cent)who are of full value as civilians (normal) than who were immediate front-linematerial (23.5 per cent) in France (class A) but almost equal proportions (38.2per cent) of potential front-line material (class B and somewhat nervousindividuals (neurotic) of not quite full civilian efficiency (43.9 per cent).The 1924-25 follow-up group is of much more usefulness to society now thanthey were to the Army at the time of discharge from the hospital. This is a verysignificant improvement over the conditions in 1919-20 of a similar-sizedgroup of war neurotics reached at that time who were as much a burden to societyas they were to the American Expeditionary Forces.

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TABLE 37.-Direct comparison of physicalclassification in France and condition in 1924-25 of the follow-up group

Classification	Military classification		Classification	Present condition
	Number	Per cent		Number	Per cent
A	35	7.6	Normal	164	35.5
	154	51.1		117	38.9
	189	23.5		281	36.9
B	241	52.1	Neurotic	208	45.0
	58	19.2		127	42.2
	299	39.2		335	43.9
C	172	37.2	Fatigued	53	11.5
	51	16.9		22	7.3
	223	29.3		75	9.8
D and T	14	3.0	Disabled, psychotic	37	8.0
	38	12.7		35	11.6
	52	7.4		72	9.4

(The upper number in each group indicates the casesdischarged from Base Hospital No. 117 before the armistice, the second, casesdischarged during the armistice, and the number below the line, the total.)

There are once more discrepancies in individual items in thiscomparative study as shown in Table 38. The proportion of class A of theprearmistice group was 7.6 per cent, but 35.5 per cent of the armistice groupwere normal in 1914. On the other hand, the armistice class A amounted to 51.1per cent and only 38.9 per cent of this group are now normal. The prearmisticeclass B amounted to 52.1 per cent but the prearmistice cases now neurotic areonly 45 per cent; the armistice, class B were 19.2 per cent and the armistice neurotic42.2 per cent. Both the prearmistice and armistice proportions of"fatigued" cases are considerably smaller than the class C cases. Andlastly, those of the prearmistice group now seriously handicapped constitute 8per cent of the group as compared with only 3 per cent of D and T dischargesbefore the armistice.

These figures show a marked tendency for improvement amongthe men of the follow-up group as a whole in the interim of five years since thestudy made in 1919-20. What the causes are that underlie the improvement is adifficult problem for complete analysis. A few that might be cited are the vismedicatrix ofnature in that length of time, the improvement of business conditions, offeringmore opportunities for civilian reestablishment, and, perhaps most essential ofall, the various governmental and social agencies focused upon the problem ofsoldier after care. At any rate, whatever the causes of improvement, thehospitalized war neurotics of the American Expeditionary Forces have now becomemore of a social asset in civilian life than they were in 1919-20 andconsiderably less of a problem as a group to themselves, to their families andto the American people.

REFERENCES

(1) Southard, E. E.: Shell Shock and After. The Shattuck Lecture. Boston Medical and Surgical Journal, 1918, clxxix, No. 3, 73.

(2) Mott, F. W.: War Neuroses. British Medical Journal, 1919, i, April 12, 439.

(3) Smith, G. Elliot, and Pear, T. H.: Shell Shock and its Lessons. 2d Ed. Longmans, Green & Co., 1917, 88.

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