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Section II, Chapter VIII

Table of Contents

CHAPTER VIII

STUDY OF CASE HISTORIES OF A TYPICAL GROUP OF WAR NEUROSES

The study to be presented here arose originally as somewhat of a military necessity in the American Expeditionary Forces. As Base Hospital No. 117 was the principal center for training neuropsychiatric personnel for the care of war neurosis cases, there were constantly passing through the hospital scores of medical officers sent there for instruction.1 A scientific summary of the clinical material there consequently was considered helpful in giving to these student officers a more concrete understanding of the war neurosis problem than otherwise would have been possible. The material presented here is the result of an inquiry made in France into the make-up of the patients at Base Hospital No. 117, amplified by later studies carried on in the United States in 1919 and 1924. It is a description of the characteristics-physical and mental, military, and social-of men in the American Expeditionary Forces who developed neurosis and were sent to the only special base hospital in France for the treatment of war neuroses. The original tabulation was done over a period of several months by a group of well-educated patients under the supervision of the writer; and later repeated by the writer in The Adjutant General's Office. The cases considered herein include, of course, only cases diagnosed as psychoneurosis.

MENTAL AND PHYSICAL MAKE-UP

THE AGES FOR THIS GROUP COMPARED WITH THOSE FOR THE ARMY AT LARGE

Whether or not the factor of age is significant in the development of war neurosis may be discovered by comparing the ages of the patients of Base Hospital No. 117 (taken at the time of hospitalization) with the distribution of ages in the Army at large. From the records of the War Risk Insurance Bureau it was possible to tabulate the ages of 3,683,134 soldiers (officers and men), and these serve as a basis for comparison. In interpreting the comparison between the figures for Base Hospital No. 117 and those for the Army at large it should be stated here that the latter ages were obtained from insurance policies taken out shortly after the soldiers' arrival in camp. Ayres2 estimated that during the World War the average American soldier spent from eight to nine months after the time of his entering camp before he reached the front; this means that the ages of the men as given on their insurance policies would all have increased by eight months or more by the time they reached Base Hospital No. 117. With this in mind the table following was prepared.


430

TABLE 1.-Comparison of ages of patients of Base Hospital No. 117 with ages furnished by 3,683,124 applicants for war risk insurance on basis of incidence of each age per 2,653 (the number of psychoneurosis cases on whom ages were obtained)a

Age

Army at large

Base Hospital No. 117

Age

Army at large

Base Hospital No. 117

16

1

2

35

10

15

17

9

7

36

9

12

18

46

34

37

7

8

19

89

127

38

7

9

20

111

152

39

6

4

21

210

164

40

5

8

22

364

307

41

4

5

23

315

334

42

3

4

24

274

302

43

3

4

25

234

227

44

2

3

26

204

224

45

2

7

27

160

140

46

2

1

28

154

141

47

1

2

29

135

110

48

1

2

30

125

104

49

1

0

31

91

79

50 and over

4

5

32

36

58

Medians

24.664

24.662

33

15

33

Q

2.315

2.315

34

13

19


aThroughout the following discussion the figures obtained from the War Risk Insurance Bureau will be converted into numbers per 2,653, in order to facilitate comparison with the figures for Base Hospital No. 117.

The median for the ages of the Army at large is 24.664 years, for the ages at Base Hospital No. 117, 24.662 years. Though the medians of the two groups are practically identical, the median for the Base Hospital No. 117 group is in reality about eight or nine months less than that for the Army at large, for the reason given above, namely, that the ages for the Base Hospital No. 117 group were taken approximately this length of time later in the soldiers' careers than were the Army at large ages.

In comparing the number of admissions under 21 years of age with the Army at large figures for the same ages, we find for the Army at large (soldiers under 21 years), 256; for Base Hospital No. 117 (patients under 21 years), 322.

Again we must consider when the data were obtained in each group and allow for the eight or nine months' difference in the dates when the two sets of ages were taken. The Army at large figures as they stand are too large for this group, since approximately two-thirds of the men recorded at age 20 would by the time of hospitalization have passed into the 21-year-old group. One hundred and eleven such men (per 2,653) were 20 years old. When two-thirds of this number is transferred over to 21 years, it leaves the relative numbers as: Army at large (soldiers under 21 years), 182; Base Hospital No. 117 (patients under 21 years), 322.

These figures reveal a marked disproportion between the admissions to the hospital of men under 21 and their number in the Army at large, 77 per cent more men from this group being admitted to the hospital than their proportion in the Army would lead us to expect. That is, there was a marked tendency for men under 21 to develop neurosis in greater numbers than their proportion in the Army would warrant.

The usual upper age-limit for Army original enlistment is 35 years. This implies a decrease in the desirability for Army service of men above that age.


431

Comparison of the two groups for the ages above 35 gives the following figures: Army at large (soldiers over 35 years), 67; Base Hospital No. 117 (patients over 35 years), 89.

The total for the Army at large group, at 34 years of age, is 13. Two-thirds of 13 must be added to the figures given above to make them comparable with those of Base Hospital No. 117, because of the eight months' difference in the time of taking ages. Allowing for this discrepancy, we must add 8 to the 67, making a total of 75. Including this allowance, there are 19 per cent more patients at these ages than the expectation in the Army at large. This difference is significant enough to warrant a second, though less marked conclusion, i. e., that men over 35 had a somewhat greater proportional liability to develop war neuroses than the numbers of those ages in the Army at large would warrant.

FAMILY AND PERSONAL HISTORY

The question of the significance of the place of lessened resistance in the individual's nervous system is perhaps the most significant problem for statistical study in connection with the nature and etiology of war neurosis. There has been a widespread tendency to imply nervous or biological inferiority in the war neurotic. By this is meant that in the past life of the individual there had been some incident or some condition in which the neurosis was latent, that the war merely revived an old or innate weakness. It was assumed that the pathological factors in the individual's make-up had been manifested earlier by such incidents as nervous breakdown, chorea, tics, and speech disorders. Also, in addition to previous personal weakness, nervous inferiority includes familial defect in the form of direct or collateral expressions of serious nervous disorders. Yet the following references illustrate the existence of a diversity of opinion regarding the relationship of neuropathic taint to the occurrence of war neuroses.

Mott,3 quite early in his experience, found that in the majority of instances of war neuroses the subject had an inborn or acquired disposition to emotivity. The same conclusion, he says, was arrived at by eminent French and German authorities. Yet later in the same discussion Mott stated that shock-not only commotional but emotional shock-due to terrifying or horrifying conditions of war, might induce hysterical manifestations in a neuropotentially sound individual, in fact, in a soldier who by his record had shown that he was neither of a timid disposition nor had any neuropathic tendency. Wolfsohn4 studied 100 of Mott's cases and found in 74 per cent a positive family history and in 72 per cent a positive personal history. Whereas Hurst5 believed the war neuroses might develop in anyone, Babinski, limited liability to the supersuggestible. Pollock,6 in a study of 200 cases, found positive family history in 4 per cent, positive personal history in 23 per cent, mental deficiency in 1 per cent. Salmon7 held that the constitutional neurotics constituted a large proportion of all cases; however, the number of men of apparently normal make-up who developed war neuroses was very striking. Rhein,8 studying incipient cases in a forward area hospital, found that of 342 cases studied 195 had negative family history and 137, positive; of 320 cases studied by him for personal history, 174 were negative and 146 positive. He explained his large


432

negative findings by saying that in the active war areas one acquired in a short time a state of nervous instability which in civil life would require months or years to bring about. The shortened period in the genesis of general paresis in soldiers at the front is a similar fact; Weygandt9 suggested a similar foreshortening for dementia præcox. According to Schwab,10 the percentage of neuropathy never appeared to be greater than 5 per cent. Viets11 held that the neuroses all had a history of more or less psychopathic disposition before the war. Kiely,12 studying 500 cases at a base hospital in the American Expeditionary Forces, found 34 per cent with positive family, 42 per cent with positive personal history. Careful inquiries into the family histories of all people, healthy as well as sick, have shown that the preponderance of such heredity for the mass of neuroses and psychoses is but a trifle more than that for healthy individuals.

The supposition that a pathological nervous incident in the life of an individual may come to light under the stress of war conditions is unquestionably true. There were many cases at Base Hospital No. 117 in which some old symptom had returned, the recurrence being usually in exaggerated form. A man who had stammered a bit in his youth entered the hospital mute or aphonic; tics or choreiform movements of childhood reawakened as generalized coarse tremors. In what might be called the sphere of subjective symptoms, phobias, worries, suspiciousness, to say nothing of those symptoms related to conditions falling under the head of constitutional psychopathic states, this same exaggeration occurred. There were several cases of men who had been previously of a slightly suspicious make-up who showed upon admission to the hospital distinctly paranoiac symptoms, these usually following upon some severe fatigue. Likewise, in many of the psychasthenics an old fear of the dark, horror for high places, self-doubtings, or other similar conditions, were greatly magnified. Several interesting cases in which there had been in childhood or throughout the previous life of the individual an obsessive fear of the dark were carefully observed. These patients entered the hospital, after evacuation from the front, in a state of terror, not only of the dark, but also of the day, and especially of being alone at any time. They were often afraid to leave the ward, and generally would venture but a short distance from the hospital alone. If they had to go anywhere at night they would wait until someone came along who was going in the same direction.

In discussing the casual significance of neuropathic taint, it is pertinent to compare our findings with the proportion of familial and personal taint in the average regiment that went overseas and saw service at the front. Bowman,13 described the testing of a regiment at one of the cantonments in the United States in which he found that 45.59 per cent of the men gave positive findings; 38.43 per cent were themselves neuropathic, and positive family histories were noted in 9.84 per cent of his cases. Only 2.2 per cent of these men were recommended for discharge;b the rest probably went to France.

Undoubtedly the attitude of the men in camp in the United States toward answering many personal questions was different from that of patients at the

bBowman in a personal communication added: "It is also perhaps well to note 24 cases who were picked out from preliminary examination for further study were not studied because of transfer to other organizations, and the actual number recommended for discharge probably would have been higher if these cases could have been studied."


433

war neurosis hospital in France. Men who were eager to cross the ocean and see action were quite loath to give information which was likely to jeopardize their chances of going overseas. But how different the attitude toward disclosing family and personal neuropathy among men who had been through several campaigns, and had been blown up or concussed, and were in a hospital suffering from troubles which, to say the least, were mysterious to them. Then again, the necessarily hasty mental examinations which were made in the cantonments in the United States could not be compared in acuity with the study which the ward surgeons put in upon their cases in the hospital service in France. Bowman's figures suggest, however, that probably in all regiments there were nearly 50 per cent of the men whose clinical histories if taken would show the presence of neuropathic taint either in their families or in themselves.

The staff physicians at Base Hospital No. 117 made inquiry regarding each patient's personal and family history. The figures used here regarding personal and family history are taken from their accounts of psychoneuroses cases assigned to their wards. Cases which were written up hastily or superficially by officers on temporary duty were excluded from consideration. As the patients were assigned to the various wards by chance this sampling is a fair one.

The data on family and personal history are summarized under two headings: Positive and negative. In considering family history, positive includes cases in which the family history showed that either the parents or near relatives were actually committed to institutions for the insane or suffered from symptoms which the ward surgeon could readily recognize as psychotic or neuropathic. Positive included also frequent occurrence in the patient's family of gross medical difficulties, such as tuberculosis, heart trouble, and the like. Negative indicates an absence of insanity or excessive disease in the family.

In taking account of the personal history of the patient, the same two categories were used: Under positive were included numerous types of difficulties-psychoses, psychopathic personality, alcoholism, mental deficiency, premature organic troubles of the heart, lungs, etc., severe neurasthenias, speech defects and hypochondriachal disorders of long standing, neuroticism, timorousness, excitability, effeminacy, temperamentality, and sex and other anxieties. Under negative were cases in which no evidence of such abnormality could be discovered in the previous personal history of the patient.

Data were obtained from approximately 1,000 case histories. The discrepancy in numbers is due to incompleteness in some of the case histories. The following tabulation summarizes the findings:


FAMILY HISTORY

Per cent

Positive

508

50.15

Negative

505

49.85


PERSONAL HISTORY

Positive

527

51.93

Negative

488

48.07


COMBINED: PERSONAL AND FAMILY HISTORY

Positive

643

63.48

Negative

370

36.52



434

By comparison with Bowman's figures of 45.59 per cent positive findings for combined personal and family history in a "normal" regiment, the members of which had previously, when recruited, been given a medical examination, and of which only a small number were discharged from the service, one finds that the supposition of an overwhelming probability of previous neuropathic taint in the war neurosis victim does not hold true for the patients of Base Hospital No. 117. There is no gainsaying that the war neurosis tended to include symptoms which had occurred in the individual's past life, and, similarly, to strike any latent weakness with telling force; but to go further and define the causation and occurrence of war neuroses in terms of these mental or nervous weak spots would be taking an extreme view, and one scarcely warranted by the fact that more than one-third of the number of cases studied in this group gave no evidence of such neuropathic background.

PHYSICAL STIGMATA

It is a traditional habit to connect psychoneurosis with the so-called physical stigmata. Jones, for instance, writing of war neuroses, said:14

The type known to neurologists as "degenerate," which contains many epileptics in its ranks, with the physical characteristics of narrow palate and crowded teeth, simian hand and coarse skin, has been found frequently among these patients; I have come to regard a narrow palate as indicating a bad prognosis.

There were few notations of physical stigmata on the case histories of patients at Base Hospital No. 117; less than one-half of 1 per cent. Anomalies of growth, such as marked facial asymmetry, Hutchinson teeth, feminine type of breast and pubic hair distribution, did occur, but these were rare in view of the total number of cases admitted.

WOUNDS

The number of men admitted to the hospital who had been wounded or injured was very small. There were some few cases of traumatic hysteria developing upon an injury suffered from an accident with horses, mules, or camions. The total number of patients admitted who had been seriously wounded was 18, or less than 1 per cent; slightly wounded, 187, or 7 per cent. These cases had recovered from their wounds at the time of hospitalization in Base Hospital No. 117. Kiely,12 studying 500 cases, found only 6 per cent who had been wounded at all-only 1 or 2 of these being wounded about the head. These facts bear out the usual theory that the soldier who is taken prisoner or physically wounded rarely develops a neurosis.

EFFECTS OF GASSING

It was difficult to differentiate cases in which gassing had been present and those in which it was assumed or imagined. If questioned, most of the men would remember having been exposed to poisonous gas at one time or another. There were 148 cases, or 5.51 per cent, in which the history of gas injury was noted by the ward surgeon in his summary, the scar of the burn often bearing out the man's assertion.


435

DRUG ADDICTION

Of all the admissions to the hospital there were only three individuals who gave evidence of being drug users. These were in no sense pronounced cases. The cases of psychoses of this sort in the American Expeditionary Forces were not many and when they occurred they were sent to hospitals handling mental cases. The relationship of drug addiction to the etiology of war neurosis, if present, is very insignificant.

ALCOHOLISM

Opinion varies regarding the significance of alcohol in the etiology of war neuroses. Canadian authorities believed an alcoholic 35 years or older a sure candidate for war neurosis. Kiely,12 in his study of 500 cases, found 4 per cent alcoholics. Lépine,15 on the basis of 6,000 cases observed, claimed that alcohol was the primary and sole cause in one-third of his cases, and that more than half, perhaps two-thirds, were influenced by it. He likened it to malarial disease in the pathology of certain countries. Read,16 on the contrary, was emphatic in his denial of the significance of alcohol as anything but contributory in the causation of war neurosis.

One of the most interesting cases of complete amnesia seen by the writer began to clear up under alcohol. The patient returned to the hospital, after imbibing freely, very much excited over some visual images related to his lost memories which were passing before him. In a short time, by simple association means, a good part of this man's memory returned.

The statistics of the cases at Base Hospital No. 117, regarding the use of alcohol, as elicited by the ward surgeons in their clinical histories, were the following: Negative-ranks from abstainer and moderate drinker to those who had been intoxicated once or twice in their lives, 2,295, or 92.73 per cent. Positive-men who gave a history of frequent alcoholic dissipation, including "demonstrations" during their hospitalization, 180, or 7.27 per cent.

Inasmuch as these figures were obtained from the men's replies to questions the ward surgeons asked them, undoubtedly there may have been some misrepresentations. However, observation of the men's behavior in nearby towns and about the grounds of the hospital showed that there were few among the group that tended to alcoholism. Furthermore, the inability of the men at the front to obtain alcoholic beverages in large amounts, practically eliminates alcohol as an important etiologic factor in war neurosis in the American Expeditionary Forces. Its part as a contributory factor, however, is difficult to determine.

SOCIAL AND ECONOMIC STATUS

BIRTHPLACE

The cosmopolitan origin of the American Expeditionary Forces is interestingly brought out by inspection of the birthplaces of the patients in Base Hospital No. 117. Sixty-four were born in Italy, 49 in Russia, 19 in Ireland, 15 in Poland, and 14 each in Canada and England. Besides representatives from European countries other than those cited, Cuba, Switzerland, Armenia, South Africa, Brazil, and the "high seas" were represented. The following


436

tabulation contains the figures for the various countries from which the foreign-born psychoneurosis patients of the hospital came:

Albania

2

Finland

4

Rumania

5

Argentina

1

France

2

Russia

49

Armenia

2

Germany

4

Scotland

6

Austria

7

Greece

10

Serbia

2

Belgium

3

Holland

1

South Africa

1

Bohemia

1

Hungary

1

Sweden

2

Brazil

1

Ireland

19

Switzerland

2

Canada

14

Italy

64

Turkey

1

Cuba

3

Lithuania

2

Wales

1

Denmark

2

Norway

7

High seas

1

England

14

Poland

15


In view of the great amount of moving from State to State the figures for the birthplace of the men are less significant than those for home addresses in drawing inferences regarding the social background of the war neurotic group.

STATE OF RESIDENCE AND OCCUPATIONAL ENVIRONMENT

The States which the enlisted men who were patients of Base Hospital No. 117 gave as their homes were compared with the percentages of enlistments in the Army as a whole coming from the same States. It must be remembered in interpreting such a comparison that a determining factor in the incidence of psychoneurosis in various divisions of the Army is the severity and duration of the campaigns in which the troops in question were used. There is, of course, no assurance that soldiers from the various States were subjected to similar severity of military stress. Yet the coefficient of correlation by the rank methodc between the percentage of Base Hospital No. 117 patients from each State and the percentage of the total Army enlistments by States is plus 0.841 (P. E. + 0.0297). This correlation would indicate that from the standpoint of proportionate representation from the States our selection of cases is in general tendency adequately representative of the constitution of the Army as a whole.

Significant interpretations regarding the types of localities from which these men came are obtained from the consideration of the percentage of urban and rural residents, density of population, percentage of foreign born, and number of males 10 years of age and over engaged in agricultural work in the various States. Tables 2 to 5 give the results of this tabulation. When either the 10 highest ranks are compared with the 10 lowest (by the addition of the percentages) or the 24 highest with the 24 lowest for the above-mentioned four considerations, the data are all similar in tendency. The States in which there were the highest percentages of native stock, of rural residents and of agricultural workers, and the least density of population, gave much smaller quotas of psychoneurosis patients than did the States high in density of population, urban residents, foreign born, and nonagricultural workers.

Or viewed from another angle, these facts are further defined by the coefficient of correlation by the rank method between Base Hospital No. 117 percentages ranked for the four qualities under study and the rank order of percentage of enlistment in the total Army. Rho is positive for density of popu-

  (footnote)


437

lation (plus 0.609, P. E ± 0.123), for percentage of urban residents (plus 0.464, P. E. ± 0.079), for percentage of foreign born (plus 0.104, P. E. ± 0.090), and negative for percentage of males 10 years and over engaged in agricultural work (minus 0.507, P. E. ± 0.072).

TABLE 2.-Rank order of States from the standpoint of percentage of urban residentsd related to percentages of the total Army enlistments and of Base Hospital No. 117 patients from those States

Rank

State

Per cent B.H. No. 117

Per cent of Army

Rank

State

Per cent B.H. No. 117

Per cent of Army

1

District of Columbia

0.39

0.42

26

Arizona

0.08

0.28

2

Rhode Island

.87

.45

27

Louisiana

.59

1.76

3

Massachusetts

7.57

3.53

28

Kansas

1.19

1.69

4

New York

12.80

9.79

29

Texas

3.05

4.29

5

New Jersey

4.28

2.80

30

Montana

.59

.97

6

California

1.66

2.98

31

Nebraska

1.11

1.27

7

Illinois

5.39

6.68

32

Vermont

.47

.25

8

Connecticut

3.17

1.33

33

Wyoming

.16

.30

9

Pennsylvania

14.70

7.93

34

Virginia

1.98

1.94

10

Ohio

5.74

5.35

35

Idaho

.32

.51

10 highest ranks

(56.57)

(41.24)

11

New Hampshire

.95

.24

36

Oklahoma

1.39

2.13

12

Michigan

4.08

3.61

37

Kentucky

1.11

2.00

13

Maryland

1.43

1.25

38

Tennessee

.79

2.02

14

Washington

1.15

1.20

39

West Virginia

1.27

1.48

15

Delaware

.16

.20

40

Georgia

1.07

2.28

16

Indiana

1.92

2.83

41

Alabama

1.31

1.99

17

Oregon

.32

.80

42

Nevada

.08

.14

18

Colorado

.63

.92

43

North Carolina

.67

1.94

19

Utah

.32

.46

44

New Mexico

.24

.33

20

Wisconsin

4.49

2.61

45

South Carolina

.87

1.42

21

Missouri

2.77

3.42

46

Arkansas

.59

1.62

22

Minnesota

1.27

2.64

47

South Dakota

.12

.79

23

Maine

1.27

.65

48

North Dakota

.63

.69

24

Florida

.33

.89

49

Mississippi

.52

1.44

Total

77.66

62.96

10 lowest ranks

(6.10)

(12.64)

Total

20.20

33.53


dObtained from Abstract of the Fourteenth Census of the United States, Government Printing Office, 1920, page 75. Includes District of Columbia and omits Iowa, rank 25.

TABLE 3.-Rank order of Statese from the standpoint of density of population related to the percentages of the total Army enlistments and of the patients of Base Hospital No. 117 from those States

Rank

State

Per cent B.H. No. 117

Per cent of Army

Rank

State

Per cent B.H. No. 117

Per cent of Army

1

District of Columbia

0.39

0.42

26

Louisiana

0.59

1.76

2

Rhode Island

.87

.45

27½

Vermont

.47

.25

3

Massachusetts

7.57

3.53

27½

Mississippi

.52

1.44

4

New Jersey

4.28

2.80

29

Arkansas

.59

1.62

5

Connecticut

3.17

1.33

30

Minnesota

1.27

2.64

6

New York

12.80

9.79

31

Oklahoma

1.39

2.13

7

Pennsylvania

14.70

7.63

32

Maine

1.27

.65

8

Maryland

1.43

1.25

33

California

1.66

2.98

9

Ohio

5.74

5.33

34

Kansas

1.19

1.69

10

Illinois

5.39

6.68

35

Washington

1.15

1.20

10 highest ranks

(56.34)

(39.41)

36

Texas

3.05

4.29

11

Delaware

.16

.20

37

Florida

.35

.89

12

Indiana

1.92

2.83

38

Nebraska

1.11

1.27

13

Michigan

4.08

3.61

39

North Dakota

.63

.69

14

West Virginia

1.27

1.48

40

Colorado

.63

.92

15

Kentucky

1.11

2.00

41

South Dakota

.12

.79

16

Virginia

1.98

1.94

42

Oregon

.32

.80

17

Tennessee

.79

2.02

43

Utah

.32

.46

18

South Carolina

.87

1.42

44

Idaho

.32

.51

19

North Carolina

.67

1.94

45

Montana

.59

.97

20

Missouri

2.77

3.42

46½

New Mexico

.24

.33

21

Georgia

1.07

2.28

46½

Arizona

.08

.28

22

New Hampshire

.95

.24

48

Wyoming

.16

.30

23

Wisconsin

4.49

2.61

49

Nevada

.08

.14

24

Alabama

1.31

1.99

10 lowest ranks

(2.86)

(5.50)

Total

79.78

67.39

Total

18.08

29.00


eObtained from Abstract of Fourteenth Census of the United States, page 22. Includes District of Columbia and omits Iowa, rank 25.


438

TABLE 4.-Rank order of Statesf from the standpoint of their percentage of foreign-bornpopulation related to percentage of the Army enlistments and of Base Hospital No. 117patients from those States

Rank

State

Per cent B.H. No. 117

Per cent of Army

Rank

State

Per cent B.H. No. 117

Per cent of Army

1

Rhode Island

0.87

0.45

26

Nebraska

1.11

1.27

2

Massachusetts

7.57

3.53

27½

Iowa

2.14

2.63

3

Connecticut

3.17

1.33

27½

Idaho

.32

.51

4

New York

12.80

9.79

29

Delaware

.16

.20

5

Arizona

.08

.28

30

New Mexico

.24

.33

6

New Jersey

4.28

2.80

31

Texas

3.05

4.29

7

California

1.66

2.98

32

Maryland

1.43

1.25

8

Nevada

.08

.14

33

District of Columbia

.39

.42

9

New Hampshire

.95

.24

34

Kansas

1.19

1.69

10½

Minnesota

1.27

2.64

35

Florida

.33

.89

10 highest ranks

(32.73)

(24.18)

36

Missouri

2.77

3.42

10½

North Dakota

.63

.69

37

Indiana

1.92

2.83

12

Michigan

4.08

3.61

38

West Virginia

1.27

1.48

13

Washington

1.15

1.20

39

Louisiana

.59

1.76

14

Illinois

5.39

6.68

40

Oklahoma

1.39

2.13

15

Wisconsin

4.49

2.61

41

Virginia

1.98

1.94

16

Montana

.59

.97

42

Kentucky

1.11

2.00

17

Pennsylvania

14.70

7.93

43½

Alabama

1.31

1.99

18

Maine

1.27

.65

43½

Arkansas

.59

1.62

19½

Wyoming

.16

.30

43½

Tennessee

.79

2.02

19½

Oregon

.32

.80

45

Georgia

1.07

2.28

21

Utah

.32

.46

46

Mississippi

.52

1.44

22

South Dakota

.12

.79

47

South Carolina

.87

1.42

23

Colorado

.63

.92

48

North Carolina

.67

1.94

24

Vermont

.47

.25

49

10 lowest ranks

(10.30)

(18.76)

Totals

67.05

52.04

Totals

27.21

41.75

fObtained from Abstract of Fourteenth Census of the United States, p. 103. Includes District of Columbia and omits Ohio, rank 25.

TABLE 5.-Rank order of Statesg from the standpoint of their percentage of males 10 years andover engaged in agricultural work related to the percentage of the total Army enlistments andof the patients of Base Hospital No. 117 from those States

Rank

State

Per cent B.H. No. 117

Per cent of Army

Rank

State

Per cent B.H. No. 117

Per cent of Army

1

Mississippi

0.52

1.44

26

Oregon

0.32

0.80

2

Arkansas

.59

1.62

27

Wyoming

.16

.30

3

North Dakota

.63

.69

28

Utah

.32

.46

4

South Carolina

.87

1.42

29

Colorado

.63

.92

5

South Dakota

.12

.79

30

Indiana

1.92

2.83

6

Georgia

1.07

2.28

31

Maine

1.27

.65

7

North Carolina

.67

1.94

32

Arizona

.08

.28

8

Alabama

1.31

1.99

33

West Virginia

1.27

1.48

9

Tennessee

.79

2.02

34

Washington

1.15

1.20

10

Idaho

.32

.51

35

Nevada

.08

.14

10 highest ranks

(6.89)

(14.70)

11

Kentucky

1.11

2.00

36

Delaware

.16

.20

12

Oklahoma

1.39

2.13

37

Michigan

4.08

3.61

13

New Mexico

.24

.33

38

California

1.66

2.98

14

Texas

3.05

4.29

39

New Hampshire

.95

.24

15

Nebraska

1.11

1.27

40

Maryland

1.43

1.25

16

Louisiana

.59

1.76

41

Ohio

5.74

5.33

17

Iowa

2.14

2.63

42

Illinois

5.39

6.68

18

Montana

.59

.97

43

Pennsylvania

14.70

7.96

19

Kansas

1.19

1.69

44

New York

12.80

9.79

20

Virginia

1.98

1.94

45

Connecticut

3.17

1.33

21

Minnesota

1.27

2.64

46

New Jersey

4.28

2.80

22

Vermont

.47

.25

47

Massachusetts

7.57

3.53

23

Wisconsin

4.49

2.61

47

Rhode Island

.87

.45

24

Florida

.33

.89

48

District of Columbia

.39

.42

Totals

26.84

40.10

49

10 lowest ranks

(56.34)

(39.51)

Totals

70.39

55.60


gObtained from Abstract of Fourteenth Census of the United States, p. 501. Agricultural work as the term used in the census tabulations also included forestry and animal husbandry. Includes District of Columbia and omits Missouri, rank 25.


439

When the draft quotas were being filled, it was found that the different parts of the country varied in physical readiness and vitality. Ayres,17 after presenting the official statistics for the physical fitness of the various States as expressed in the percentage of men accepted of all those called for national service, says: "In general, it is noteworthy that the best records are made by those States that are agricultural rather than industrial and where the numbers of recently arrived immigrants are not large." It should be observed, while noting the striking similarity for these data and those of Ayres, that there need not necessarily be any relationship between the percentage of physical defect among recruits and the percentage of neuropathic tendency among those selected after an examination for physical fitness has eliminated the unfit.

Another aspect of the problem, which should be considered in attempting a definition of the gross environment factors from which the war neurotics were recruits, is occupation. This has already been touched upon from one angle (agricultural work).

In Table 6, the Bureau of the Census data on occupations are compared directly, for each type of work, with the occupations given by the Base Hospital No. 117 patients (officers and enlisted men) in their clinical records. Several items, viz., mining, manufacturing, trade, and public service, involving about 50 per cent of the group, were similar in proportion in both sets of data. It is noteworthy, however, that whereas the percentage of males over 10 years in the United States in employment of some kind who were doing agricultural work was 29.8 per cent in 1920, only 11.5 per cent of the hospital patients gave agricultural work as their occupation when questioned at the hospital. On the other hand, the professional quota in the census is 3.4 per cent, while in the total hospital groups it is 7.2 per cent; likewise, the percentage of men in clerical work in the country at large was 5.11 per cent, while among the hospital groups it was 15.91 per cent; work related to transportation took in 13.8 per cent of the hospital groups and but 8.6 per cent of the males of the country at large. There were fewer (2.5 per cent) of the hospital group engaged in domestic work than the quota for the country at large (3.7 per cent). The last might be accounted for by alien exemptions and the ages of men engaged in domestic work. While recognizing the obvious tendencies of the data, it should also be remembered that 293 patients gave their occupation as "labor" and 124 were students. These cases, comprising 15.50 per cent of the group, are not used in the computations in Table 6 because of the indefiniteness of description and the inability to allocate them in terms of the Bureau of the Census classification. The data taken in comparison with the census figures unmistakably indicate that so far as occupational milieu was concerned men who were engaged in clerical, professional, or transportation work were liable to develop war neurosis in greater proportion than their quota in the total male population would warrant.


440

TABLE 6.-Comparison of distribution of types of occupation of Base Hospital No. 117 patientswith certain other groups

Type of work defined by 1920 census

Base Hospital 117 total group

1920 Census2

Enlisted men in A.E.F.3

Enlisted men, Base Hospital No. 117 patients

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

1. Agriculture

261

11.5

9,869,030

29.8

161,975

29.9

257

12.1

2. Extraction of minerals

53

2.3

1,087,359

3.3

12,239

2.3

52

2.5

3. Manufacturing and mechanical trades

789

34.7

10,888,183

32.9

151,429

28.0

780

36.6

4. Transportation

313

13.8

2,850,528

8.6

70,231

13.0

312

14.7

5. Trade

253

11.1

3,575,187

10.8

36,816

6.8

214

10.1

6. Public Service

45

2.0

748,666

2.3

18,099

3.3

26

1.3

7. Professional

163

7.2

1,127,391

3.4

34,748

6.4

117

5.5

8. Domestic Service

57

2.5

1,217,968

3.7

4,535

0.8

57

2.7

9. Clerical

339

15.9

1,700,425

5.1

51,429

9.5

319

14.5

Total1

2,273

100.0

33,064,737

100.0

541,501

100.0

2,134

100.0


1Does not include 4,937 of American Expeditionary Forces given as "education, extent of" and 37,034 given as "laborer" (total, 7.2 per cent). Likewise for Base Hospital No. 117 total group, 293 who gave occupation of laborer and 124 as students are omitted (total, 15.50 per cent).
2Fourteenth Census of the United States, 1920, iv, 3.
3Personnel System of the U. S. Army, Vol. I, U. S. Government Printing Office, 1919, i, 213-216.

There are available some occupation statistics on over half a million enlisted men of the American Expeditionary Forces, which are useful for comparison with our own. These data are arranged in Table 6 according to the census categories for the purpose of comparison. As indicated in the footnote to Table 6, two groups are omitted as inadequately descriptive and incapable of being fitted into this classification. Otherwise the group totals 541,501. As one would expect, these figures show that the enlisted men of the Army in France were not a perfect sampling of the occupational cross section of the male workers of the country; especially is the variation from the census notable in professional and clerical work, domestic service, transportation, and trade. Only in the agricultural figures are the two sets of facts practically identical.

When the enlisted men of the Base Hospital No. 117 patients are compared with the American Expeditionary Forces, figures for occupations of enlisted men, we find certain items in disagreement. The quotas of patients, especially for agriculture, and also for public service and domestic service are considerably less than expectation, whereas the quotas for manufacturing and mechanical trades, clerical work, and trade, are greater than expectation. The most striking difference is again in the small percentage in the agricultural group, while the greater proportion in clerical and domestic work and in trade are the most significant differences in the other direction, namely, toward a greater representation among the psychoneurosis patients than their proportional quotas. There is a slightly smaller percentage of the patients in professional work than the proportion of the American Expeditionary Forces, soldiers. This difference may be accounted for by errors in the collection of the American Expeditionary Forces, data; the very small number who gave the occupation "student" being indicative of a possible exaggeration of occupational status by these individuals into the professional ranks. In general, the tendency is for the patients to be engaged in bookish, indoor, commercial work in greater proportion than the Army in general and to have a lesser proportion of men engaged in agricultural work. Unfortunately these data on the Base Hospital No. 117


441

group do not lend themselves to interpretation by any of the occupational scales now obtainable. In the succeeding chapter this problem will be reviewed in the light of more adequate data. For the present, however, it may be noted that the war neurotic group, which is high in the trade and clerical types of work and low in agricultural work when compared with the enlisted men of the American Expeditionary Forces, is probably at least the equal of the latter in general occupational rating.

REFERENCES

(1) History of Base Hospital No. 117, A. E. F., prepared by the commanding officer of the hospital. On file, Historical Division, S. G. O.

(2) Ayres, L. P.: The War with Germany. Washington, Government Printing Office, 1919.

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

(4) Wolfsohn, Julian M.: The Predisposing Factors of War Psychoneuroses, Journal American Medical Association, 1918, lxx, No. 5, 303-308.

(5) Hurst, Arthur F.: Hysteria in the Light of the Experience of War. Archives of Neurology and Psychiatry, 1919, ii, 563.

(6) Pollock, Lewis J.: An Analysis of a Number of Cases of War Neuroses. Illinois Medical Journal, 1920, xxviii, No. 3, 209.

(7) Salmon, Thomas W.: The Care and Treatment of Mental Diseases and War Neuroses ("Shell Shock") in the British Army. Mental Hygiene, New York, 1917, i, No. 4, 509-547.

(8) Rhein, John H. W.: Neuropsychiatric Problems at the Front during Combat. Journal of Abnormal Psychology, 1919-20, xiv, No. 1, 1.

(9) Weygandt, W.: Versorgung der Neurosen und Psychocen im Felde. Medizinische Klinik, 1914, x, No. 39, 1503.

(10) Schwab, Sidney I.: The War Neuroses as Physiologic Conservations. Archives of Neurology and Psychiatry, Chicago, 1919, i, No. 5, 525-653.

(11) Viets, Henry: Neuroses and Psychoses in Base Hospital No. 33. Albany Medical Journal, 1919, xl, No. 1, 17.

(12) Kiely, Charles E.: Five Hundred Cases of Shell-Shock. Ohio Medical Journal, 1919, xv, No. 11, 711-718.

(13) Bowman, K. M.: Report of the Examination of the -- Regiment, U. S. A., for Nervous and Mental Disease. American Journal of Insanity, 1919, lxxiv, 555-6.

(14) Jones, D. W. Carmalt: War-Neurasthenia, Acute and Chronic. Brain, New York and London, 1919-20, xlii, October, 176.

(15) Lépine, Jean: Troubles mentaux de Guerre, Paris, 1917, Mason et Cié.

(16) Read, C. Stanford: Military Psychiatry in Peace and War. H. K. Lewis & Co., London, 1920, 34.

(17) Ayers, -- : Op. cit. 21.

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