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Section II, Chapter XI

Table of Contents

CHAPTER IX

A POSTWAR STUDY OF A TYPICAL GROUP OF WAR NEUROSES CASES IN 1919-20 AND 1924-25

THE 1919-20 STUDY

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

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

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

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

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


444

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

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

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

NORMAL

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

NEUROTIC

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


445

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

FATIGUED

Third comes the group called "fatigued." Most of these men can not work regularly without suffering and being confined to bed. The symptoms here are ready fatigability, severe headaches, lack of ambition and depression (general neurasthenic coloring). Whereas the "neurotic group" are able to work, though with much discomfort, this group can work only on the average about one-half of the time. Some of them are fortunate in having easy jobs or considerate employers and so manage to support themselves after a fashion. In some cases where the men are married, their wives also are working to meet the expenses of living.

DISABLED

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


446

PSYCHOTICS

Fifth is the psychotic group, including such conditions as dementia pręcox, psychopathic personality, and epilepsy. An interesting commentary is the infrequency of psychotic outworkings among the former patients of Base Hospital No. 117 as a group. In the 1919-20 study, only one suicide was reported-a man of poor stock and make-up, never at the front, who entered the hospital after the armistice was signed and was evacuated with the diagnosis "neurasthenia." Otherwise there were relatively few men (10, or about 1 per cent) whose condition had changed by 1920 from the psychoneurosis diagnosed at the hospital to a psychosis. By 1925 four deaths had been reported as suicides. Twelve were definitely psychotic, 14 were returned as either "in hospital; parents uncertain of address," or "lost" with a psychopathic coloring attaching to their disappearance. For instance, one man enlisted in the Navy under his brother's name, causing the family considerable trouble when he later deserted. The outside total of possible psychotics was 28 cases diagnosed psychoneurotic in France, or 3.4 per cent of the group. This is striking evidence favoring the psychological conception of war neuroses, for the mere possibility of insanity developing in 830 men over a period of seven years would probably not be less than this total.

In viewing the 1919-20 civilian status of these men in relation to their physical classification in France, when discharged from Base Hospital No. 117, several significant considerations arise. First of all, the American Expeditionary Forces physical classification was a practical estimate of future Army usefulness. It took into consideration such matters as health, strength, and endurance. Obviously these are factors which would be of significance in both Army and civilian life. Therefore, if the classifications were adequately made, then some positive correlation should exist between them and the 1919-20 conditions of the men. Second, it should likewise be appreciated that the ability of a man to return to the front calls upon factors in him differing from those that would be called forth in his attempting to get back, for example, to clerking or to farming in civilian life. Military conditions facing the man in France were obviously very different from civilian circumstances upon his return home. It is quite possible for Army misfits to be normal and even very successful in civil life. Third, the Army estimate of the value of a man before the armistice, when further battle service was under consideration, and during the armistice would be based on different factors; the latter would more nearly accord with the criteria of civilian usefulness. Consequently, throughout this discussion figures are given separately for the two groups of cases, those discharged from Base Hospital No. 117 before the armistice and those discharged during the armistice. The total figures are likewise used when the group as a whole is under consideration. The data on military classification are presented in several tables, and the conclusions from each of them are given in order.


447

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

Physical classification

Column 1

Column 2

Column 3

Column 4

Totals for follow up

Totals for hospital

Percentage of follow up

Percentage of all cases at B.H. No. 117

A

36

142

8.2

9.7

152

366

47.6

32.6

188

508

24.8

19.6

B

210

696

47.9

47.4

68

316

21.0

28.1

278

1,012

36.6

39.2

C

171

548

39.0

37.4

51

276

15.9

24.6

222

824

29.3

31.8

D

11

32

2.5

2.2

46

139

14.4

12.4

57

171

7.5

6.6

Tb

10

48

2.3

3.3

3

27

1.0

2.4

13

75

1.8

2.9

    

Total

438 (57.8)

1,466 (56.7)

100.0

100.0

320 (42.2)

1,124 (43.3)

100.0

100.0

758 (100.0)

2,590 (100.0)

100.0

100.0


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

Table 7 is concerned with the problem of the adequacy of sampling of the follow-up group as compared with the total hospital group from the standpoint of physical classification. The selection of cases used in this study is a good one, especially in reference to the proportions before and during the armistice, i. e., 57.8 per cent compared to 56.3 per cent and 42.2 per cent to 43.3 per cent (see totals in columns 1 and 2). Furthermore, the percentages of each class of the follow-up group and of each class of the total hospital group are also indicative of a good sampling (see the figures below the line, lowest figures of each group of three in columns 3 and 4; i. e., 24.6 per cent compared to 19.6 per cent, 36.6 per cent to 39.2 per cent; 29.3 per cent to 31.8 per cent; 7.5 per cent to 6.6 per cent; 1.8 per cent to 2.9 per cent). Likewise, the percentages of each class in the pre-armistice group of the follow up and of the hospital service (given on the top line in each grouping in columns 3 and 4) are nearly identical, i. e., 8.2 per cent compared to 9.7 per cent; 47.9 per cent to 47.4 per cent; 39.0 per cent to 37.4 per cent; 2.5 per cent to 2.2 per cent; 2.3 per cent to 3.3 per cent. There is more variation in the armistice figures (given in the middle of three in columns 3 and 4) than in the others; but it is, however, a fair sampling from the standpoint of the proportions of each class in the total hospital group (i. e., 47.6 per cent compared to 32.6 per cent; 21.0 per cent to 28.1 per cent; 15.9 per cent to 24.6 per cent; 14.4 per cent to 12.4 per cent; 1.0 per cent to 2.4 per cent).


448

Several other facts are to be ascertained upon inspection of the data on Table 7. First, the military fact is apparent from the totals at the bottom of column 2 that there were almost as many cases discharged from the hospital during the armistice as before it. The sudden ending of the war just after the United States had thrown our great Army into it, the population of Base Hospital No. 117 at the time of the signing of the armistice, the use of Base Hospital No. 117 as a reclassification center for war neurosis cases after the armistice was signed-these facts are the explanation for the nearly equal figures for discharges before and after the armistice began. Second, another military fact, it is notable that there was considerable difference in the percentage usage of the different classes before and during the armistice; namely, in class A the difference between its use in 10 per cent of the cases before the armistice and 33 per cent after the armistice had begun. The infrequency before the armistice of the physical classification A indicates that the members of the hospital personnel were only willing to send back to the front immediately 1 man in 10 of the discharged psychoneuroses cases, whereas during the armistice one in three were sent out class A to full duty in an army at peace.

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

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

The 37 per cent class C before the armistice indicates that it was not practical with three-eighths of the men to try to so groom them for front-line duty. The C class discharges dropped from 37 per cent before the armistice


449

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

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

Class A

Class B

Class C

Class D

Class Tb

Total

Number

Percentage

Number

Percentage

Number

Percentage

Number

Percentage

Number

Percentage

Number

Percentage

Normal

15

41.7

94

44.9

55

32.2

2

18.2

5

50.0

171

39.0

70

46.1

22

32.8

19

37.3

10

21.7

3

100.0

124

38.7

85

45.2

116

41.8

74

33.3

12

21.0

8

61.5

295

38.9

Neurotic

8

22.2

47

22.4

41

23.9

2

18.2

---

---

98

22.4

35

23.0

17

25.0

8

15.7

9

19.6

---

---

69

21.5

43

22.9

64

23.0

49

22.1

11

19.3

---

---

167

22.0

Fatigued

4

11.1

32

15.1

29

17.0

2

18.2

---

---

67

15.3

28

18.4

13

19.4

12

23.5

11

23.9

---

---

64

20.0

32

17.0

45

16.2

41

18.5

13

22.8

---

---

131

17.3

Disabled

8

22.2

37

17.6

42

24.6

5

45.5

3

30.0

95

21.7

19

12.5

16

23.8

10

19.6

15

32.6

---

---

60

18.6

27

14.3

53

19.1

52

23.4

20

35.1

3

23.1

155

20.4

Psychotic

1

2.8

---

---

4

2.3

---

---

2

20.0

7

1.6

---

---

---

---

2

3.9

1

2.2

---

---

3

.9

    

Total

1

.5

---

---

6

2.7

1

2.2

2

15.4

10

1.3

36

100.0

210

100.0

171

100.0

11

100.0

10

100.0

438

100.0

152

100.0

68

100.0

51

100.0

46

100.0

3

100.0

320

100.0

188

100.0

278

100.0

222

100.0

57

100.0

13

100.0

758

100.0


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

Lastly, Table 8 shows (figures in the "Totals" column) that the recoveries or nonrecoveries from war neuroses of the group studied in relation to military classification gives percentages about the same for those discharged before and those discharged during the armistice. In the two largest groups, i. e., "normal" and "neurotic," the percentages before and during the armistice are nearly identical (39 per cent and 38.7 per cent and 22.4 per cent and 21.5 per cent, respectively). The chances that a man discharged in class A, for instance, would be normal in 1919-20 were about equal for him whether he was discharged before or during the armistice. In other words, the prognostic value of military classification for the group of men discharged from Base Hospital No. 117 before and during the armistice is about the same in terms of civilian readjustment.

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


450

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

DIAGNOSIS IN FRANCE IN RELATION TO 1919-20 CONDITION

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

It must be appreciated that the diagnoses referred to, which were devised for the psychoneurosis cases at Base Hospital No. 117, were not used with entire uniformity by the medical officers. Hysteria might be given as the diagnosis by one, whereas the same symptoms drew the diagnosis concussion neurosis from another. These variations were chiefly attributable to officers assigned to the hospital for temporary duty or for training. On the whole, however, the diagnoses were similarly used, for the majority of the cases were diagnosed by a small group of men, the original staff (or others under their supervision), whose notions of the different types of neuroses for the most part coincided. Thus, the great majority of the diagnoses follow the scheme of classification used at the hospital, and the error, above mentioned, though it does enter, plays but a minor part.

Our first inquiry into the question of diagnosis and its relation to present condition is in regard to the selection of cases in the follow up. Table 9 gives the frequency of usage of the various diagnoses at Base Hospital No. 117 in France; Table 10 gives the frequency of their occurrence in the follow-up group compared with the total hospital group. Inspection of the percentages for totals in Table 10 for each diagnosis (given below the lines) shows that the follow up is a good sampling of the total hospital group. For instance, hysteria occurs in 27.6 per cent of the cases in the hospital service and 25.9 per cent in the follow up; concussion neurosis occurs in the relative proportions 22.1 per cent and 22.9 per cent; neurasthenia 12.1 per cent as compared to 14.4 per cent; others run 2.8 per cent to 3.8 per cent; 5.1 per cent to 5.4 per cent; 2.1 per cent to 2.2 per cent; 8 per cent to 6.7 per cent; etc.


451

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

Diagnoses

Physical classification

Totals

A

B

C

D

Tb

Hysteria

30

119

208

19

3

379

93

92

98

49

6

338

123

211

306

68

9

717

Concussion neurosis

17

236

64

0

9

326

112

79

38

17

1

247

129

315

102

17

10

573

Neurasthenia

14

69

95

0

9

187

15

18

56

37

1

127

29

87

151

37

10

314

Hypochondriasis

2

10

41

5

0

58

4

1

18

16

0

39

6

11

59

21

0

97

Exhaustion

13

49

7

1

2

72

28

30

9

0

0

67

41

79

16

1

2

139

Effort syndrome

3

17

7

0

1

28

3

8

12

3

3

29

6

25

19

3

4

57

Anxiety neurosis

4

55

55

2

2

118

14

24

15

3

0

56

18

79

70

5

2

174

Concussion syndrome

42

112

11

1

15

181

37

30

7

0

3

77

79

142

18

1

18

258

Psychasthenia

3

4

18

2

1

28

2

2

2

6

0

12

5

6

20

8

1

40

Timorousness (state of anxiety)

1

3

11

2

3

20

11

6

15

1

0

33

12

9

26

3

3

53

Anticipation neurosis

0

4

18

0

0

22

1

0

2

2

2

7

1

4

20

2

2

29

Gas neurosis

2

11

8

0

0

21

11

13

3

3

0

30

13

24

11

3

0

51

Gas syndrome

0

2

1

0

---

3

1

6

0

1

---

8

1

8

1

1

---

11

Traumatic neurosis

1

1

1

0

1

4

Gastric neurosis

0

0

0

1

0

1

Post-operative neurosis

1

1

1

1

1

5

No disease found

10

4

3

---

2

19

34

7

1

---

11

53

44

11

4

---

13

72

    

Totals

142

696

548

32

48

1,466

366

316

276

139

27

1,124

508

1,012

824

171

75

2,590

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


452

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

Diagnosis

Totals for follow up

Totals for hospital group

Percentage of follow up

Percentage of hospital group

Hysteria

101

379

23.1

25.9

95

338

29.7

30.1

196

717

25.9

27.6

Concussion neurosis

98

326

22.4

22.2

76

247

23.7

22.0

174

573

22.9

22.1

Neurasthenia

63

187

14.4

17.8

46

127

14.4

11.3

109

314

14.4

12.1

Hypochondriasis

12

58

2.8

3.9

9

39

2.8

3.4

21

97

2.8

3.8

Exhaustion

21

72

4.8

4.9

17

67

5.3

5.9

38

139

5.1

5.4

Effort syndrome

10

28

2.3

1.9

6

29

1.7

2.6

16

57

2.1

2.2

Anxiety neurosis

40

118

9.1

8.1

21

56

6.7

4.9

61

174

8.0

6.7

Concussion syndrome

53

181

12.1

12.4

19

77

5.9

6.9

72

258

9.5

10.0

Psychasthenia

8

28

1.8

1.9

7

12

2.2

1.1

15

40

2.0

1.6

Timorousness (state of anxiety)

13

20

2.9

1.4

4

33

1.3

2.9

17

53

2.2

2.0

Anticipation neurosis

12

22

2.8

1.5

0

7

0.0

0.6

12

29

1.6

1.1

Gas neurosis

5

21

1.1

1.4

10

30

3.1

2.7

15

51

1.9

1.9

Gas syndrome

1

3

0.2

0.2

0

8

0.0

0.7

1

11

0.1

0.4

Traumatic neurosis

0

4

0.0

0.3

Gastric neurosis

0

1

0.0

0.1

0

5

0.0

0.2

Post-operative neurosis

1

19

0.2

1.2

No disease found

10

53

3.1

4.7

11

72

1.4

2.8

    

Total

438

1,466

100.0

100.0

320

1,124

100.0

100.0

758

2,590

100.0

100.0


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


453

Table 11 gives the relationship of diagnoses to condition in 1919-20. The psychotics are combined with the organic group; individual statistics for those classed psychotics here are to be found in Table 12. Some of the diagnostic groups are very small. They are included in part for the sake of completeness, for, since they are a representative sampling of the total hospital service, their proportionate size is a just index of their frequency of occurrence in Base Hospital No. 117 in France.

TABLE 11.-Condition in 1919-20 in relation to diagnosis in France

Normal

Neurotic

Fatigued

Disabled and psychotic

Total

Number

Percentage

Number

Percentage

Number

Percentage

Number

Percentage

Number

Percentage

Hysteria

26

25.7

29

28.8

20

19.8

26

25.7

101

23.1

34

35.8

18

18.9

20

21.1

23

24.2

95

29.7

60

30.6

47

24.0

40

20.4

49

25.0

196

25.9

Concussion neurosis

44

44.9

28

28.6

8

08.2

18

18.4

98

22.4

29

38.1

17

22.3

18

23.7

12

15.8

76

23.7

73

41.9

45

25.9

26

14.9

30

17.2

174

22.9

Neurasthenia

27

42.8

10

15.9

15

23.8

11

17.4

63

14.4

9

19.6

9

19.6

15

32.6

13

28.2

46

14.4

36

33.0

19

17.4

30

27.5

24

22.0

109

14.4

Concussion syndrome

29

54.7

6

11.3

9

17.0

9

17.0

53

12.1

9

47.3

6

31.6

1

5.3

3

15.8

19

5.9

38

52.8

12

16.7

10

13.8

12

16.7

72

9.5

Anxiety neurosis

17

42.5

13

32.5

4

1.0

6

15.0

40

9.1

9

42.9

7

33.3

4

19.0

1

4.8

21

6.7

26

42.6

20

32.9

8

13.1

7

11.4

61

8.0

Exhaustion neurosis

11

52.4

0

0.0

4

18.6

6

28.6

21

4.8

8

47.0

4

23.5

1

5.9

4

23.5

17

5.3

19

50.0

4

10.5

5

13.2

10

26.3

38

5.1

Hypochondriasis

3

25.0

1

8.3

2

16.6

6

50.0

12

2.8

4

44.4

2

22.2

0

0.0

3

33.3

9

2.8

7

33.3

3

14.3

2

9.5

9

42.8

21

2.8

Psychasthenia

3

37.5

0

0.0

1

12.5

4

50.0

8

1.8

2

28.6

2

28.6

2

28.6

1

14.2

7

2.2

5

33.3

2

13.3

3

20.0

5

33.5

15

2.0

Gas neurosis

1

20.0

2

40.0

1

20.0

1

20.0

5

1.1

6

60.0

2

20.0

1

10.0

1

10.0

10

3.1

7

46.8

4

26.6

2

13.3

2

13.3

15

1.9

Anticipation neurosis

4

33.3

4

33.3

1

8.3

3

25.0

12

2.8

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

4

33.3

4

33.3

1

8.3

3

25.0

12

1.6

Effort syndrome

1

10.0

3

30.0

0

0.0

6

60.0

10

2.3

4

66.7

1

16.7

1

16.7

0

0.0

6

1.7

5

31.2

4

25.0

1

6.2

6

37.5

16

2.1

Timorousness

5

38.5

2

15.4

1

7.7

5

38.5

13

2.9

3

75.0

0

0.0

0

0.0

1

25.0

4

1.3

8

47.1

2

11.8

1

5.9

6

35.3

17

2.2

Gas syndrome

---

---

---

---

1

100.0

---

---

1

0.2

---

---

---

---

0

0.0

---

---

0

0.0

---

---

---

---

1

100.0

---

---

1

0.1

No disease found

0

0.0

0

0.0

0

0.0

1

100.0

1

0.2

7

71.0

1

10.0

1

10.0

1

10.0

10

3.1

7

63.7

1

9.1

1

9.1

2

18.2

11

1.4


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


454-455

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


456

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

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

Diagnosis

Per cent

Diagnosis

Per cent

1. Anxiety neurosis

75.5 (N-61)

8. Timorousness

58.8 (N-17)

2. Anticipation neurosis

75.0 (N-12)

9. Effort syndrome

56.2 (N-16)

3. Gas neurosis

73.4 (N-15)

10. Hysteria

54.6 (N-196)

4. No disease

72.5 (N-11)

11. Psychasthenia

53.3 (N-15)

5. Concussion syndrome

69.5 (N-72)

12. Neurasthenia

50.4 (N-109)

6. Concussion neurosis

67.8 (N-174)

13. Hypochondriasis

47.6 (N-21)

7. Exhaustion neurosis

60.5 (N-38)


Thus it is seen that the typical war neuroses-notably the concussion, gas, and anxiety types-rank very high in percentage of successful readaptation, while the more pronounced constitutional types rank lower. A commentary of no little interest here is that the conclusions offered by these data approach very nearly the prognoses made by the medical staff of the hospital, while the men were still in France, as to the future well-being of the various types of these cases. The exhaustion, concussion, and anxiety cases were given the best prognosis, the effort syndrome cases, the cases of neurasthenia, psychasthenia, and hypochondriasis the worst. Hysteria was placed in between these groups. And no one predicted any marked number of psychotic outworkings from these symptoms. These facts are in the most part borne out by the above figures. The fact that the true battle neuroses-the concussion cases, for instance-are readjusting themselves better proportionately than the timorous, neurasthenic, or hypochondriacal types is interesting, showing, as it does, how incorrect are the popular notions of war neuroses. Men who developed nervous symptoms in the cantonments at home are usually viewed with suspicion by ordinary persons and regarded almost as malingerers by many. The facts here indicate that the hypochondriasis, psychasthenia, neurasthenia, and timorousness groups, due perhaps to the long continued nervous state before the onset of symptoms, often playing upon constitutional susceptibility, do not readjust themselves nearly so well as the actual concussion cases; in other words, many men who never saw action have a more serious aftermath in symptoms than those who were actually in the thick of it, and were concussed by exploding shells or driven into an anxiety state by the fearful conditions and terrible sights at the front.

Among the cases of hysteria, the majority are having difficulty getting along in civil life, and, though earning their own living and seemingly carrying on their work, still they are constantly unhappy because of neurotic residues in the form of headache, insomnia, jumpiness, speech disorders, and often tics. On the whole, the men who had hysteria retain enough of their old condition


457

to handicap them seriously in their personal lives, though not always directly in their business activities. A little more than one-half of them are able to earn their living and ask financial aid of no one, but the great majority are nevertheless constantly seeking advice from physicians. The symptoms in France were usually so gross and vivid that one may believe they probably tended to lay stronger habit foundations than any of the other symptom groupings. An interesting point in reference to neurosis aftermath applicable to nearly all neurosis types, is derived from a physiological truism to which Mott2 refers in discussing psychoneurosis: "Consciousness of the existence of an organ or structure interferes with its normal automatic or habitual action." War neurotics, who were sensitive for months to every change in their bodily feelings, who were keenly introspective and analytic of the existence of the various organs and structures of the body, are guilty of continuing even now this search for symptoms in themselves. And it is rare indeed that this search is unrewarded; for example, anyone can produce a headache by introspection of the contents of the cranium continued over several minutes. These men are slow to recognize the feeling of well being, quick to note any signs of possible ill being. This morbid practice may be the basis of many of their present difficulties.

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

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

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


458

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

AGE AT TIME OF HOSPITALIZATION

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

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

Age

Normal

Neurotic

Fatigued

Disabled

Psychotic

Totals

16

0

1

0

0

0

1

17

0

0

0

0

0

0

18

2

2

2

2

0

8

19

13

10

7

8

3

41

20

15

7

10

6

0

38

21

28

13

2

8

1

52

22

37

19

15

15

0

86

23

37

26

16

15

0

94

24

40

13

16

24

1

94

25

22

16

14

12

0

64

26

27

13

9

12

0

61

27

12

9

5

6

0

32

28

15

6

10

3

2

36

29

9

6

4

2

1

22

30

3

5

6

8

1

23

31

9

8

3

8

0

28

32

3

4

3

6

0

16

33

3

1

0

1

0

5

34

2

1

0

0

0

3

35

1

0

1

0

1

3

36

0

1

0

0

0

1

37

---

1

---

1

---

2

38

---

---

---

1

---

1

39

---

2

---

---

---

2

40

---

---

1

1

---

2

41

1

---

---

---

---

1

42

---

---

---

---

---

0

43

---

---

---

---

---

0

44

2

---

---

---

---

2

45

1

---

1

1

---

3

46

---

1

---

---

---

1

47

---

---

---

---

---

0

48

---

---

---

---

---

0

49

---

---

---

---

---

0

50 plus

1

---

---

---

---

1

N

=283

165

125

140

10

723

Medians

=24.25

24.38

23.69

24.69

26

24.46

Q

=2.125

2.625

2.32


(Median for total hospital group, 24.66 years.)

In so far as these data are significant, the factor of age enters but little in relation to the type of social readjustment of the Base Hospital No. 117 group of war neurotics in 1919-20. The median of the "fatigued" group is a little over one-half a year less than that of the "normal" group, and the median for the "disabled" group almost one-half a year above the "normal" group median. The median is 24.47 years for the combined "normal" and "neurotic" groups (that is, for those who were carrying on in civilian life in 1919-20) and 24.68 years for the combined "fatigued" and "disabled" groups. Thus, a comparison of medians indicates a slight tendency for younger men to be doing better in civil pursuits than the older men. When distributions for the groups are studied


459

from the standpoint of dispersion on the basis of the percentage of men 21 years of age and under, and the percentage of men 36 years of age and over in the various groupings of present condition, as Tables 15 and 16 show, there is also indication of a slight tendency for the younger men to be readapting themselves better than the older men.

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

Age

Normal

Neurotic

Fatigued

Disabled

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

21 years and younger

58

20.5

33

18.2

21

16.8

24

17.1

22 to 35 years (inclusive)

220

77.8

127

78.8

102

81.6

112

80.7

36 years and older

5

1.7

5

3.0

2

1.6

4

2.2

Total

283

100

165

100

125

100

140

100


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

Condition

21 years and younger

22 to 35 years (inclusive)

36 years and older

Number

Per cent

Number

Per cent

Number

Per cent

Normal

58

42.7

220

39.2

5

31.25

Neurotic

33

24.3

127

22.7

5

31.25

Fatigued

21

15.4

102

18.2

2

12.5

Disabled

24

17.6

112

19.9

4

25

Total

136

100

561

100

16

100


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

Often the opinion is expressed that those who, after the war, were not fully recovered from war neuroses were for the most part men of inferior stock and make-up. In other words, persistence of symptoms is supposed to be related primarily to neuropathic make-up. The accompanying data tend to confirm this opinion. In the matter of personal history prior to hospitalization as shown in Table 17, there are 56.4 per cent of those who are now normal who gave a negative history; 47.5 per cent of the neurotic group and 47.6 per cent of the fatigued group who were negative; and 45.4 per cent of the disabled group. For family history, likewise, the normal group has the highest percentage of negative cases; i. e., 52.8 per cent; the neurotic 46.8 per cent; fatigued 44.8 per cent; and disabled 45.5 per cent. When family and personal history are combined the same tendency is present; for Table 17 also shows that 42.2 per cent of the normal group, 31.2 per cent of the neurotic and of the disabled, 32.2 per cent of the fatigued group were negative. There is thus a definite tendency for those of good stock and make-up to readapt themselves better to civilian life than those in whom personal or familial taint is found; still, many war neurotics are now disabled who gave a good history, and a number are now carrying on who were of poor stock and make-up. Thus, evidently, according to these data, stock and make-up alone, though significant, do not afford a sufficient basis for the prognosis of civilian readaptation.


460

Table 18 shows that on the whole the follow-up group are an adequate sampling of the hospital group from the standpoints of family stock and personal make-up.

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

Family history

Personal history

Combined family and personal history

Positive

Negative

Positive

Negative

Positive

Negative

Number

Per cent

Number

Per cent

Number 

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Normal

127

47.2

142

52.8

117

43.6

151

56.4

159

57.8

116

42.2

Neurotic

84

53.2

74

46.8

82

52.5

74

47.5

110

68.8

50

31.2

Fatigued

69

55.2

56

44.8

65

52.4

59

47.6

84

67.8

40

32.2

Disabled

78

54.5

65

45.5

77

54.6

64

45.4

96

68.1

45

31.9

Total

358

51.5

337

48.5

341

49.5

348

50.5

449

64.1

251

35.9


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

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

Family history

Personal history

Combined family and personal history

Positive

Negative

Positive

Negative

Positive

Negative

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

One thousand
unselected cases

508

50.2

505

49.8

527

51.9

488

48.1

643

63.5

370

36.5

Follow-up

358

51.5

337

48.5

341

49.5

348

50.5

449

64.1

251

35.9



SOCIAL STATUS IN RELATION TO PRESENT CONDITION 

PRE-WAR OCCUPATION

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


461

TABLE 19.-Relation of pre-war occupationa to condition in 1919-20

Normal

Neurotic

Fatigued

Disabled

Psychotic

Total of follow-up

Total hospital serviceb

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Agricultural

34

13.9

14

10.4

25

22.5

22

16.8

2

33.3

97

15.5

261

11.5

Mining

4

1.6

2

1.5

2

1.8

5

3.8

1

16.7

14

2.2

53

2.3

Manufacturing

79

32.3

51

37.8

35

31.5

43

32.8

1

16.7

209

33.3

789

34.7

Transportation

24

9.8

20

14.8

19

17.1

22

16.8

---

---

85

13.5

313

13.8

Trade

26

10.6

8

5.9

5

4.5

13

9.9

2

33.3

54

8.6

253

11.1

Public service

3

1.3

4

3.0

1

0.9

5

3.8

---

---

13

2.1

45

2.0

Professional

29

11.9

16

11.8

9

8.1

9

6.9

---

---

63

10.0

163

7.2

Domestic service

5

2.1

2

1.5

4

3.6

2

1.5

---

---

13

2.1

57

2.5

Clerical

41

16.5

18

13.3

11

9.9

10

7.6

---

---

80

12.7

339

15.9

Total

245

100.0

135

100.0

111

100.0

131

100.0

6

100.0

628

100.0

2,273

100.0


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

TABLE 20.-Relation of 1919-20 condition to pre-war occupation

Agricultural

Mining

Manufacturing

Transportation

Trade

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Normal

34

35.0

4

28.6

79

37.8

24

28.2

26

48.1

Neurotic

14

14.4

2

14.3

51

24.4

20

23.5

8

14.8

Fatigued

25

25.8

2

14.3

35

16.7

19

22.4

5

9.3

Disabled

22

22.7

5

35.6

43

20.6

22

25.9

13

24.1

Psychotic

2

2.1

1

7.2

1

0.5

---

---

2

3.7

Total

97

100.0

14

100.0

209

100.0

85

100.0

54

100.0


Public service

Professional

Domestic service

Clerical

Number

Per cent

Number

Per cent

Number

Per cent

Number

 Per cent

Normal

3

23.0

29

46.0

5

38.4

41

51.2

Neurotic

4

30.8

16

25.4

2

15.4

18

22.5

Fatigued

1

7.7

9

14.3

4

30.8

11

13.8

Disabled

5

38.5

9

14.3

2

15.4

10

12.5

Total

13

100.0

63

100.0

13

100.0

80

100.0


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

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

Rank order

Occupation

Number

Per cent

Rank order

Occupation

Number

Per cent

1

Clerical

80

73.7

Domestic

13

53.8

Professional

63

71.4

7

Transportation

85

51.7

3

Trade

54

62.9

8

Agriculture

97

49.4

4

Manufacturing

209

62.2

9

Mining

14

42.9

Public service

13

53.8


aCombined ''normal" and ''neurotic" groups in Table 19.

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


462

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

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

In comparing the civilian value of this group of men in terms of our categories of readjustment, with their military worth based upon the hospital's classification, an estimate is obtained of the social value of the group of men reached in the follow-up in two different social situations; first, the Army at war and during an armistice, and second, civilian life in America in 1919-20. Tendencies regarding these facts may be noted by comparing those classified A upon discharge with those now reporting themselves "normal," the B class with the "neurotic," C class with "fatigued," and D and T combined with "disabled" and "psychotic" combined. Furthermore, the class A and class B groups may be combined and compared with the "normal" and "neurotic" figures.

Table 22 gives us a summary of the 1919-20 condition of members of the group on whom we have data. Practically 61 per cent, the combined "normal" and "neurotic" groups of the men located in 1919-20, were self-supporting in civil life or sufficiently strong and well to be on active duty in the Army or to be attending school or college. Of this 61 per cent, there were 22 per cent in the "neurotic" group who were able to support themselves, though, from a health standpoint, they were by no means well. The remaining 39 per cent in the "fatigued," "disabled," and "psychotic" groups were either in hospitals when last heard from or were having difficulties of various sorts. The "fatigued" group were the only ones of those last mentioned who were able to work at all, and they could work, on the average, only two or three days a week.

Table 22 is, in effect, a comparison of the military classification of usefulness to an army of a group of neurotics, as a group, with their civilian value in terms of usefulness to society and to themselves a year or so later, after returning home. It is a striking fact to be gathered from the table that whereas there are almost twice as many of the follow-up group proportionately who are "normal" and of full usefulness in civil life as there were those who were class A and presumably of full use to the Army, still, when one gets the sum of percentages of those of full use (class A) and of prospective full use (class B) and compare with it the sum of those "normal" and those "neurotic," the figures are practically identical (i. e., 61.4 per cent as compared to 60.9 per cent). There are about the same proportions who are now (1919-20) partially or wholly disabled, and drags on society, as there were of men who were almost, or actually, useless for combat service.


463

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

Physical classification

Number

Per cent

1919-20 condition of follow-up group

Number

Per cent

A

36

8.2

Normal

171

39.0

152

47.6

124

38.7

188

24.8

295

38.9

B

210

47.9

Neurotic

98

22.4

68

21.0

69

21.5

278

36.6

167

22.0

C

171

39.0

Fatigued

67

15.3

51

15.4

64

20.0

222

29.3

131

17.3

D (and unclassified)

11

4.8

Disabled, psychotic

102

22.3

46

15.4

63

19.6

57

9.3

165

21.7


When individual items in Table 22 are compared, though the same tendencies hold, the discrepancies are greater. For instance, the proportion of class A of the prearmistice group compared with the proportion of "normal" of the prearmistice group gives 8.2 per cent class A and 39.0 per cent "normal." On the contrary, for the armistice group there are 47.6 per cent class A and only 38.7 per cent "normal." In class B, the figures are reversed, the "neurotic" group of the prearmistice discharge from the hospital contain 22 per cent of the cases whereas class B comprised 47.9 per cent of those discharged before the armistice; the percentages of class B and "neurotic" are identical for the armistice group. And the proportions of Army and civilian disabled in the two groups for the armistice group are practically identical.

A general conclusion which may be drawn from the above facts is: When the civilian status of an unselected group of 800 war neurotics returned to civilian life, is estimated in 1919-20 with the five categories used here, "normal," "neurotic," etc., and the proportions of each status compared with the estimates of Army usefulness (military physical classification) made in France in 1918, we find that although there is a tendency for a greater proportion to be first-rate citizens (normal) than first-rate front-line material (class A), still, by and large, the group is as great a weight upon societyb as it was upon the Army in war times in France.

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

bIn attempted explanation of the serious carry-over of symptoms by the men of the follow up, it is necessary to include, of course, a consideration of the significance of the pension issue in relation to present condition. Psychoneurotics are liable to be seriously influenced by factors related to Government compensation. An estimate of the relationship between the present condition of the former patients of Base Hospital No. 117 and exaggerated desire for Government aid is extremely difficult of definition and beyond the scope of this study.


464

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

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

THE 1924-25 STUDY

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

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


465

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

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

Physical classification

Totals for follow up

Total for hospital

Physical classification

Totals for follow up

Total for hospital

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

A

35

7.6

142

9.7

D

8

1.7

32

2.2

154

51.1

366

32.6

36

12.0

139

12.4

189

23.5

508

19.6

44

5.9

171

6.6

B

241

52.1

696

47.4

Tb

6

1.3

48

3.3

58

19.2

316

28.1

2

0.7

27

2.4

299

39.2

1,012

39.2

8

1.5

75

2.9

C

172

37.2

548

37.4

    

Totals

462

60.5

1,466

56.3

51

16.9

276

24.6

301

39.5

1,124

43.7

223

29.3

824

31.8

763

100.0

2,590

100.0


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

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


466

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

Class A

Class B

Class C

Class D

Tb

Totals

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Normal

18

51.4

94

39.0

48

27.9

2

25.0

2

33.3

164

35.5

59

38.3

23

39.7

19

37.2

16

44.4

0

0.0

117

38.9

77

40.7

117

39.1

67

30.0

18

40.9

2

25.0

281

36.9

Neurotic

11

31.4

113

46.9

79

45.9

3

37.5

2

33.3

208

45.0

69

44.8

27

46.5

19

37.2

11

30.5

1

50.0

127

42.2

80

42.3

140

46.8

98

43.9

14

31.8

3

37.5

335

43.9

Fatigued

3

8.6

20

8.2

27

15.7

1

12.5

2

33.3

53

11.5

15

9.8

4

6.8

2

4.0

1

2.8

0

0.0

22

7.3

18

9.5

24

8.0

29

13.0

2

4.6

2

25.0

75

9.8

Disabled

3

8.6

12

4.9

17

9.9

0

0.0

0

0.0

32

6.9

6

3.9

3

5.2

9

17.6

8

22.2

1

50.0

27

8.9

9

4.7

15

5.0

26

11.7

8

18.2

1

12.5

59

7.7

Psychotic

0

0.0

2

0.0

1

0.6

2

25.0

---

---

5

1.1

5

3.2

1

1.7

2

4.0

0

0.0

---

---

8

2.7

5

2.6

3

1.0

3

1.4

2

4.6

---

---

13

1.7

    

Totals

35

100.0

241

100.0

172

100.0

8

100.0

6

100.0

462

100.0

154

100.0

58

100.0

51

100.0

36

100.0

2

100.0

301

100.0

189

100.0

299

100.0

223

100.0

44

100.0

8

100.0

763

100.0


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

DIAGNOSIS IN FRANCE IN RELATION TO CONDITION IN 1924-25

In attempting to learn what relationships prevailed in 1924-25 between the various diagnostic groups and civilian readjustment, our first question again is concerned with the selection of cases. Table 25 gives the frequency of usage of the various diagnoses in the total hospital service, with their occurrence in the follow-up of 1924-25. It shows that the follow-up group is a good sampling of the total hospital service from the standpoint of diagnosis; for example, the percentage of cases of hysteria in the follow-up is 27 and in the total hospital group 27.6. Concussion neurosis is even closer to exactness, 22.2 per cent of the follow up and 22.1 per cent of the total hospital group; neurasthenia is 12.5 per cent of the follow-up and 12.1 per cent of the total hospital service.

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


467

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

Diagnosis

Totals for follow-up

Totals for hospital group

Per cent of follow-up

Per cent of hospital group

Diagnosis

Totals for follow-up

Totals for hospital group

Per cent of follow-up

Per cent of hospital group

Hysteria

119

379

25.8

25.9

Psychasthenia

7

28

1.5

1.9

87

338

28.9

30.1

3

12

1.0

1.1

206

717

27.0

27.6

10

40

1.3

1.6

Concussion neurosis

93

326

20.2

22.2

Timorousness (state of anxiety)

10

20

2.1

1.4

77

247

25.6

22.0

5

33

1.6

2.9

170

573

22.2

22.1

15

53

1.9

2.0

Neurasthenia

56

187

12.1

12.8

Anticipation neurosis

6

22

1.3

1.5

39

127

13.0

11.3

0

7

0.0

0.6

95

314

12.5

12.1

6

29

0.8

1.1

Hypochondriasis

10

58

2.1

3.9

Gas neurosis

10

21

2.1

1.4

12

39

4.0

3.4

9

30

3.0

2.7

22

97

2.9

3.8

19

51

2.5

1.9

Exhaustion

31

72

6.7

4.9

Gas syndromea

5

3

1.1

0.2

19

67

6.3

5.9

2

8

0.7

0.7

50

139

6.6

5.4

7

11

0.9

0.4

Effort syndrome

9

28

1.9

1.9

Traumatic neurosis

3

4

0.7

0.3

2

29

0.7

2.6

Gastric neurosis, postoperative

1

1

0.3

0.1

11

57

1.4

2.2

4

5

0.5

0.2

Anxiety neurosis

40

118

8.7

8.1

No disease

2

19

0.4

1.2

12

56

4.0

4.9

13

53

4.3

4.7

52

174

6.9

6.7

15

72

1.9

2.8

Concussion syndrome

61

181

13.2

12.4

    

Totals

462

1,466

100.0

100.0

20

77

6.6

6.9

301

1,124

100.0

100.0

81

258

10.6

10.0

763

2,590

100.0

100.0


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

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


468

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

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

Normal

Neurotic

Fatigued

Disabled and psychotic

Totals

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Hysteria

32

19.6

60

29.0

15

28.9

12

32.4

119

25.9

33

28.1

33

25.9

8

36.4

13

38.2

87

29.0

65

23.2

93

27.9

23

31.1

25

35.2

206

27.1

Concussion neurosis

42

25.8

39

18.9

10

19.2

2

5.4

93

20.3

31

26.4

35

27.8

6

27.3

5

14.7

77

25.7

73

26.0

74

22.1

16

21.6

7

9.8

170

22.4

Neurasthenia

16

9.8

26

12.6

8

15.4

6

16.2

56

12.2

13

11.1

18

14.1

2

9.1

6

17.7

39

13.0

29

10.4

44

13.2

10

13.5

12

16.9

95

12.5

Concussion syndrome

20

12.3

28

13.5

9

17.3

4

10.8

61

13.4

6

5.1

12

9.4

0

0.0

2

5.9

20

6.7

26

9.3

40

11.9

9

12.2

6

8.3

81

10.7

Anxiety neurosis

19

11.5

17

8.2

1

1.9

3

8.1

40

8.3

5

4.2

3

2.3

2

9.1

2

5.9

12

4.0

24

8.6

20

6.0

3

4.1

5

7.0

52

6.9

Exhaustion neurosis

16

9.8

13

6.3

2

3.9

---

---

31

6.8

11

9.3

8

6.3

0

0.0

---

---

19

6.3

27

9.6

21

6.3

2

2.7

---

---

50

6.6

Hypochondriasis

0

0.0

8

3.0

---

---

2

5.4

10

2.2

3

2.5

6

4.7

---

---

3

8.8

12

4.0

3

1.1

14

4.2

---

---

5

7.0

22

2.9

Psychasthenia

3

1.8

1

.5

1

1.9

2

5.4

7

1.5

2

1.6

1

.8

0

0.0

0

0.0

3

1.0

5

1.8

2

.6

1

1.3

2

2.9

10

1.3

Gas neurosis

3

1.8

4

1.9

1

1.9

2

5.4

10

2.2

4

3.3

3

2.3

0

0.0

2

5.9

9

3.0

7

2.5

7

2.1

1

1.3

4

5.8

19

2.5

Anticipation neurosis

3

1.8

1

.5

1

1.9

1

2.7

6

1.3

0

0.9

0

0.0

0

0.0

0

0.0

0

0.0

3

1.1

1

0.3

1

1.3

1

1.4

6

0.8

Effort syndrome

2

1.2

3

1.4

1

1.9

3

8.2

9

1.9

1

2.5

0

0.0

1

4.5

0

0.0

2

0.7

3

1.1

3

0.9

2

2.7

3

4.3

11

1.5

Timorousness

5

3.1

3

1.4

2

3.8

0

0.0

10

2.2

3

1.7

1

0.8

0

0.0

1

5.9

5

1.7

8

2.8

4

1.2

2

2.7

1

1.4

15

1.9

Gas syndrome

2

1.2

3

1.4

---

---

---

---

5

1.1

1

0.9

1

0.8

---

---

---

---

2

0.7

3

1.1

4

1.2

---

---

---

---

7

0.9

No disease

0

0.0

1

.5

1

1.9

---

---

2

0.4

4

3.4

6

4.7

3

13.6

---

---

13

4.3

4

1.4

7

2.1

4

5.5

---

---

15

1.9


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


469

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

Rank

Diagnosis

Per cent

Rank

Diagnosis

Per cent

1

Gas syndrome

100.0 (N-7)

8

Neurasthenia

76.8 (N-95)

2

Exhaustion neurosis

96.0 (N-50)

9

Hysteria

76.7 (N-206)

3

Concussion neurosis

86.5 (N-170)

10 

Gas neurosis

73.6 (N-19)

4

Anxiety neurosis

84.6 (N-52)

11

No disease

73.3 (N-15)

5

Concussion syndrome

81.5 (N-81)

12

Psychasthenia

70.0 (N-10)

6

Timorousness

80.0 (N-15)

13

Anticipation

66.7 (N-6) 

7

Hypochondriasis

77.2 (N-22)

14 

Effort syndrome

54.4 (N-11)


aSee p. 456 for comparative figures of 1919 follow-up group.

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

AGE

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

As far as the factor of age enters to explain readjustment in 1924-25, there does seem to be a tendency for the extremes of the distribution to be less well readapted than the more central groups. In Table 29, the figures show that there is a higher percentage of cases in the fatigued and disabled groups at the extreme ages than in the middle ranges. Likewise, in Table 30, the percentages of cases having difficulties is higher at the extreme ages than in the middle range of ages, i. e., from 28 to 35. There is thus a tendency for the extreme age groups, the younger and the older men, to be making poorer readaptations than the men of the middle range of ages.

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

Age

Normal

Neurotic

Fatigued

Disabled

Psychotic

Totals

22

1

1

---

1

---

3

23

1

2

1

---

---

4

24

7

12

1

---

---

20

25

9

18

5

6

---

38

26

21

20

9

6

1

57

27

21

21

7

4

---

53

28

33

52

8

3

1

97

29

34

46

20

9

2

111

30

35

34

8

6

3

86

31

21

26

4

5

---

56

32

24

34

6

3

---

67

33

19

19

4

3

1

46

34

8

20

4

4

1

37

35

11

12

2

2

1

28

36

14

8

7

4

---

33

37

5

9

2

2

---

18

38

2

2

2

2

1

9

39

2

2

---

1

---

5

40

---

2

1

1

---

4

41

4

1

---

---

---

5

42

1

---

1

---

---

2

43

---

1

---

---

---

1

44

---

1

---

---

---

1

45

---

1

1

---

---

2

46

---

---

---

---

---

---

47

2

---

---

---

---

2

48

---

---

---

---

---

---

49

---

---

---

---

---

---

50 and over

5

3

---

---

---

8

N

280

347

93

62

11

793

Median

30.39

39.06

29.80

30.58

30.67

30.93


470

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

Age

Normal

Neurotic

Fatigued

Disabled

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

27 years and younger

60

21.4

74

21.3

23

24.7

17

27.4

28 to 35 years (inclusive)

185

66.1

243

70.0

56

60.2

35

56.3

36 years and older

35

12.5

30

8.7

14

15.1

10

16.3

Totals

280

100.0

347

100.0

93

100.0

62

100.0


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

Condition

27 years and younger

28 to 35 years (inclusive)

36 years and older

Number

Per cent

Number 

Per cent

Number

Per cent

Normal

60

34.5

185

35.7

35

39.2

Neurotic

74

42.5

243

46.8

30

33.7

Fatigued

23

13.2

56

10.8

14

15.7

Disabled

17

9.8

35

6.7

10

11.3

Total

174

100.0

519

100.0

89

100.0


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

The data in Table 31 indicate that, in so far as they apply to this group, previous family and personal histories are not in themselves very significant determiners for present condition. In fact the group now classed as normal herein gives a poorer personal history than the neurotics, and a poorer combined personal and family history than the neurotics and fatigued. Of course, not all the cases are included, as the data were missing on some cases from the clinical histories written in France. Furthermore, all data on family and personal history are apt to be unreliable unless collected for specific purposes and under definite directions, which is in many cases not true of these data. But from the data available family and personal histories, as previously shown in the 1919-20 study, are not very significant in themselves in relation to civilian readaptation. Whereas in the 1919-20 group a slight tendency existed for a better readjustment to be made by those giving negative histories, by 1924, this tendency has decreased almost to insignificance.

Table 32 shows that on the whole the follow-up group are an adequate sampling of the hospital group from the standpoint of family stock and personal make-up.


471

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

Family history

Personal history

Combined family and personal history

Positive

Negative

Positive

Negative

Positive

Negative

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number 

Per cent

Normal

128

56.6

98

43.4

112

51.6

105

48.4

149

68.0

70

32.0

Neurotic

141

53.0

125

47.0

124

47.1

139

52.9

163

62.4

98

37.6

Fatigued

36

58.1

26

41.9

64

52.5

58

47.5

81

67.9

38

32.1

Disabled

21

42.0

29

58.0

24

52.2

22

47.8

32

68.1

15

31.9

Total

326

53.9

278

46.1

324

50.0

324

50.0

425

65.8

221

34.2


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

Family history

Personal history

Combined family and personal history

Positive

Negative

Positive

Negative

Positive

Negative

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number 

Per cent

Total Base Hospital
No. 117 patients

508

50.2

505

49.8

527

51.9

488

48.1

643

63.5

370

36.5

Follow-up group

326

53.9

278

46.1

324

50.0

324

50.0

425

65.8

221

34.2


Lastly, it is a rather interesting commentary on the whole conception of "neuropathic" taint that there are so many men (over four-fifths) now able to carry on in this group of men, and (by comparison with the findings in 1919-20, which was about three-fifths) an increasing number and proportion who give a neuropathic (i. e., war neurotic) history. Smith and Pear3 have expressed very well the looseness and inadequacy of all explanation of nervous or mental disease in terms of so-called "neuropathic" taint. It is noteworthy that this group shows no very significant relationship between these factors of make-up and the capacity of readaptation to civilian environment.

SOCIAL STATUS IN RELATION TO PRESENT CONDITION 

PRESENT OCCUPATION

Again the adequacy of sampling of the follow-up compared to the hospital service is important. It must be realized at once that when only the present occupation is considered, the psychotic and disabled patients will automatically be excluded, for they are not at work. Likewise many of those reported at work were doing things described in a way difficult to allocate with the Bureau of the Census categories. Taking the 562 cases which remain in the 3 groups, and comparing them with the proportions of the total hospital group, we find (in Table 33) that the sampling is a selected one in the divisions of transportation (7.7 per cent of this follow-up group instead of 13.8 per cent in the total hospital figures), trade (18.1 per cent instead of 11.1 per cent), public service (5.5 per cent instead of 2 per cent), clerical work (11.2 per cent instead of 15.9 per cent), though upon inspection of the other categories (agriculture, mining, manufacturing, professional) it is noted that the sampling is a good one.


472

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

Normal

Neurotic

Fatigued

Total of follow-upb

Total of hospital service

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Agriculture

9

3.7

49

17.0

10

32.3

68

12.1

261

11.5

Mining

9

3.7

4

1.4

---

---

13

2.3

53

2.3

Manufacturing

79

32.5

95

32.9

10

32.3

184

32.8

789

34.7

Transportation

16

6.6

25

8.7

2

6.4

43

7.7

313

13.8

Trade

51

20.9

49

17.0

2

6.4

102

18.1

253

11.1

Public service

16

6.6

14

4.9

1

3.2

31

5.5

45

2.0

Professional

23

9.5

13

4.5

---

---

36

6.4

163

7.2

Domestic service

10

4.1

7

2.4

5

16.1

22

3.9

57

2.5

Clerical

30

12.4

132

11.1

1

3.2

63

11.2

339

15.9

Total

243

100.0

288

100.0

31

100.0

562

100.0

2,273

100.0


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

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

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

Agriculture

Mining

Manufactur-
ing

Transporta-
tion

Trade

Public
service

Professional

Domestic
service

Clerical

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Number

Per cent

Normal

9

13.2

9

69.2

79

42.2

16

37.2

51

50

16

51.6

23

63.9

10

45.4

30

47.6

Neurotic

49

72.1

4

30.8

95

51.5

25

58.1

49

48

14

45.1

13

36.1

7

31.8

32

50.8

Fatigued

10

14.7

---

---

10

5.4

2

4.7

2

2

1

3.2

---

---

5

22.7

1

1.6

     Total

68

100.0

13

100.0

184

100.0

43

100.0

102

100

31

100.0

36

100.0

22

100.0

63

100.0


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

Rank order

Occupation

Number

Per cent

Rank order

Occupation

Number

Per cent

1

Mining

13

69.2

6

Domestic service

22

45.4

2

Professional

36

63.9

7

Manufacturing

184

42.2

3

Public service

31

51.6

8

Transportation

43

37.2

4

Trade

102

50.0

9

Agriculture

68

13.2

5

Clerical

63

47.6


473

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

Rank order

Occupation

Number

Per cent

Rank order

Occupation

Number

Per cent

1

Agriculture

68

86.8

6

Trade

102

50.0

2

Transportation

43

62.8

7

Public service

31

48.4

3

Manufacturing

184

57.8

8

Professional

36

36.1

4

Domestic service

22

54.6

9

Mining

13

30.8

5

Clerical

63

52.4


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

PRESENT CONDITION OF THE GROUP AS A WHOLE

The five years intervening since 1919-20 saw the development of good improvement in the Base Hospital No. 117 group. Whereas in 1919 the percentage of those reached who were able to carry on (that is, normal or neurotic), was only 60.9; by 1924-25 this had grown to 80.8 as shown in Table 37. The fatigued group who were able to work but half the time amounted to 9.8 per cent as compared with 17.3 per cent in 1919-20, and the disabled or psychotic who were practically unable to work at all, amounted to 9.4 per cent instead of 21.7 per cent in the previous study.

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


474

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

Classification

Military classification

Classification

Present condition

Number

Per cent

Number

Per cent

A

35

7.6

Normal

164

35.5

154

51.1

117

38.9

189

23.5

281

36.9

B

241

52.1

Neurotic

208

45.0

58

19.2

127

42.2

299

39.2

335

43.9

C

172

37.2

Fatigued

53

11.5

51

16.9

22

7.3

223

29.3

75

9.8

D and T

14

3.0

Disabled, psychotic

37

8.0

38

12.7

35

11.6

52

7.4

72

9.4


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

There are once more discrepancies in individual items in this comparative study as shown in Table 38. The proportion of class A of the prearmistice group was 7.6 per cent, but 35.5 per cent of the armistice group were normal in 1914. On the other hand, the armistice class A amounted to 51.1 per cent and only 38.9 per cent of this group are now normal. The prearmistice class B amounted to 52.1 per cent but the prearmistice cases now neurotic are only 45 per cent; the armistice, class B were 19.2 per cent and the armistice neurotic 42.2 per cent. Both the prearmistice and armistice proportions of "fatigued" cases are considerably smaller than the class C cases. And lastly, those of the prearmistice group now seriously handicapped constitute 8 per cent of the group as compared with only 3 per cent of D and T discharges before the armistice.

These figures show a marked tendency for improvement among the men of the follow-up group as a whole in the interim of five years since the study made in 1919-20. What the causes are that underlie the improvement is a difficult problem for complete analysis. A few that might be cited are the vis medicatrix of nature in that length of time, the improvement of business conditions, offering more opportunities for civilian reestablishment, and, perhaps most essential of all, the various governmental and social agencies focused upon the problem of soldier after care. At any rate, whatever the causes of improvement, the hospitalized war neurotics of the American Expeditionary Forces have now become more of a social asset in civilian life than they were in 1919-20 and considerably less of a problem as a group to themselves, to their families and to the American people.

REFERENCES

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

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

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

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