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Section II, Chapter V

Table of Contents

CHAPTER V

WAR NEUROSES AS A MEDICO-MILITARY PROBLEM

War neuroses as a medico-military problem present three important aspects for consideration, each of which necessitates some special notice.

First, there is the military aspect of the problem. This concerns itself with the important fact that, in most instances, the soldier with a war neurosis is physically intact and very often in splendid physical condition. His symptoms of disease are disturbances due to an intricate physical mechanism of defense based primarily on the primitive instinct of self-preservation. He obviously can not be classified as mentally unfit; no more can he be regarded as physically disabled, yet he is incapable in this state of acting the part of a soldier. The fact that at times he has only a limited power of volition over his disability removes him from the class of malingerers. As many of these patients have been good soldiers, judgment as to their potential ability for further military life must be suspended. Where to place such an individual, and what to do with him, are questions that present themselves immediately. A soldier physically fit, mentally not affected, in every outward aspect a good fighting type, not a coward, often wanting to get back to the lines but held in the grip of a mechanism which negatives his soldierly impulses, presents a problem that again and again has mystified an officer who has at heart the best interests of the men under his command. Where the number of 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 military importance. Therefore, no statement of the problem of the war neuroses can be made without considering from the very beginning its military significance. Many of the errors made in attempting to solve the problems of the war neuroses among soldiers might have been avoided if at all times the military point of view had been kept in mind. This point of view might be expressed as the effort toward returning such a patient to his former status as a soldier with the basic assumption that this is a thing possible to accomplish.

The second aspect is purely clinical. A traumatic incident or a series of them acting on the human organism, causes that organism to respond functionally 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, to designate them in some way, differentiate them from similar types seen in other conditions, and to devise some adequate means by which they can be treated and managed. The significant thing is that the war neuroses are essentially reactions to the varying incidents of war and that usually there is present a known set of etiologic factors. There is, further, a varying effect from the etiologic incident, and a therapeutic aim, which has as its chief incentive the return of the subject of war neurosis back to the conditions which, in the first instance, caused them to appear.


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The third phase of the statement of the problem is the definition of mechanism. For it is necessary to know something of the processes which activate the clinical syndrome, as the surface symptoms are more a result of this deeper-lying, but not readily understood process. These must first be appreciated before anything really tangible can be done for the victims of war neurosis. Incidentally, it is this emphasis upon the underlying mechanism and not on symptomatic expressions, this apparent indifference, in fact, to specific symptomatology, which differentiates war neurosis from almost every other clinical problem.

MECHANISM AND CLINICAL EXPRESSIONS

The conception of war neurosis as a defensive mechanism or as a part of a system of physiologic or bodily conservation may be approached with less difficulty if it is made clear just what is implied by these terms. It is necessary, also, to appreciate the fact that the defense meant here is not conscious, but automatic and probably altogether outside of volition.

There exist in all living organisms, sets of factors which work toward saving them from destruction. There exists, likewise, in each important function of that organism, a mechanism for preventing the function from becoming excessive and for preventing injury to it as a whole or to its respective elements. Living would be impossible if this did not exist. The protection may be purely automatic and adjustable to mechanical factors, as, for instance, the hypertrophy of the heart. It may be chemical, as in the immunity defense. It may be various combinations and mixtures in which polyglandular activities come into play. It may be physiologic in respect to functional adjustments and physical when deeper and more intricate activities of consciousness are at work. The latter may be termed physiologic, but for convenience 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 principle has long been recognized and, by whatever term it has been designated, it has been an admitted fact to be considered always in the attempts to understand the phenomena of life. When the mechanism of defense, whatever its nature is, becomes inactive or less efficient, the living organism may be said to approach destruction, or, if it fails completely, the organism dies. It is possible, perhaps, to divide the defense mechanism into two classes, one acting to prevent the mechanical using up of the living tissue-the wear and tear of the machinery of life-the other acting to resist and modify the exogenous factors of a destructive kind to which every living thing is ceaselessly exposed. It is obvious that, even if no sharp line of demarkation can be said to separate these two, yet the adjustability of the defense shows, in either instance, a difference in the quality of promptness and speed with which it can be put into action. The mechanically incited defensive organization is apt to be slow and cumbersome, taking place gradually according to the progress which the changed conditions of the mechanism itself necessitates, while the other must be capable of meeting quickly and decisively the immediacy of an oncoming event. Therefore, the latter type of defense must possess a certain power of selection or adaptability, 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 of view as this they show the characteristics of an exquisitely adjustable and often complicated piece of psychical machinery, adequately and, in a sense, personally fulfilling the purpose of protecting the individual against reexperiencing a series of destructive events to which he recently has been exposed. The analogy between the organically activated or sensitized probably goes no further than this, and the comparison has served its purpose if the fact has been made clear that the neuroses defensively considered are a part of a mechanism so fundamental for the preservation of life, as a physical phenomenon, that their existence can not well be doubted. There is nothing new in this conception. Freud long ago, and others before him, had seen in the neuroses something more than a collection of symptoms simulating organic diseases. Many students of the neuroses have been impressed with the apparent needless overemphasis of symptoms in face of slight degrees of possible determining factors, and they must have seen in this, or dimly felt at any rate, that some other incentive was at work than merely processes of reaction on the part of the organism. It was in this zone of overresponse that the explanation was to be found.

With the appearance, in the early nineties, of Freud's Abwehr-Neurosen, the conception of the neuroses as defense mechanisms began to make slow headway among the neurologists. To many of them the rest of the Freudian psychology was not convincing. That conception, however, was so helpful and clarifying that it gained the support and belief of many to whom anything else coming from that school would not have been acceptable.

The war neuroses have given the opportunity to test out this aspect of the Freudian psychology by furnishing thousands of cases in which a well known, and more or less constant, etiology was always to be found, and in which the resulting reactions might be studied, divorced completely from the cloud of etiologic sexual entanglements which so confuse the attempt to understand the peace neuroses.

With this conception of the neuroses in mind there remains to study them as they show themselves clinically in varied disease pictures, and to attempt to understand what these pictures mean and how they came about. The test of the accuracy of this conception is to be found in the light that it can throw on origins and mechanisms and the use that can be made of it in appreciating why the thing has happened. A further test will be shown if the facility by which symptoms can be treated and the patient restored to the condition he was in before is increased. The war neuroses show themselves clinically in a variety of confusing types. Classification seems almost impossible because the same symptoms are represented by types that are obviously distinct. In a group of a hundred acute cases, for example, there will be many symptomatic types, such as frank hysterias, anxiety groups, pure sensory disassociation forms, individual over-reactions, concussion forms, episodal and transient mental states.


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Two ways are open in facing so complex a clinical demonstration. The first is to regard classification as of little consequence, but merely to find some few labels grossly descriptive of large groups and then to think of them as a whole and approach the therapeutic task by some mass form of treatment. The other way is to attempt a grouping, not based on clinical appearances alone, but on mechanism and the most immediate of the etiologic factors concerned. The former method has been adopted by most of the English and French neurologists. It has a certain advantage, chiefly in the avoidance of intimate study of individual types, and in supplying a ready means of avoiding difficult and controversial questions in regard to terminology. For example, it would be perfectly feasible to say that all war neuroses belong to one of two groups-neurasthenia or hysteria-implying that those showing primary fatigue elements belong to the former, those showing paralyses, sensory anomalies, convulsions, etc., to the latter. A third group might be made up of the concussion types. Some of the very best therapeutic results have been obtained by those to whom a further effort seemed useless. It should by no means be inferred because no effort is made to classify or carefully group cases, that the work is unworthy of praise.

It seemed, however, in our own experience, that in the long run the more minutely the cases were studied the more effective the therapeutic methods became. The first and essential step was to disintegrate the mass into groups. The smaller groups made easier an intensive study of mechanisms forming, by comparison with other groups, a standard of measurement. Furthermore, the various groups which sprang up almost automatically as a result of this tendency to analyze the material, became centers about which clustered specially developed therapeutic methods, prognostic experiences, disability classification questions and characteristic sets of mechanisms. All of this lent to their study a surprisingly increased amount of interest. A common differential diagnostic language grew up, at first limited to the staff at Base Hospital No. 117, which later spread to the forward areas and became, in a measure at any rate, the means by which neuropsychiatrists could communicate with others about their cases.

Therefore, the attempt to classify or group the war neuroses seems to be justified by the use which was made of the grouping and by the impulse it gave to a closer scrutiny of individual cases as they fitted themselves into this or that class. It must be understood that a grouping of this kind is of value only if it fulfils the test of utility. If it does not, it deserves to be given up without further argument. That it did seem to stand this test, at least in the experience of Base Hospital No. 117, is the reason for its description here.

The following groups were recognized as diagnostic entities at 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 set to work, the average soldier must undergo a series of events which tend to weaken what may be roughly and rather inexactly termed his ordinary self-control. By


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this is meant that he must be put temporarily in a condition where his normal mechanism of inhibition is seriously weakened. By inhibition in this sense is meant the totality of his power to control the natural exhibition of the phenomena of fear, terror, nervousness, horror, etc. To this must be added the positive factor which strengthens the inhibitory impulses-the military quality which keeps alive and ever present in consciousness the recently acquired traditions and customs of a soldier. This is an element of morale. The mental process by which this is accomplished is suppression or repression. Inhibition is merely a larger and more physiologic way of expressing it.

The important circumstances which tend to weaken this faculty are: Exhaustion; fatigue (the more chronic phase of exhaustion); and then, in succession, sleeplessness, lack of food or water, worry, responsibility, and incidents of a particular, horrifying or unaccustomed kind, loneliness, strangeness, ill-treatment, etc. The list of these incidents might be endlessly multiplied, but enough has been set down to indicate their character. The importance of incidents like those mentioned and others of a similar kind lies in the fact that they tend, each of them or in combination, to weaken the individual and to prepare the way for the reception of the final traumatic incident. They create in the soldier a favoring terrain; they further tend to develop in him a soil of receptivity, in which the neuroses, given the proper setting, can easily develop, become fixed and chronic. In opposition to these, the soldier, according to his peculiar personal make-up, struggles either forcibly or feebly, according to the measure to which he has surrendered himself to his career as a soldier. Back of all this lies, no doubt, many an emotionally-tinged impulse, leading straight back to his former nonmilitary existence. Among these may be mentioned the mass effect of discipline, or morale, the grip of idealism which led him to offer himself as a fighter, his experience with the Army as an antagonist, the memory of killed friends or comrades, 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. They form the counterflow against the onrush of factors which center about the condition called fatigue or exhaustion. It is to be noted that in whatever stage of fatigue the soldier now happens to be, he is still in possession of consciousness and a knowledge of himself. In no way has he departed from the condition of a consciously controlled human being. No matter how feebly the inhibitory impulse is asserting itself, it is still to some degree active, and to that extent the soldier is aware of himself as a soldier, perfectly responsible and responsive to the demands of his position. It may be argued that in 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 neurosis structure instinctively fortified by the necessity of self-preservation, to take complete hold of him. At this stage there comes into play a very important and significant psychologic element in fatigue. This is a very unusual and possibly suddenly developed state of suggestibility. This extraordinary state of receptivity not only to outside things, but also to ideas, memories, and emotions of endogenous origin, form, perhaps, the most favoring circumstance for the development of the neurosis which at this moment is awaiting an opportunity to enmesh the individual in its defensive system.


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From this point on two sets of things may happen. Both of them have a precipitating effect and both tend to act in a positive and dynamic fashion equally effective in the production of the first and necessary phase of a war neurosis. One set of incidents has to do, in a certain proportion of cases, with the purely mechanical results of a shell explosion in the immediate neighborhood 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 some hours, as the case may be. As a rule, he either falls or is thrown to the ground, or wanders about in a confused way, and immediately enters into a state in which conscious inhibition is for the time being totally in abeyance. The other set of incidents has to do, not with a mechanically working factor, but with the appearance on the scene of some sudden, unusual or terrifying experience which, emotionally overloaded, tends to produce exactly the same condition.

The question of concussion, around which so much controversy has 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 a case 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 of this factor tended to lessen, though not enough to make it take a secondary place in the list of causative moments. In the earlier days of the war the explosive incident was often combined with a burial experience; that is, the soldier was not only thrown in the air but was covered with trench débris of all kinds, the two forming a twin traumatic incident which often had important consequences in the symptomatic sequence which followed. In the experience of the American Expeditionary Forces burial incidents were infrequent, a fact which decreased by so much the emotionally laden incident, which later became one of the most important of the fixation mechanisms.

The very constant reports in a soldier's history, as given by himself, of a shell explosion experience led the British Expeditionary Force medical service to inquire more exactly into its accuracy. For a time shell shock could be diagnosed only if there was documental evidence by witness of a shell explosion near enough to a soldier to produce a concussion effect. In some instances the soldier's recollection of what happened was not supported by the reports that came from the front. How large the error finally turned out to be is not known, but that the doubt was sufficiently important to warrant the effort 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 this subject, and all that can be relied on is the account given by the soldier as far as he could remember, and on the symptomatic sequence of events which he presented. These, as a rule, are unmistakable and can scarcely be imagined by the average soldier. Whatever may be the percentage of shell concussion experiences in cases of war neuroses, concussion still remains, in a large series of cases, the most important of the immediately working traumatic incidents. It was so important a factor that at one time concussion and its resultant neuroses became from a percentage point of view a very important, perhaps, all things considered, the most important group in the entire classification.


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Whatever the immediate factor may be, a period of unconsciousness, confusion, or a dazed condition appears to be one of the most significant and almost necessary preliminary states favoring the development of a neurosis. Such a condition offers to the protective mechanism the opportunity to work, unaffected by the ordinary control of the touch with reality, which is implied when consciousness remains undisturbed. It is true that a neurosis can develop without an intermediary state, but in these instances the mechanism at work is of a much slower and more complicated kind, leading to approximately the identical condition through endogenous processes largely activated by emotional hyperreactions, breaking through consciously acting repression.

Considered as a process, and nothing else, evidently a state is reached by the soldier going into a neurosis when, for the time being, his conscious control is weakened or lost; at that period the instinctive reaction takes possession of him, and, uncontrolled by anything that he can at that moment interpose to counteract it, opens the way for the self-preservation instinct to obtain its fullest influence. At any rate, he remains under its control until one of two things happens: One leads back directly to the restoration of himself in his soldier capacity, in which instance no neurosis develops; the other, further and further away from his normal soldier self into something totally unlike and alien to the thing that he was, and then he begins to show one of the many types of the war neurosis.

In the course of this process another important element in the mechanism comes into play, especially during the period of transportation to a hospital and in the early days of the soldier's stay there. The process by which the initial symptoms become either temporarily fixed or tend to further elaboration has been described by various terms, none of them very satisfying. What happens is that there is given an opportunity for more complete concentration and introspection, so that the individual removed from contact with his accustomed environment and away from the external influences of military discipline, easily surrenders himself to his neurosis, which automatically tends to further elaboration and intensification of symptoms. If this is not counteracted by intensive medical intervention skillfully planned, and, above all, promptly put into effect, the war-neurosis subject falls under the complete sway of his neurosis and the picture becomes wholly that of a well-developed and chronic type. That there is more at work in this stage than pure automatism and unconscious impulses must be admitted. That there gradually develops a fairly active desire not to get well, but to remain in the apparently safe grip of the neurosis instead of facing a return to conditions which led to its production, seems also evident. There are seen here also the beginnings of another process, that is, a struggle between the innate desire to return as a soldier and the automatic persistence of the preservative tendency previously alluded to. Cases left untreated, neglected, or contemptuously handled rapidly develop into this state, and as a result form the most difficult subjects for subsequent treatment.

Before venturing to classify these cases, or rather to label them when grouped, it was necessary to redefine such terms as had been used before and to define the terms that were new. This implied in some instances a rather new, or at least a novel point of view, and a departure from some of the cherished


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landmarks of our old neurology. Two factors necessarily influenced all the conceptions in classification. One was that the war neuroses were essentially war-born conditions, and that etiologic incidents were all colored by this fact. The other was the conception of the defensive or protective character of the neuroses frequently referred to in this chapter. A classification which implies a theory may seem artificial and dogmatic and applicable only to a limited series of differing conditions. This and other objections more vital might be advanced. For example, this classification is confusing because three things are considered in the grouping and given unequal prominence: Etiologic traumatic incidence; symtomatic expression; and what may appear at first sight to be an arbitrary selection of psychologic mechanisms.

It appears necessary to point out these defects for the reason that classifications are so often the objects of needless controversy and too much emphasis is often placed on them-an emphasis by no means justified in this instance when the modest origin of these attempts is considered. If this attempt at grouping, then, served the purpose of usefulness, it might take its place as a pragmatic constituent of the work done at Base Hospital No. 117.

There is a condition to which much that has been described above does not apply. It is mentioned here because it occurs very largely in the officer class, and may or may not have as an etiologic factor the acute traumatic incidents seen so frequently in the soldier types. The anxiety neurosis has a mechanism which is more complicated than the other neuroses and in which the defensive element is obscured by the presence of an intense and persistent conflict. This conflict has its origin in the necessity, which an officer at all times is conscious of, to conceal from the men under him and from himself too, every evidence of emotional stress he may be passing through. This he does by the use of repression. The repressed material of his experiences, notably those in which emotional loading is strongly present, activate the conflict between his desire to maintain and follow the tradition and training of an officer and the strongly intrenched but completely unacknowledged instinct to save himself. The essential difference between his reaction to the sequence of traumatizing events, just described, and that existing in the case of the soldier, lies chiefly in the fact that there is an ethical element at work which intensifies the conflict and causes him, in many instances, a great degree of mental distress, suffering, and self-accusation. This produces the state of anxiousness which is sometimes the chief and often the only evidence, externally at least, of his neurosis.

It is not to be inferred from this that only the officer class can be afflicted with this type of neurosis. Any soldier, especially one of some education or in whom there exists a well-developed ethical sense capable of introspective attention, may show this type of neurosis.

The anxiety type of neurosis presents a much more highly developed, pure, psychologic defense than the other forms. Its relation to physical factors is often much more difficult to demonstrate. In fact, it is often found developing after a rather long sequence of physically acting traumas showing markedly insidious progress and evidently originating from insignificant and not easily demonstrable beginnings. Its defensive character is chiefly in the fact that it renders the officer incapable of positive action, reducing him to a state


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of neutrality. In this condition he becomes, one might almost say, the prisoner of his conflict and remains inert, without energy, without initiative, controlled almost wholly by the emotional stress engendered by the conflict going on within him. He is frequently unaware that such a conflict is present, the repressing mechanism working automatically to keep out of his waking 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 of the emotional strain he is under. These external signs of fear, worry, etc., are dissociated in his own consciousness from the sources to which they owe their origin, and he is thus as much a puzzle and mystery to himself as he is often to the neurologist under whose care he may happen to be.

Several bits of qualification must be added to much of what has been written in this attempt to state the clinical problem of the neurosis from the point of view of its underlying mechanisms. It is necessary to appreciate the fact that in trying to trace the sequence of happenings which a soldier passes through on his way to a neurosis an average of such experiences was recorded, something that might be accepted as a plan of a physiologic experiment if the soldier could be made into a laboratory problem. There is no thought of making this entirely applicable to every case of war neuroses, or, in fact, is it certain that anyone ever passes through just the things that were described. Of all things in the world the war neurosis lends itself least to dogmatic statements, but what has been set down appears to be a reasonable explanation based on an analysis of many hundreds of cases.

The expression "his neurosis" has been used frequently in this chapter. The purpose of this was to hint at the very personal character of these defense systems, and any serious study of such cases will show the interesting fact that to each war neurosis subject the symptoms do become personalized, unique, and individual. Thus in attempting to describe them expressions having the touch of ownership appear to be warranted.

The clinical problem of war neuroses, then, may be summarized in some such way as this: There is a set of determining factors sensitizing the individual to one of or the set of direct causative incidents. These, as a whole, are capable of being set down in the order of their assumed importance. The immediately determining factor has a definite traumatic quality, either mechanical, as in the case of shell explosions, or emotionally directive, as in the case of unusual or terrifying experiences. A certain degree of initial disturbance of consciousness appears to be either necessary or a very favoring circumstance for the development of the neurosis structure itself. The disturbance may be anything from a slightly dazed condition, associated with some degree of confusion, to complete loss of consciousness lasting several hours. Associated with the disturbance of consciousness there develops some degree of automatism, or a stage in which conscious inhibition is so lost or weakened that the individual becomes a primitive organism reacting to the primitive processes of instincts. In this state the instinct of self-preservation asserts itself. Instead of instinctive flight or concealment taking place, a manifestly impossible condition in most instances, there develops 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 finds himself at that time and also according to his make-up. From the temporary fixation of symptoms the rest of the clinical manifestations of the neurosis tend to unroll themselves, influenced by the peculiar mechanism which was then set in action. The neurosis tends to elaborate, become fixed and stereotyped after the initial stage according to the individual experience of the soldier, his surroundings, the kind of hospital he may be in, the character of his medical treatment, the attitude of his nurses and doctors toward him, and other circumstances 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 further maintenance of the neuroses. At this place in its development a cure must be effected, if the patient is to be restored to his former condition.

As was previously stated, the attempt to classify such cases as came to Base Hospital No. 117-and their number amounted to 3,000-was made for the purpose of so grouping them that more exact study would be possible, and that the mechanism underlying their production could be more effectively inquired into preparatory to a more direct method of treating them. It was apparent almost from the start that there were cases that seemed to correspond almost exactly to types met with in civilian neuroses and to these the terms commonly used there could be applied.

What appeared to be necessary, however, was a new definition to meet the conditions which the stress and strain of war implied so that the designation, war neuroses, might be justified.

NEURASTHENIA

There was a group of cases in which the chief evidence of disease was a manifest and intense condition of fatigue, the chief neurosis element of which was a marked subjective sensation of tiredness. Fatigue was an essential accompaniment of all muscular and mental effort, as it was of all special sense activities. In such cases it was possible to demonstrate the presence of a fatigue reaction, which can briefly be described as an overresponse to a minimal stimulus, or rather an overeffect to the resultant of a minimal stimulus. To such cases it seemed that the designation neurasthenia might be given. In this group, a very small one by the way, all the presenting symptoms were interpreted and analyzed as depending on the factor of fatigue, and this factor was amplified further by its subjective incidence. In other words, the primary experience was carried over into the neuroses as a fixed and powerfully acting preventive toward any moderate muscular or mental effort. The emotional background secondarily produced was that of a state of simple depression, with a concomitant fact of irritability.

The protective quality of a state such as this is clearly evident and needs no further emphasis. Such patients presented all the symptomatic evidences of a typical neurasthenic of civilian life, with this difference-they did not show the physical appearances so commonly met with in the usual neurasthenic types. When they did it was certain they were not war neuroses alone, but the development of war neuroses on conditions that had existed prior to enlistment.


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Two types could then be recognized: (1) A neurasthenia differing in no important way from the neurasthenia of civil life, and (2) an acute, acquired neurasthenia-that is, a definite clinical variety of war neurosis. The distinction became the more obvious when it was noted that the acute cases presented few, if any, of the organic characteristics of the old neurasthenia, very few of the vasomotor disturbances, such as sleeplessness and cardiac irritability. Some of the extreme cases eventually did, but as a rule the evidence of neurasthenia was centered rather about the subjective sensation and its controlling power on the patient's activities than on the physical reaction due to disturbances of an internal kind.

What appeared to determine the presence of the neurasthenic type of war neurosis was the effect of a previous state of exhaustion, an acute experience which led to its further elaboration as a neurosis. That out of this could and did develop the typical neurasthenia was likewise true. Of all types of neuroses, perhaps the neurasthenia cases gave the poorest prognosis and resisted treatment most stubbornly. The absence of previous symptoms of neurasthenia in many of these cases, except the congenital type, led to the attempt to place them in a special class and very quickly they came to be recognized as characteristic but not common clinical pictures. Another part of this picture was the fact that there was nothing mysterious to the patient about his symptoms, their cause or their significance. No conflict of any kind seemed to develop. Its mechanism was automatic but wholly and completely conscious. A typical case follows:

A., L. J., pvt., Co. L., 30th Inf. Born in Massachusetts; 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 good health; 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, gave it up and worked on farm, but it did not do any good.) Venereal disease denied.

History of present condition: Arrived in France, in April, 1918; to the front in May, 1918. Chateau Thierry, June 6; not under shell fire until July 14, and was able to carry on for about 11 days afterwards. Shells at first only made him a little nervous, but he kept constantly getting worse. Had been working pretty hard, and states had little to eat and drink. Finally while "digging in" amidst heavy barrage lost consciousness and remembers "coming to" in hospital about five hours later; 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; "gets winded quick." "Not very strong." Not much energy-neurasthenic type?

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-duty in 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 at his old job and was getting along very well. The work was done in a large airy room 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 came home, the firm I worked before the service, they have promoted me to examiner on cloth, which was not my position before entering the service. I feel nervous at times, but not as much as when I returned. I think that probably my work does it as I am responsible for everything that goes through my hands. No diseases or operations since discharge, or before entering service. Weight 170 pounds when I returned home; after three months reduced to 120 pounds. Stopped work for a while and felt better; weight now is 165 pounds and feeling pretty good."

PSYCHASTHENIA

The second group of cases which early differentiated themselves were those in which doubt was a prominent symptom. In such instances there was little evidence of fatigue, or not at all after a short period of rest, or indeed, without it. Such patients were capable of considerable mental and physical effort, but they complained chiefly of doubt, hesitation, and an almost complete incapacity of choice. To this group, not a very large one, the term psychasthenia was given, chiefly because the symptoms corresponded accurately to the psychastenic condition of civilian neuroses. Here two types began to show themselves; one, the typical psychasthenia of other days-the congenital scrupulous type, the exaggerator of small differences, the individual incapable of making decisions owing to the conflict of differences; fear as a consequence of choice preventing decision. The type is too well known to warrant any further description in this place. The other was an acquired state similar to this without a previous history of this kind.

If the condition of psychasthenia is reduced to its simplest expression, incapacity of the function of choice appears to be its primary departure from the normal. It is the fear of the consequence of choice through experience or through the anticipation of what the choice may bring about, that creates the static condition which is the chief characteristic of the psychasthenic's attitude toward events which tend to focus on him.

The term in Janet's sense seems to have too broad an application for the type which develops among the war neuroses. Here it is seen more as an evidence of the peculiar twist which the neurosis in its defensive adaptation causes. Perhaps, as is often the case, the type that the neurosis finally develops into depends on some congenital peculiarity of the individual or on some experiences in his past life, which are awakened and are set again into activity by the more recent emotionally-tinged traumatic incidents. An attempt to connect up the acute psychasthenic symptoms in war neuroses with events long past and forgotten with the purpose of proving this point was not successful.

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 of admission, April 6, 1918, transferred from Base Hospital No. 15; motorman; alcohol, moderate. Family history: Father 45, living and well, moderately alcoholic; 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; good recovery; nature of trouble not known, not nervous now. Left school at 16-2 years in high school, good progress; five years motorman at Lynn, Mass.; had rheumatism at 23, back and legs; pretty healthy; was struck by lightning (or rather schoolhouse was) at 12; scared of thunderstorm since; pretty even tempered; sociable; no especial fears. Was overcome with heat, July, 1917, just after 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 heat prostration in July (see personal history); came to France October, 1917; well up to present illness and efficient; present illness, went up the line with the 26th Division the beginning of February and carried on normally till March 23 at Soissons; nerves all right till then. Town was shelled and shells were striking all around; one fell about 50 yards away; patient was not knocked down; he was scared 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 head with a rifle about 10 days before and after this shelling his head ached on the hit (left) side of his head; headache better now; easily startled, any noise makes 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 to admission to Base Hospital No. 15.

Subjective symptoms: 1. "Jumping"-"any noise startles me and makes me jump." 2. Not much sleep (average 4 to 5 hours). Dreams much of bombardments (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 (chiefly left-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 at enlistment, 185 pounds now. Well developed and nourished. Mucous membranes fair color. He has several dime-sized skin infections on his face and some hair follicle 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 whistling and chimes; get trembling and jerky; excited last night by excitement of another patient, made threats to "get the ward men." Calmed down and slept fairly. April 22, loud-mouthed and easily startled. Works fitfully, but gets a fair amount done. May 11, 1918, returned to labor duty, class C, to-day. On the whole, in practically same state as on admission. Works fairly and will be useful. May get a grip on himself later on, but it is doubtful. Doubtful stuff for the front in any case.

Report of disability board, May 10, 1918: Unfit for full duty because of psychoneurosis, psychasthenia. Disability did not exist prior to enlistment and did not originate in the line of duty. Nature of duty recommended: 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 at former employment. Unable to do anything at present. Feels "pretty rocky." Present condition poor. On July 24, 1924, he wrote that he was sick in bed and under a doctor's care and receiving compensation from the Government. He had not worked since his discharge.

HYPOCHONDRIASIS

The next group is the third of the consciously produced neuroses, and to this the term hypochondriasis was given because it so exactly fulfilled the condition on 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 of any of the groups. Indeed, it is questionable whether a pure hypochondriasis can develop de novo from war experiences alone. In almost all cases in which this diagnosis 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 and primitive tendency found among all peoples; that is, the automatic release from duty, 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 to receptive impressions from the external world; that is, the skin and special sense mechanisms are capable of transmitting a greater bulk and variety of sensory impressions and having them perceived as impressions, than is found among normal individuals. This lowering of the sensory level is also found in the receptive mechanism having to do with sensations arising from within the body, probably through the autonomic system. This intensification of the sensory margin has its chief effect in developing an increased capacity of attention-the hypochondriacal individual has not only a capacity to become aware of a flood of unusual and strange sensations arising externally and internally, but also has his capacity of attention sharpened to their perception when received. By that very sharpening of attention the facility of final interpretation of such sensations is increased. He thus becomes aware of a constant inrush of sensory impressions which tend more and more to occupy his field of consciousness. This mass of wrongly interpreted and wholly new and strange sensations is the crude material out of which the neurosis is fabricated. This fabrication takes on the picture of disease which becomes more and more definitely personalized as the process goes on. Naturally the experience with, or knowledge of, disease, together with the suggestions obtained from observation, rumor, and surroundings, influences the variety and dramatic quality of the particular disease in question. The collection of ideas concerning disease tends to occupy more and more the patient's field of active consciousness so that he lives practically controlled by them. When he responds to a constellation of this kind more than he can possibly do to the world about him, when his mental life spins eternally about this or that picture of disease, which at all times fills his field of consciousness, the complete picture of hypochondriasis may be said to have developed.

This completed picture should be sharply differentiated from what may be called a hypochondriacal attitude. This latter is very common among soldiers, but only as a temporary state which quickly disappears with rest and improvement. The true case of hypochondriasis shows no change under either condition and apparently is uninfluenced by treatment of any kind. It has been said that true hypochondriasis is rarely found as an acute or acquired type of the war neuroses. This is in a measure true, but it is quite possible for a clinical state closely resembling this to develop on the foundation of a slight and often insignificant or passing trauma or condition, insignificant in proportion to the more dramatic kinds of traumas so frequently mentioned in this chapter. For example, it was sometimes found that a soldier who had been operated on previously for appendicitis, under the influence of a series of traumatizing events, would develop a neurosis of this hypochondriacal type which appeared to center about the operation or the scar remaining as an evidence of it. Previous to such an experience the whole appendicitis incident had been completely forgotten, but suddenly there developed a complete picture of postoperative adhesions, pains, and a widespread area of scar tenderness. From such a


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beginning the whole picture tended to spread, involving neighboring organs, until the patient was entirely in the grip of an everspreading collection of disease ideas. It is of some significance that in such cases the therapeutic outlook was more encouraging than in the type previously mentioned.

It is necessary to emphasize once more that the hypochondriacal tendency is often found entirely dissociated from the true neurosis, but even in its partly developed form, the essential mechanism as described could easily be demonstrated; that is, the increased capacity for automatic attention and the lowered threshold of sensory receptivity. In hypochondriasis, again, the neurosis is consciously determined and thus belongs to the group of which neurasthenia and psychasthenia are members. These three, then, form the first subdivision, the consciously originating neuroses. This does not at all imply that they are either willfully or designedly produced, but that 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, stomach trouble, constipation; maternal aunt, nervous. Previous personal history: Indigestion (chronic constipation).

History of present condition: Inducted, March 10; France, April 2; front, July 15; left, July 16. "We were getting ready to 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 pretty thick." One burst about 20 feet away, one hit apple tree and knocked patient down, and dirt flew all around; patient up all right as runner for captain. Another man tells of shell exploding right in back of him when he fainted 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 and arms; 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 of heart; 4, shortness of breath at night; 5, spells of vomiting; patient had stomach trouble previous to war-probably a severe ease of concussion, delayed several hours before overcoming. C., of patient's platoon, says company hadn't eaten for 14 days, been under severe bombardment, patient asked for drink, shell landed 20 feet away, patient "keeled over," French Red Cross man fixed him up and C. took him to first-aid station, 100 yards away. Patient wouldn't let himself be carried, was in a pretty bad fix; "shell might have scared him; 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 of disability board, September 26, 1918: Disability did not exist prior to entry into service. L. O. D. Nature of duty recommended: Return to ordinary duty. Classification A. Condition: Improved.

On December 8, 1919, patient reported that since returning from France he had worked for two months but could not keep it up. Not working at present. Has pains in back and chest. Had not put any claim in for disability as yet. A letter received on July 31, 1924, indicated that this man had been receiving vocational training ($100 a month) from December, 1921, and studying to be a stationary engineer. In January, 1921, he was operated upon for gastric ulcer at the Philadelphia Navy Yard. He said that he was 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 are concerned, because both represent unconsciously produced neuroses, and both are types of a dissociation process. The one shows itself by dissociation of motor, sensory, special sense functions, and in some instances of the function of memory; the other, by purely psychical forms. The one-hysteria-showing no evidence of conflict; the other-anxiety neurosis-arising out of a conflict with a strong moral or ethical component. Hysteria was regarded as being in a sense a type of cortical dissociation, very often almost anatomic in its demonstration; the other has to do with much deeper and more illusive qualities of consciousness touching more closely on the factors concerned in personality. Another striking difference lies in the reaction to therapy. Hysteria was the most easily cured of all the neuroses, anxiety the most difficult. A curious and interesting point of difference was found in the fact that in hysteria there was little relation to pre-war conditions or experiences. In the anxiety neurosis analysis often led back directly to pre-war conflicts in which the same or similar elements could be demonstrated. They did not necessarily give rise to a neurosis then because the repressive mechanism sufficed to tide the patient over, but it was often easy to appreciate how definitely the stage was set, by virtue of the patient's former experience with conflict processes of less intense form.

Hysteria, then, is to be considered as a type of war neurosis caused by the mechanism of dissociation, by which functional activity in either its motor, sensory, or physical capacity is blocked from consciousness and conscious control. If an organ of special sense is involved the dissociation process tends to separate out one or more of its coordinating functions from the control of the complete mechanism. The part, or parts, in either instance divorced from consciousness can maintain itself in one of three ways. It can cease to act at all; it can act abnormally, that is, in a qualitative sense; or it can hyperact, that is, in a quantitative sense. In other words, there can be paralysis, uncoordinated or perverse forms of action or convulsive-like movement. This same thing is found naturally in the sensory and special sense fields. The dissociation process is most frequently set in activity by a somewhat sudden emotional or physical shock and, if in the latter instance, the precipitating factor is most often the effect of a shell explosion or some type of trauma associated with some degree of violence. The type of reaction in hysteria in respect to both localization and function bears a definite relation to the local effect of the trauma. Blindness is often the result of the acute blinding sensation of an explosion, deafness due to momentary loss of hearing. For the same reason, sensory disturbances are due to numbing of areas of skin following disturbance of atmospheric pressure in the zone of an exploding shell, etc. The emotional precipitating factors have the same curious localizing tendency, with the exception that here suggestion or imitation seem to show a more active influence. It is necessary to point out that in hysteria, particularly the acutely established types, is shown less clearly the characteristic protective defense than in some other types of neuroses, and it must 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 then chiefly in the direction of fixing it and making it more permanent.

A sudden shock having a positive degree of physical incidence may throw out of activity a certain function or a part of it, certainly too rapidly for any kind of physical mechanism to be set going. In such instances the instinctive action of self-preservation arises later, automatically making that loss of function fixed, thus establishing it as a neurosis of the war type.

Such a conception of hysteria is a departure from the usual thinking on this subject and naturally differs essentially from the theory of Babinski so much in vogue in the literature on war neuroses, but it seems impossible to escape from some notion of this sort, in the face of the almost instant appearance of symptoms after an explosion incident and the tendency to fixation and elaboration of the symptoms following the slow return of consciousness. Whatever rôle suggestion plays, it surely can be regarded as only 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 are the amnesias, which may be regarded as pure types of dissociation in the purely psychical sphere, and they obey apparently the same sequential rule as the cruder forms of response. The single and most reliable diagnostic evidence of hysteria is found in the presence of the dissociation process. When the symptom is capable of being described as due to that, and if it meets the necessary requirements of a hysterical symptom, not necessary to mention here, the diagnosis of one of the many forms of hysteria found in the war neuroses can be made.

Another characteristic of a hysterical symptom is that in its disappearance it may pass through any one or a combination of the three forms which have been described. Complete paralysis often recovering through the phases of tremors, exaggerated movements, etc., aphonias recovering through the phase of stammering, etc. The synthesis with consciousness very often is not direct and immediate, but indirect and incomplete. Two cases of this group are the following.

O. C., sgt. Co. F., 362 Inf. Born, Illinois; age, 25; race, white; date of admission, September 10, 1918; source Base Hospital 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: Drafted September, 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 day for 3 to 4 days. No more attacks until rifle practice, after a few strenuous days again developed and then after coming to France during hand grenade practice a man in patient's platoon pulled the pin from grenade but became too excited to throw it and let it drop, he warned his men and they managed to get away unhurt. But he became much excited and that night after taps had an attack in which his whole body shook, was nervous and had queer numb sensations over body, profuse perspiration, was not unconscious, no tongue biting, no incontinence, did not fall.

Subjective symptoms: Complains of pains around heart, trembling of entire body. (Soldiers call him ''shakes".) Poor stuff. Hysteria. Class C.

Objective symptoms: Ambulatory. General condition, good; skin and mucous membranes, healthy.


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Diagnosis: Psychoneurosis, hysteria. Report of disability board, October 4, 1918: Disability did not exist prior to entry into service. Disability is in line of duty. Nature of duty recommended: Labor in the line of communication.

Disposition: Class C-1.

Final diagnosis: Psychoneurosis, hysteria.

On December 13, 1919, he wrote that he had improved wonderfully in the last three weeks. Not working as yet, as he was discharged only a short time ago, but plans to do so in a short time. Is to be given 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, he wrote 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 as an indexer of crankshafts and making 50 cents per hour. He received compensation of $20 a month for eight months. This was cut to $8 for three months.

B., F. E., corpl., Co. I, 102 Inf. Age, 19 years; race, white; born, Connecticut; date of admission, June 15, 1918; transferred from Base Hospital No. 1. Accountant; alcohol, moderate. Family history: Father, 42, gets tired very easily; very nervous temperament; excitable; two paternal aunts nervous; one has St. Vitus's dance; another was paralyzed in an arm and again in a leg-all cleared up. Previous personal history: Left school, 17; had two years at high school and two years at agricultural school; pneumonia, twice; grip, likely; last attack, 1916; followed by 3 weeks of pain in back, similar to present; no neuropathic history; variable mood.

History of present disease: Came to France October, 1917. Was not up in Soissons in February. Was in hospital with pains in right abdomen. (Old appendix, 1915, operation.) Went up to Toul with 26th Division, April 1. "Not at all nervous." Was on duty until April 21; all right except for diarrhea, which was getting worse (began in January). Was sent down from the line because of "exhaustion"-poor sleep; stomach upset because of diarrhea, and he couldn't eat. Says he was knocked down by a shell on the above date, but he kept on running; was paralyzed after; shakiness developed 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; no blood; bowels apt to move at any time during day; 2, pain in back-comes and goes; 3, some pains around old appendix operation; 4, flat feet; sleeps all right; appetite all right; composed. Tells glibly how his abdominal adhesions were 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 before I 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 made out of abdomen. Nervous system: Coarse finger tremor not marked. Diagnosis-transfer card: 1, psychasthenia; 2, spondylitis, chronic, 8th and 9th dorsal vertebræ.

Diagnosis of ward surgeon: 1, psychoneurosis, hysteria, line of duty; 2, spondylitis, chronic, 8th and 9th dorsal vertebræ, 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 vertebræ, existed prior to entry into service, not in line of duty.

Condition on completion of case, cured.

On September 20, 1919, he stated that he was a cost accountant before enlisting. Expects to take position in same work. His health is excellent but exceptional loud noises, such as a band, a blast, a factory whistle, a passing train, or particularly a thunderstorm will set his nerves aquiver for periods ranging from five minutes to three hours. Is trying gradually 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 but through power of will am able to keep it in check with the exception of organic trouble. For several months I have been troubled with stomach trouble and my physician lays the blame to nervousness wholly. Of the old troubles, my worst day of the year is the 4th of July and secondly those in which thunderstorms occur.

I am very strong physically, being 5 feet 7 inches in height and weighing 180 pounds, but this does not keep me from tiring easily. I can stand only a small amount of manual labor and my other labors must not be too monotonous if I am to work the whole day at the same job. Exercise in the form of games does not tire me and gives me the sleep which I would not get otherwise.

ANXIETY NEUROSIS

It is in anxiety neurosis that the most complete example of psychical dissociation is met with, that is, a dissociation unaccompanied by anatomically expressed loss of function. Anxiety neurosis has to do with a more general process and reaches down more deeply into personality than the more superficially located mechanism seen in hysteria. Something of the etiology and the primary reaction has already been touched on in the consideration of hysteria above. There remains to describe progress and final clinical results. The subject of an anxiety neurosis must be thought of as an individual in whom the repression faculty is well developed. This may come about as a personal characteristic, or it may be due to the position of authority given by his military status. Naturally the officer falls most easily into this class and it is in the officer class that the majority of instances of anxiety neurosis are found. Next would come certain types of the noncommissioned officers, chiefly such as have received their commissions recently, and then soldiers who by virtue of education and the development of higher standards are inclined to react easily to ethical considerations. While this may be the general type which develops this form of neurosis, there are always found exceptions which apparently do not fit into the conditions as set down. Such exceptions are probably insufficiently studied or understood.

In the typical case-for the purposes and necessary limits of this discussion only such can be considered-there is present, almost from the beginning, the essential elements of the mechanism of an anxiety neurosis. These are conflict, repression, not only of the memory of the experiences themselves, but also of the expression of the emotional reaction associated with them, and a certain degree of what may be called the ethical point of view in the presence of the antagonism between what is regarded as the right thing to do and the natural innate tendency toward self-preservation. These, of course, form only the basic groundwork of the process, indicating enough of the mechanism to warrant 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 his dislike or objections to discipline, obedience, authority, and many of the other essential phases of military life. His repressive mechanism not only has to do with the ideas themselves, but also with the external evidence of his attitude toward them; that is, his conduct must depart in no way from the correct military form. For these, and indeed for most of the experiences associated with actual combat duty, the repressive function is amply sufficient to keep the officer from ever approaching the territory of the neuroses.


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The repression faculty has a well-known tendency to become automatic and to act entirely without the intention of the individual. As the officer advances in his training as military life grips him more and more intensely, and as military discipline forms him into a silent part of the big army machine, he is less and less in need of any active manifestation on his part of this faculty or repression which was so much a part of the mental discipline of the earlier days of his training. It must not be forgotten that in the American Expeditionary Forces the professional class of officers was necessarily a small one and that most of the nonprofessional officers were taken out of civilian pursuits of various kinds in which no trace of military atmosphere, and certainly none of active combatant duty, were to be found. Therefore, there was no important set of military or officer traditions to which the future officer had long ago accustomed himself.

Therefore, it should be appreciated that in our Army the traditions of of conduct in general, and particularly those associated with active military life, had been very recently acquired, so recently that they were only superficially grafted on the officer's personality. There was need, then, to exercise, whether consciously or not, that form of inhibition called repression in order to maintain such traditions under circumstances of difficulty. This was especially necessary when the officer met front-line conditions, 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 the stress of trench or open warfare he held himself in a measure responsible. In addition to this he realized that the technical side of his profession, a most difficult and intricate thing, was also but recently and often most laboriously acquired and had now to withstand the actual and often bitter test of real combatant conditions. Notwithstanding these heavy burdens, very few officers, it must be acknowledged, even under the adverse conditions associated with front-line duty, developed neuroses. Those who did had to face peculiar sets of circumstances which tended to break down the inhibitory processes which held them 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 alluded to, and as a result of shell explosion with a concussion sequence, the faculty of conscious inhibition was temporarily lost and the officer acted for the time being as a primitive instinctive piece of human machinery and during the period of semi-automatism, confusion, or haze, the beginning of the neurosis of the anxiety type was laid. If some of these things did not happen in an acute manner, then a series of smaller and less important incidents brought the officer 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 activity as the reality of the situation became more and more apparent. It is this antagonistic relation of conflict to repression that tends toward the separation of emotion from experience. This supplies the mechanism of dissociation alluded to before. There results then the clinical picture of a state of intense anxiety with the external evidences in the way of facial expression, depression, apathy, loss of sleep, dreams, and even the objective appearance of fear, tremor, rapid pulse, vasomotor reactions, in the face of the complete unawareness and lack of understanding on the part of the patient, of what really is at the basis of his discomfort.


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The battle experiences repressed and in a sense partially forgotten, tend to express themselves by freeing their emotional content or by spinning themselves out in dramatic and terrifying dreams. There is present, then, the evidence of fear, and even terror, without being related to either actual experiences themselves or even to the actual memories of such experiences. In this state there develops a series of conflicts which must be regarded 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 to go 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 desire to escape front line conditions. (3) The conflict between the desire to avoid the dangers and discomforts of the front, and previous ideas of duty, valor, etc., and family, social, personal, and class standards. (4) Conflict between the desire to escape and the feeling of inadequacy, in a military sense, of the responsibility of an officer in command of men. (5) Conflict between the impulse to go forward and the wish, expressed or not, to go back to former conditions in the United States. (6) Conflicts which had reference to events or similar types of conflict in pre-war experience.

Naturally there are many other kinds of conflicts, but these were so common in the cases seen in Base Hospital No. 117, that some of them were predicted in certain individuals and were actually found to be present.

Enough has been said of anxiety neurosis to indicate at least what is believed to be its fundamental mechanism, and to establish the fact that such a group of cases exists characterized by this mechanism. A case history illustrating 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 of admission, transfer Base Hospital No. 17; born, New York; mechanic; abstainer. Family history: Mother and sister had had "nervous breakdowns." No alcoholism; paternal uncle insane. Exanthemata. High school: Normal progress. Had headaches relieved by glasses; formerly somnambulist; afraid of thunderstorms until 14.

History of present disease: Enlisted June, 1917; France September, 1917. While in training camp did not like the instructors, but was not unhappy and not sorry he enlisted. After coming to France he liked it. Went into front line during March and April. Shelling did not bother him. Shelling was constant, "but it didn't amount to much because we had dugouts." During May was in rear. Became rather disgusted with excessive drilling; thought his outfit should have been given rest. Went into front lines at Chateau Thierry in June and welcomed the opportunity of getting some open warfare. For first four days he rather enjoyed it and although under shell fire and seeing a goodly number of casualties, he was not conscious of any fear, merely wondered whether one of the shells would "get him." June 5, his company advanced under fire to relieve French. He saw many French dead, with heads shot off and others staring at him. He was detailed to assist in burial. This disgusted and horrified him because he never could bear to touch a corpse. He then began to realize for the first time what shell fire was. For several nights he could not sleep because the dead Frenchmen would be constantly before him. At the same time shells began to terrify him. He began to tremble under fire but tried to conceal his fear and to carry on. His condition was exaggerated by the fact that his own artillery was not working very efficiently. June 14, while under heavy shelling in open, and after position of company had been changed several times, he began to tremble, became weak and had to go to dressing station. He quieted down as soon as he was in quiet hospital. For first few weeks had terrifying dreams. Dreams have been absent for weeks.

Subjective symptoms: Condition on admission-Says he feels fine now. Knows that he will not continue to feel so well if kept in hospital. Other patients make him nervous.


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They shake and jump at every little noise. He says he was always unable to look at people who were shaking, or to listen to people who were stammering. Does not think that he is unusually susceptible just at present. Wants to go back to company.

Objective symptoms: Condition on admission-Good. Weight, normal, 150. General condition good. Diagnosis on transfer card: Anxiety neurosis. Diagnosis of ward surgeon: Anxiety neurosis (mild). Any duty in line of communication 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 not working at all at present. Upon discharge he started to drive a truck but could not continue to do so. He saw a doctor who ordered him to be quiet and do no work until he gave him permission. He says he is all right mentally.

On January 5, 1920, he wrote that he had received $7.50 a month compensation, and that he was in the same condition he was in except rheumatism bothers him more and more.

In the summer of 1924 he wrote that he was a teacher of industrial subjects receiving $2,200 for 10 months. He said:

I feel pretty good but can not stand any sudden and loud noises as on July 4. My breathing bothers me quite a bit.

The United States Government gave me a two-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 they represented reactions not to actual experiences in battle but to the anticipation of such experiences. The neuroses, therefore, acted not as protections against the repetition of events already lived through, but as protection against initially experiencing them. As a whole, they probably were patients who had shown symptoms of the neuroses in training camps at home, the manifestation of which had most completely developed. On the way over or after they reached the concentration camps in France, the symptoms became manifest again, and under the spur of immediacy rapidly took on the characteristics of a well-defined neurosis picture. The anticipation group was never a very large one and rapidly declined after active fighting began. Since they formed less than 10 per cent of the total material, evidently most of them were excluded by the neurological examinations made in the home training camps. Any of the clinical types of neurosis could be found in the anticipation group. This appeared to show that the memory of a past experience, imitation, suggestion, rumor-if emotionally intensified sufficiently-could arouse, in given instances, the defensive instincts to take the form of a neurosis, in the presence of a sufficient degree of receptivity and expectancy on the part of the individual.

The anticipation neuroses are not war neuroses in the narrow meaning of the term, but it was found necessary to include it in a classification and to place in it such cases as had never been at the front, as well as a few patients who developed the attitude of anticipation toward reexperiencing former experiences. They reacted similarly to the group for whom the anticipation neuroses were at first devised. The history of such a case, as fell 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 ever since. Always healthy. Enlisted March 29, 1916, Jefferson Barracks; went to El Paso (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. Was never afraid when shells broke around him, but rather enjoyed them; had never been 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 and started running toward woods and fell in ravine. Began to shake all over; knew everything that was going on around him, but couldn't control his nerves. From field hospital went to Base Hospital No. 6, July 3, 1918, until coming here.

Subjective symptoms: 1. "Nervous, shake all over, any little noise, can't stand it." 2. "Never afraid of anything, but now whenever anything drops I jump." 3. "Short of breath, sometimes I can't breathe." 4. "Can't sleep well, the least little noise wakes me up." Appetite good.

Objective symptoms: Body clean; weight, normal, 168, present, 158; general condition good; blood pressure, systolic 125, diastolic 95; heart tachycardia 94; abdomen, slight protrusions due to muscle weakness over each inguinal region; nervous system, quite marked general bodily tremors; pupils, regular, good reaction; knee jerks, slightly increased; osseous system, slight lateral curvature of spine to left about 10-12. Diagnosis on transfer card: Psychoneurosis of war.

Report of disability board, August 24, 1918: Nature of disability-psychoneurosis, anticipation neurosis; disability did not exist prior to enlistment in service; disability is in line of duty; classification B-2; condition, improved; nature of duty recommended, labor in the lines of communication.

On September 20, 1919, he wrote that he was back at home and at work as a salesman. He was feeling fine and doing well. On July 22, 1924, he wrote that he was working in a paper mill, salary 40 cents per hour. He was feeling fairly well, though a little nervous sometimes. He was receiving compensation at the rate of $9 per months at the time of writing.

EFFORT SYNDROME

Very little will be said about the effort syndrome in this place. So much has been written about this condition and there is still so much controversy on the subject that nothing can be added toward clearing it up from the point of view of its place in a list of war neurosis types. It was common enough in the material at Base Hospital No. 117, and formed so distinct a picture that it was one of the most easily classified. From the point of view of its defensive quality it is a typical neurosis, associated with the exhaustion types, but has a more definite localizing quality. It frequently followed gas poisoning, being the most persistent perhaps of its after effects. Its close association with emotion and the emotional reactions of the cardiac and respiratory functions seems to justify its position among groups of a functional defense system. Clinically, it is too well known to describe here, and it is mentioned because, mechanistically considered, it ought to have a place in any classification 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, Base Hospital No. 30; rubber-tire salesman and repairman; alcohol, moderate. Family history: Father, 50, neurosis-invalid type; rheumatism. Previous personal history: Left school at 14, seventh grade; at 8, in bed six months, infected, broken ribs below left axilla. "Heart trouble right along," always short of wind; easily startled; nervous with excitement.

History of present disease: Came to France October, 1917; up to the line February, 1918. Had hard times sometimes keeping up on account of shortness of breath. Carried on till July, 1918. Going over top, first time, dropped from exhaustion. As he arose a shell exploded near by and 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 a little better; not much.


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Subjective symptoms: Present complaints-1. "Heart and lung trouble "-"nervous." "I seem to get all my breath on the right side. At night I have to jump out of bed sometimes to get my breath and on a hike I have to drop out to get my breath. Nervous; body shakes. When I am walking I get weak-kneed." Headache for two days; appetite fair; tastes sometimes after eating.

Ward surgeon's note: Rather hypochondriacal attitude and manner. 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 operations in lower axilla-left. Pulse, 100; regular; variable rate. Too much muscle tenseness. Nervous system: General tremor, moderate. Deep reflex is difficult to get 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 take long breath; always been short-winded; pain in side and in heart; cough; head-shake tic; some stammer; appears quite neurotic; says always been some nervous; when in camp seemed like he couldn't last out in hikes. Gets upset in excitement. Does little detail work. Many hypochondriacal complaints. Pulse from 80 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 well and after receiving vocational training had obtained a satisfactory position.

EXHAUSTION

Exhaustion has its place in a classification of war neuroses because it connotes defense of a chemical or polyglandular kind. These patients came into the hospital in some numbers at first, but with the establishment of the forward-area hospitals fewer were seen. They represented a large percentage of the material seen in the triages and a considerable number of those seen in the advanced hospitals. In the earlier months of fighting they were often mistaken for and designated as war neuroses. As forming the foundation on which the neurasthenia type of war neurosis often developed, they deserve some mention here.

TIMOROUSNESS, OR STATE OF ANXIETY

Timorousness, or a state of anxiety, was a term given to a small group of individuals who frankly admitted that they were afraid to face conditions at the front, and deliberately gave way to this fear, refusing to accept or develop any compromise between themselves and what they had to do as soldiers. These are the true and only types of cowards. In them no repression of the kind mentioned here exists. This is not a neurosis, of course, as the whole mechanism is entirely too open and frank. At first sight such cases ought to be dealt with outside of a hospital, but in the case of a soldier the condition was so strange and departed so much from the usual conduct of a soldier that such an individual was not considered normal enough to be handled from the military side alone. They would belong probably in the same class as conscientious objectors, the difference being in respect to the kind of thing that interfered with their willingness to act the part of a soldier. The following is a case history of this condition:


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B., W. C., pvt., Co. B, 12th R. R. Engrs. Age 24 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 had epilepsy. Previous personal history: Went two years to high school; never was sick. Venereal, none.

History of present disease: Enlisted October 17, 1917; France, May 14, 1918; front July 17, 1918. July 18, on Chateau Thierry front 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; could not work at his railroad work on account of shells making him nervous. Dropped tools or whatever he had in hand when explosion came. Asked for work farther back, as could not stand shells. Present complaint: Complains of weakness and nervousness. Soreness in old wound in thigh; noise causes him to become nervous and to have headache; dreams some of shells and airplanes.

Impression: A man of fair intelligence, but of rather weak, neurotic tendencies; was wounded by shrapnel and when returned to front 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; weak leg. Weight, normal, 114; present, 130. General condition, fair. Vascular system: Pulse 80; after slight exercise, 92; full and regular. Knee-jerks active; pupils react normally; coarse generalized tremors. Diagnosis of ward surgeon: Psychoneurosis, state of anxiety. Progress (later report): Very much improved; still has little tachycardia; says feels good but not as strong as formerly. Composed. Fearful of returning to shell fire. Sure he would go to pieces again. Complains of cough sometimes at night; pulmonary examination negative. O. K. for duty Class A since armistice.

Report of disability board: Disability did not exist 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 and claimed to be bothered by a wound received July 18, 1918. Was working at old trade as machinist but could not do the work. Is doing much more inferior work.

On July 22, 1924, he wrote: "At present I am taking a degree course in mechanical engineering under Section No. 2 Training. Not nervous at present time. When I first got back I was somewhat nervous but I am not bothered with it at present or none within the last three and one-half years."

GAS AND CONCUSSIONS

Under gas and concussion were included cases in which the primary symptoms of a concussion or gas experience were elaborated into the structure of a neurosis by the mechanism of fixation and defense. In the concussion neurosis the headache, vertigo, amnesia, temporary blindness, instead of passing away in a few days, as they normally do, begin after a comparatively free interval, to become apparent again, with a definite degree of persistence and exaggeration which had all the characteristics of a definite neurosis. In the gas neuroses the hoarseness, difficulty in breathing, pain in swallowing or talking, pressure sensation in the chest, dyspnea, etc., show exactly the same tendency until there develops a chronic picture of gas poisoning long after the acute symptoms have any right to be present. In gas, too, the actual pain of a skin burn persists as a widely spread burning and parasthesia, long after the primary burn has healed and all trace of it has completely disappeared. The syndrome of these types is included here, because at times such patients were sent down to the hospital either through a mistake in diagnosis or on account of transportation necessities.


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The following cases illustrate these conditions. The first two are gas syndrome and gas neurosis; the third and fourth, concussion syndrome and concussion 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 a paralysis, subsequent to "grip." Previous history: Common-school education. No neurotic irregularities in make-up or history. No gunshot wounds or 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 until gassed (Verdun) on October 16; mustard and chlorine, he was told; carried on anyway until sent out by his officer on October 21; in hospitals until sent to Blois, November 24. Sent from there here, December 3, 1918, for reclassification. No history suggestive of a neurosis; possibly an exhaustion with a rather persistent bronchitis following gassing. He had night sweats and loss of weight. Patient does not appear at all a neurotic type.

Subjective symptoms, conditions on admission: Complains of cough and pain in front of chest and easy fatigability.

Impression: Some exhaustion, associated with chronic bronchitis following gassing.

Objective symptoms, condition on admission: Ambulatory. Weight, normal, 156; present, about 140. General condition: Rather tall and spare; looks a little emaciated, but has a good color. Skins and mucous membranes, 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 sounds less clear than right; but no persistent râles. Pupils: Left a little irregular, larger than right, but both react normally. Deep reflexes all increased, 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 duty recommended, return to United States.

January 6, 1920, he was getting along pretty well, although he had a hard time of it at first. Is doing well at present.

On July 25, 1924, he reported that he was in vocational training studying to be a shoe repair man. He had worked as a carpenter for about 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 feeling well, 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, Neurological Hospital 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 at 16-8th grade; always healthy, usual diseases of childhood; "had spasms until 6 years old." Well ever since; rheumatism two years ago; never nervous.

History of present case: Enlisted April, 1917. France, May, 1918; went to front July 14, Chateau Thierry. Under heavy shell fire for about three 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 men told him he was gassed with chlorine and a little mustard gas. Very nervous and shaky; 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 shells bursting near him. Stayed two days; got more and more nervous and fell down. Awoke in Neurological Hospital No. 1 and hence here. Dreams continually of battle, hears the whizzing of the shells, but "they never light." Sleeps very poorly. Says he is all right here, but couldn't stand the shells at the front.

Subjective symptoms: Insomnia-battle dreams. Very good material, somewhat nervous in make-up. Talks freely and frankly of condition and doesn'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: Nothing of note.


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Diagnosis: Psychoneurosis, gas syndrome. Report of disability board, October 23, 1918: Disability did not exist prior to entry 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 doing different work from his pre-war occupation; working in a steel factory. It is too hot there for him, as he works with hot steel. Gets a pain over his heart every 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 received no compensation from the Government and was feeling fine.

A., A., pvt., Co. L, 102d Infantry. Age, 21 years; race, white; born, Massachusetts; date of admission, May 31, 1918; source of admission, transfer Base Hospital 18; machinist; alcohol, moderate; family history negative. Previous personal history: Good health; left school at 14-9th grade; steady worker; no neuropathic history.

History of present condition: Came to France October, 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 was on his way up to join his company. A shell landed about 6 feet away. Didn't hear 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 over again. He got up and was helped to aid station; he felt nervous and weak and was shaking all over. Was at Field Hospital No. 101 about 10 days; felt all right and returned to duty about May 1. Upset by a thunderstorm, and the batteries near him would keep him awake. Became jumpy. Could not sleep; headaches. Stayed on duty about two weeks. Came to hospital about the middle of May.

Subjective symptoms: Present complaints: Weak spells and headaches. "I'll be feeling fine and all of a sudden I get dizzy. 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 a lot of noise I get nervous." Appetite and bowels fair. Patient is of limited intelligence; speaks in a low, rather quick, tense voice; restless with hands. Slight nodding, jerking of the head; feels quite a bit better; may be fit for line duty again.

Objective symptoms, condition on admission: Very slight generalized tremulousness more marked in hands, variable; body clean; weight, normal, 140; present, slightly underweight; general conditions fair; eye grounds normal; skin and mucous membranes: on forehead, pea-sized reddish area; some pustular and some scab covered. Acne. Vascular system: Pulse 100; 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, and about May 1, 1918, was upset by a thunderstorm and a barrage; became jumpy and developed sleeplessness and headaches. He came to the hospital about the middle of May. His chief complaint on admissions here were weak spells, headaches, and being easily startled. He was a little tense and restless and had a slight nodding head tremor. He was negative physically aside from a bad facial acne. He showed good improvement while in the hospital.

Dispositions: Return to duty B-1. July 3, 1918.

Final diagnosis: Psychoneurosis (concussion neurosis).

Postwar history, 1919-20: Present condition, poor. Is bothered with slight headaches and at times has dizzy spells. Has returned to his old work but does not like it, as it is in a cotton mill and he can not stand it. Is a yarn boy now; was formerly a fixer of machines. Has not worked 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 not sleep well. The least bit of excitement makes me feel faint. I get tired quick at night but can not sleep sound. At present I am working one week and loafing a week. While out in the air I feel good, but while working inside I am all in at night. If I had a job outside I would feel a lot better. I have had three years of vocational training and it was a failure in my case, as I was knocked about and did not have a chance to learn enough to make a living at it. It is a long story and if you so desire I will write you later about my training career. If it 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 under date 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 of neurosis, traumatic. He was considered to be disabled to a degree of 5 per cent with regard to vocational handicap. The report from the office of The Adjutant General of the Army shows treatment April 15, 1918, for psychosis, traumatic acute due to exhaustion of concussion of high explosives in action in line of duty May 19 to July 3, 1918.

He was given training on May 10, 1920, for one year as a cabinet maker. On May 12, 1920, he entered training at the Lowell Vocational School, Lowell, Mass. On August 16, 1921, he changed from training in the 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 change his training from cabinet making to either telegraphy or plumbing. There was some question at that time whether the man would succeed in any work which required the skillful use of tools. The requirements for telegraphy were beyond his limited educational background.

On May 15, 1923, he was rehabilitated as a cabinet maker, and was examined by the bureau examiner in the Veterans' Bureau on May 7, 1923. The diagnosis was traumatic neurosis mild. His case was rated on June 7, 1923, and he was given a 10 per cent rating on this neuropsychiatric condition and was considered competent.

A follow-up visit was made by the Employment Service 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 was getting $21.26 a week. He has been working for this concern since the date of rehabilitation with the exception of one week and his work was considered satisfactory, 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, although rehabilitated as such.

He was examined again by the Veterans' Bureau on May 28, 1924, and his disability was considered of a noncompensable degree 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 neuropathic history; left school at 17; third year high school; good health; operation for undescended testicle July, 1917. ''When I take a long hike it leaves me pretty stiff the next day."

History of present disease: Came to France December, 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't himself 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 he arrived at C. H. 13.

Subjective symptoms: Present complaints: 1. "Dull headache all the time. I don't shake much but I am a little nervous." Easily startled; shooting pains in forehead and back of head. 2. "My wind isn't what it always has been." "Takes a long time to get 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-body clean; weight, normal 130; present, normal. Wax in ears. Pulse, 88, regular. Right testicle half descended. Moderate fine finger tremor. Diagnosis on transfer card, shell shock. Diagnosis of ward surgeon, psychoneurosis (concussions syndrome).

Report of disability board: Did not exist prior 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, concussion syndrome. 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 great deal better than when discharged and the only time that I can notice any trace of nervous trouble is upon being excited over some happening or some loud noise at an unexpected time. I can see no reason why my compensation should have been discontinued, as I have one bad lung at the present time which gives me some trouble. I really think if the proper authorities were advised that I would be given a just examination and no doubt would be entitled to some adjustment. If anything can be done it would be greatly appreciated.

I drew compensation from the time I was discharged in 1919 until the fall of 1922, when it was discontinued. Don't know just why it was dropped as the disability which I had besides the nervous trouble still exists and have been unable to get any satisfaction from the bureau 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, a number of times the dates I can not remember. In the spring of 1923 I was in the Veterans' Hospital at Jefferson Barracks in St. Louis for about five weeks and discharged from that place with a discharge marked "condition unchanged."

GENERAL SYMPTOMS COMMON TO WAR NEUROSES

The classification or grouping has shown that the different types depend rather on certain sets of distinctive mechanisms and on certain almost specific traumatizing experiences than on symptomatology or on the final clinical picture. It is, therefore, necessary now to describe some of the more general symptoms common to many of these types and then to touch on some of the more 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, the reactions of the organism as a whole; (2) the fixation process, especially in its initial stage; and (3) the convalescent conflict.

There are certain symptomatic reactions of the organism to emotionally effective traumas, which represent its protective response as a whole and furnish the symptomatic background of the neurosis. As has been shown, such symptoms are capable of elaboration, fixation, and stereotype, according to the type of mechanism set in activity. For this reason some or all of those about to be mentioned may he found in any of the groups which have just been described. They may be regarded either as instantaneous reactions taking place at the moment of traumatic impact, or arising afterwards as a result of the emotional responses accompanying the traumatizing incident. These are, in the main, 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 origin and purely physiologic in expression. They appear to be so closely associated with hyperemotional states seen in other than war experiences that they must be looked on as very general types of reaction with no specific war incidence at all. For this reason they are found as a kind of symptomatic background to almost all of the severer types of neuroses. The majority of the cases showed headache, and considerably more than one-half had insomnia. In most of the latter the insomnia was of brief duration, the headache was often very persistent. The headache in cases of concussion is somewhat differ-


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ent, approaching closer to a specific symptom. Even in the development of the neurosis out of the concussion experience the headache had a more persistent character, a more definite localization, and appeared to produce more discomfort than those found in the other conditions. The characteristic headache was one of the most insignificant items in the diagnosis of concussion neurosis.

It is apparent, then, that there are in the war neuroses, more or less sharply defined clinical groups, sufficiently characteristic to warrant giving to them separate neurological designations. The first six of them have a more or less characteristic mechanism; the gas and concussion neuroses are separated out because of a definite etiologic sequence, the others are questionable neuroses but should be included in a classification in use at a neurological hospital in the war zone.

TREATMENT

No adequate statement of the treatment developed in a special hospital such as Base Hospital No. 117, can be given without describing the history and growth of the place, its spirit and purpose, and the individuals composing its staff. Therefore, the merest outline of methods used can be mentioned here. Each staff member was encouraged to work out and develop his own particular notion as to the best way to treat these cases; in this way, while many personal therapeutic technical methods were developed, often to a remarkably high pitch of efficiency, nothing new or original can be said to have been discovered. Whatever unusual facility there might have been developed in the handling of these cases came more from the importance attached to the study of 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 later months of its activity. In the beginning, evacuations were made indirectly to Base Hospital No. 117. After the St. Mihiel operation the forward screening was perfected enough to keep all but severe cases from reaching the rear areas. The therapy found effective in the acute cases (it was from these that the technique was developed) was found effective in the chronic types. But it took longer for the symptoms to disappear. The result with chronic cases was not as good as in the acute cases.

The first principle of the hospital was to cure the soldier and send him forward. If this was not possible he was to be fitted for military service in the Services of Supply with the hope that he would soon reach the front-line status. Very few cases were to be sent to the United States; therefore, recommendation to this effect was permitted only in the absolutely hopeless cases, and these chiefly on account of some undercurrent organic malady or previously undiscovered organic lesion of the nervous system. After the armistice began, however, the hospital received a great many cases from other places. These were chronic, defective, and other types, representing the unsuccessfully treated residue of hospitals, camps, and division back areas. As an offset to this the percentage of higher classification during the armistice increased likewise, so that the balance was maintained and perhaps ran to more cured cases than at any other time in the hospital's history. Very few cases of war neuroses devel-


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oped de novo after November 11. The therapeutic problem after that time became much simpler and required much less effort and time.

The second general therapeutic principle was that a patient's stay at the hospital was to be as short as possible-the average in the whole hospital was slightly above three weeks. This included the officer material which required long treatment, and also included delays in getting patients out due to transportation difficulties and all other sources of block incident to a hospital operating at the time of active fighting.

The third general therapeutic principle was that all attempts made to cure a patient should be instituted as promptly as possible-within 48 hours if it could be arranged. Associated with this was the idea, also, that when the attempt was made it should be followed through to a finish at one sitting. This, of course, refers only to the hysterical symptoms.

The fourth principle was that the war neuroses were caused by a mechanism not under the patient's control in its initial phases, but subsequent to that, in two to four weeks, there might be a contributing factor in the retention of symptoms through the desire or wish of the patient to remain protected by his neurosis. At least this possibility was kept in mind, so that if a cure was not effected within that time the question of the patient's cooperation was brought up.

The fifth principle was that work of some kind was one of the most important aids in effecting symptomatic cures, so that always more than 80 per cent of the patients were engaged in work of some sort. This work was of a varied sort, work in the fields in season, road making, wood chopping, and work in 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 meet war conditions within a comparatively short distance from the front areas.

Of the more general and usual methods of treatment of cases of this kind nothing will be said, such as rest for exhausted cases and isolation for excited or markedly tremulous cases. Such things form a necessary part of every hospital, and it will be taken for granted that such methods were carried out as effectively as they could be in a hospital equipped under the handicaps existing in France at that time.

Such methods as presented an individual therapeutic view were to be found naturally in the hysterias and in the anxiety neuroses, and a description of what was tried out and found of value will be set down, rather to indicate the general trend of therapeutic effort than completely to describe them.

The point in view in hysteria was that the symptoms were the result of a promptly acting shock-dissociation process, either materially or emotionally produced. If in the former it was not in any sense due to definite organic changes in the brain but to some sort of preorganic thing, possibly of a molecular or circulatory sort-anything which does not preclude the possibility of an equally prompt restoration to the normal. It was further appreciated that there was a mechanism of fixation of symptoms from which the neurosis tended to develop and become elaborated, so that if the emotionally fixed objective symptom could be removed thoroughly, the rest of the neurosis structure would rapidly disintegrate.


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Inasmuch as hysteria was thought of as a mechanism of unconscious origin, coming into activity without the patient's awareness and often without his subsequent knowledge, its symptoms were regarded by the patient as being mysterious and strange. He himself, then, neither understood what they were, why he had them, nor to what they were due. The first logical step, therefore, was to attempt to explain to the patient something about the mechanism that had been at work in making of him an hysterical type of war neurosis. The second was to assure him both of its unconsciousness and of the possibility of rapid disappearance provided he gave his cooperation, chiefly by developing a condition of receptivity as far as he was able to do so. The next step was the acquirement of an attitude of expectancy. Then followed the use of the many methods of suggestive symptomatic treatment designed to remove as quickly and thoroughly as possible, symptoms in the order of their importance to the patient. This, in turn, was followed by after-treatment aimed to emphasize the fact that the symptoms had disappeared, and furthermore, to fix the notion of the mechanism originating the symptoms and then to fix the mechanism of their disappearance. The last step was an attempt to so increase automatic inhibition that the symptoms could not reappear. This last was still in process of development when the war ended.

In the phase of explanation only very simple methods were used, depending much on the intelligence and understanding of the patient. With an understanding and belief in a definite mechanistic production of hysteria, it was not difficult to impart such belief to the patient. Without such belief and knowledge it would have presented great difficulties. The attitude of receptivity and expectancy grew up in the patient's mind automatically, as his belief and faith in his physician took hold of him, or it arose from his eagerness to get rid of an embarrassing or handicapping group of symptoms. It was possible in many instances to increase the attitude by maneuvers designed to stimulate 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 preparatory qualities to the attack on the symptoms themselves. Some of the staff developed, to a high degree, what was called ward morale. This meant the influence of the cured cases and cases cured of a similar set of symptoms, on the individual about to be treated. It also had reference to a rather mysterious thing called ward atmosphere. This was a reflection of the attitude of the nurse, physician, and patients to a patient who showed neither aptitude nor inclination to meet the cooperative demands which his case warranted. It is rather difficult to describe in a few words. In certain wards patients were cured quickly and remained so. It was not customary in these wards for patients to show symptoms for more than a little while after admission. It is of interest that this aspect of ward morale did not simply happen, but was consciously and carefully worked out by the physician and nurse.

The immediate attack on the symptoms was carried out by means of one or more of the suggestive methods in vogue throughout all the neurological services in all the armies. The suggestive treatment was either intensive-in which case, as a rule, the faradic current was used-or it was gradual, being


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given at intervals. In some instances the battery was not used at all, persuasion and command, argument and reasoning being all that was required. In other instances, again, some other material type of suggestion was employed, as tuning forks or stethescopes in deafness, and tongue depressors in aphonias. Whatever method was used, great care was always taken to convince the patient that the results attained were only intensifications of what he was perfectly able to do himself. The faradic current, for instance, used to stimulate a muscle in a case of paralysis, was only a means of demonstrating the functional capacity of the muscle, so that the idea of its paralysis, engendered by the process dissociating it for the time being out of consciousness, was negatived.

The personal modifications of the technique of intensive suggestion, developed by members of the staff at Base Hospital No. 117, was used in every type of hysteria and in all its various manifestations. It was very generally effective in causing these symptoms to disappear. Tremors of all kinds, choreiform movements, fixed position, all types of paralysis, blindness, aphonias, deafness, etc., were daily cured, often in a few minutes, seldom taking as much as an hour. There is nothing surprising in this, especially if one considers that a certain percentage of these disappeared of themselves. Of more importance and of greater interest was the surprising degree of individual technique which grew up about each of the more expert therapeutists of the staff.

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 exercises leading back to the event for which the amnesia existed and for which it exercised its protective influence. By bringing into full consciousness this event and forcing the patient to face, and square himself with it, the path of reassociative memory was found, and the amnesic block gradually grew less and finally disappeared. It was either complete, leaving the thread of memory without a break, or some small remnant of block still persisted. In the latter instance it might be left as a perfectly harmless amnesic islet, as it was termed, or dissipated by putting the patient under a very mild degree of hypnosis. In this condition, no great difficulty was found in reestablishing the flow of consciousness again. A small series of amnesias was treated from the start by hypnosis.

The therapy of the anxiety neuroses was a much more difficult thing to develop and apply. The condition itself presents a much more complicated form of neuroses than the cruder reactions of hysteria. The anxiety neurosis, as has been said, dips down deeply into the personality and touches on factors that are associated with the make-up of the individual. It has a strongly ethical character, presenting conflicts of various kinds. This dissociation has very little direct material expression and presents, for this reason, little opportunity for a direct therapeutic attack. An anxiety neurosis case takes a great deal more time both to develop and to treat, and the individual who is capable of having it has reacted to it much more deeply than a hysteria 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 certain amount of study must be given to past experiences, to his former life, to his career in the


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Army, and to the succession of events which brought him into the hospital. It is necessary to acquaint the patient at first-hand with the causes that led to the condition, the nature of the condition. He must be instructed as to the nature of conflict, his in particular, and as to the function of repression. Above all, he must be taught to face the whole matter as a section of experience which has come into his life, and which will remain as a part of himself as long as he lives or until the memory of it becomes fainter with the piling up of those of more recent origin.

The therapeutic aim in the anxiety neuroses had formerly been to encourage the patient to forget his experiences and to aid by his own effort the automatic repressive tendency already existing. The new point of view was to attempt 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 terrifying they happen to have been. It was in a sense a modified psychoanalytic procedure adapted to a war-born condition, divorced from a good deal of the technical complications of the method used in peace times.

A patient was encouraged to talk about his experiences, to go over the emotional states which accompanied them, and to examine himself as critically as he could in reference to them. It is one thing to face a past event and to measure oneself in the light of that event; it is quite a different thing to try to forget an event and thus allow the criticism, so to say, to go on unconsciously and the resulting emotion to remain as the only conscious evidence of the conflict going on sublimated and beyond reach. The former state of mind was encouraged in the patient, the latter was to be avoided.

The chief conflicts found in the anxiety neuroses were analyzed out in some such manner as this. The technique differed according to the individual therapeutists. None found it necessary, however, to employ any more complicated technique than that of question and answer. A perfectly frank account of experiences, with the proper narrative sequence of events, together with the critical comments of the physician, was all that was required in many instances to prepare the way for a successful therapy. The knowledge of such cases acquired by the therapeutists led to the proper emphasis of the points he was trying to make, much in the way that a trained psychoanalyst in the Freudian sense indicates to his patient the line of associative events he desires to bring up into active consciousness. In the peace neuroses this is frequently a matter of great difficulty on account of the patient's unwillingness to face the embarrassing nature of the conflict from his point of view. In the war neuroses the conflict is formed out of simpler elements and, since the whole thing is more recent, the repressive function has had much less opportunity to bury them deeply in the lower levels of consciousness. Furthermore, the conflicts were so frequently conventionalized and so often found repeated in different individuals that it was an easy matter to present them to the patient with only a little assistance from him. In this way the rapport between patient and physician was not difficult to establish, because it was found that there was little to conceal and less possibility of deception. The favoring element therapeutically was, of course, the central motive underlying all efforts of treatment, that is, the duty and necessity of fulfilling his obligation as a soldier-the return to duty. Only


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in exceptional cases was this ever a matter of argument or even of doubt. There could be little weighing of contending motives in such a situation. The duty of a citizen may present many points of conflicting interests, that of a soldier none. That is, none, if the point is reached, when he is brought face to face with the definite reality of his military position.

Although the methods of treatment and the general therapeutic attitude toward a patient with anxiety neurosis can be set down in so simple a manner as this, the implication does not follow that the procedure was an easy one or that it was always successful. Such certainly was not the case, for no conditions in the war neuroses were so difficult to handle or required so much effort. 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 who became in a way anxiety neurosis specialists. The contrast to hysteria in this respect was marked. Almost anyone after a little instruction could treat the ordinary hysterical case successfully, whereas only a few ever qualified as good therapeutists for the anxiety cases.

The therapeutic methods in use in the other types of the war neuroses need scarcely be mentioned in detail. Apart from the usual symptomatic treatment, the conventional hospital manner of handling the daily discomforts of a ward full of patients, there was little to distinguish this hospital from any other. Drugs were given as seldom as possible, and then only to meet the simple complications of an average patient in a hospital. Bromides, hypnotics, and analgesics were given with the greatest reluctance, and for the most part the patient did better without them. It was necessary at all times to combat the natural desire of a patient for some more tangible evidence of treatment, but this the nurses were for the most part able to do.

Therapeutic use was made of many other agencies not usually mentioned in describing methods of treatment. All of them had to do with strengthening 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 and cleverly designed sermons touching on the spiritual phase of courage, loyalty, devotion, and patriotism. The sermons and religious exercises were planned in part toward this end, as were the weekly talks by members of the staff and sometimes by visitors to the hospital. In other ways the military atmosphere was kept alive by every means possible. The decorations in the recreation huts were all planned to keep the military atmosphere in the minds of the soldiers through stirring posters and scenes of actual war conditions. The walls were covered by sketches 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 place in this hospital; intelligent insight and appreciation of the mechanism of the war neuroses in a measure took its place. The military necessity was accentuated and kept constantly in mind, but notwithstanding a certain grimness in the hospital's attitude to its patients, not the slightest suggestion of harshness or


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severity was ever permitted. The war neuroses were regarded as temporary conditions into which a soldier might fall and thus become a subject for medical treatment. The treatment was found to fail unless the efforts made to help him met with the cooperation of the patient and a desire on his part to get well. The hospital was planned and equipped for the purpose of returning him to duty and, given his support, in most cases, this was accomplished. 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 helping on his case, be it chaplain, civilian aid, nurse, or some other specially qualified member of the hospital personnel.

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