THo JrftUOCJL Ioo_-L

C___

three littinss brought about relief of symptoms but sinco abreaction in specdl alone was usually insufficient in this comod form of trealmellt he proviclod 0 upboIslered dummy to asaillt the aClins out of the repressed emodoll

some jnstan~~ken ro~~ h=~~~~~~ ilIustrate tbe vanous metFiOd~ 01 treatment

The routine trealment of hysterics in base hospitals of Ihe American Expeditionary force (Schwab and Fenton) started with a simple explanation of the hysterical mechanism of (be Igtmptoms The patient was asampured of irs unconscious nature and of rapid diWlPpearancc ot symptoms provided he pve his cow()pcration Then foUow~ Che use f _OBC of tbe ~anymelhod~ ot US~llve symptomatic trcalment fioanYI du_e empham wal lald on the f~ce that the ~JptOIbfgt had diSoaP pearcd aDd on the mlaquohamsm of theu dNppearflJlCe Fol hysterical amnHias a$s(Xiluive exercises leading back to the events conltemed ~ere ~v()Cated In COJItrast Co cases of oonshywrwon hysteria which rapid) responded to praclicaHy any form of treatment great difficulties were met in the treatment of anxiety states A modified psycho-analytic procedure adapted to a war~born condition divorced from a ~ deal

~~~ ~h~oic~~~ ~~e t=ti~t~~m~ iW cc of reprcMion he Vtat encouraged 10 talk fly about his erptt1CJlCes to SO over tbe emotional states that accompanied them aDd to examine bimself as critically as be could Hit tlttef current conftids were analysed out in this way

In case of COflverslon hysteria a process or re-edueation on similar linn wt practised by MacCurdy In a simple explanashytoo talk the patient was ssured that Ms legli for instance were not rean) paralysed bJt that he had forgotten how to

=nnp~o~a~h~ ~~~ndn~~s~ev~~g~~ r~~~ro~ which was lost or di~turbed was n-ot vitally affected Tbe recovery of function was attribuled to tbe patienrs efforls and not to thOle ot tbe pbysician Various tricks were used 10

demonstrate he middotpresence of the capacity wbich seemed to have Bone liuch as a sudden lound with jumping in h)~ter~ea

response t9 etectnca~ Active movemen11 were ben

of incompJete dissocialion the psychic origin of the

a [ear of insanity A physician aBa)s Iheir morbid

fean and diminishes the difficulzin over authority hich are Any ph)slcian who has

sense and a natural internt tgtf_rjJiICPtiiJl~to-_be-~lD-lhpoundtreatmmt~Jl_~

use man) of lhex cases

after operations

theoretical

who

be

to t bull mind h~rem he Oltl~ il1ing or he IlfTlC

fo~termg the Ide Ihal ~c OCCIIPahonai therap) ldaPICU (Q

reguiren~1l~l~W~S iOJr~Qy__ given_T~~r~farLabcnce from tbe mlht~ry atm()~phcre grantmg of lea c and

beneficial In mo~t patients the smptorm eleued up under rmplomatic 1reatment of this

cQnHrsntionlt copaining the trnderlim eonshy-

yen X4~

NEUROSES IN WAR

MEDICAL PROBLEMS IN WAR Thi$ s the last 01 three aticl~ ~~~~~~~~l 1i~~ra~ur~_~_~_~J_~~

NEUROSES IN WAR BY

E WIITKOWER ID Phystcuiff and HQIl~y Slewart Research Edow

the TaVS(OLok Clinic london

ANO

IIp the

pYemed or at leat postponed the outbreak of neuroi which when fuUy developed rltquired prolonged treatment The recovery rate of incipient QCurotic ltata W1S given as 38 per cenL in lbe observations of Rouay Sriau and Omiddotolsnitz gt

Insfructio ofMO and talks of bull suitablecharacter to the line commanders and privates on the nature and aymptoms of Qeuroscs in war time proved to be valuable (Bailey and M PriGltej

~

Treatmeru of oeuroees practice in so far as the bave to be ada pled to tho special circumstances Tho necessity for the rapid restoration of man power imposes

lime limit upon any therapeutic metbodst $0 that tho ns of lreatmet a bound to be limited 10 the qUidlt

removal of syOlpoms with little conoideration-for under bull lyinll difticultie The method of Irea_t employed in 1914--18 are rcviewd by Crichton-Miller and ohcflIshyTh embraced the whole nwge of psychotherapy and may be divided according to the aim joto coverina and uQCoVeriq methods and according to the pro-shycedurc jnto authoritarian and benevolent methods Tho covedng methods are directed toward8 a removal ot symptoms the uncovering methods attempt to approach the undetlyiog causative factors Preferencc was gi~ to any ot theoe method accordin to the place o( treat ment the time availBbJc and the personalily lIaining and psyChoPlh~logil oUook oC the ph~icial

bull Place or Treat_

A graphic description of the conditions prevailing and of the emergency measures undertaleo at a field hcspilaI was given by llhein The men arrived dirty~ muddy Silent) trembling tense with drawn (aces and relaxed

~ijlJLsect1ilkJ1g~__ aUlll~-IU ~ part of lb scanty furniture They seemed in the

depressed awed anXIous afraid they had acquired -nme incuratc afTccli~gt (hal thtmiddoty wer~ parulyseU or wc losing Iheil mi Is A arCtlll anuhsis of the menial ~ltllc of men under lhltfflC lOodilions was of COUrse out of the

a warm howermiddot they feU into a deep

1 hen a division ~f cases took hyperemotivity~ or $tates of tremor few days of rest (Jrbers in a mort

scvere lnd chronic stare tmtl (0 be ~nt 10 Ihe rear (neml agrccment exists Ihal lhe ptiue of Iralmcnt hoold be as ncar lhe lighling lioe as practicabl~ since by hi means t(entment couJd be reduced in lime from

hs or weeks to da)s or houn (Holmes Hart~ Roussy IHermine) The ltiIlalh of organlzalion are di~lIsseU

clsewhere prophvlaelilt measures dvncac(j (MalCurdy Methods or Treatmtftl I) eumClI1cd the mentll hygiene (t h~ combt(41nt

end jncltl(td ~bemiddotituiJ+i--of--r~F4fottFM4(Jof1middot ttfl4--M~~tieprerntG 0111 ocISjliipahl(C1mimuir-allu from duty as frequenlly as the military situHion stress the nelte5siIY for a hopeful yet mili1ary alrrlClsphere permit 1 f10PS were nol to be left too long in one -in lhe wards and for complete co~operafion IXIWCtll all

-Sedor or in u lonely position (Goodwin Short p(rlods members of the st~iff nurses and visitoNi Wherc po~slblc Of _r~--~~~~-~sCc-iwipoundl~~~~g prourolllal s~ mplolllgt often new eacs sbvuld _~e_~e~~~v~~ _i~~__~~~~_CllJiILtyenh

or cured cales (Nonne) The physical resime

cOI11mOlllyrecommeodcd COJIIilted ot nllt and quiet hypooll durill the lint few d r writers who looked 011 the cuew AI akin to malin

1eriRi-JRa4meAt~p1IDisb1llcntandjnclwted Hures as isOlalion tevere restriction of diet

tomiddot excted wards (lewaodowsky) 8pplicatio~ Df pamful el~trual currents a~ prolonaed baths until recovery Wuchbrodtl The chrcf exponent of the mos

form of eiectrolberapy was Kaufmann whose t consisted of three phaIa (I) stJggeltive pre

[naration-the patient was told_ that painful ekdrical vould be applied whkb were certain to cure bi$ i (2) Application of atronamp bradtc currents for

h (3 - bull Th n two OUR ~ active mlHtary el(e~ses e

cure was usually completed In One SIUtfllmiddot Thls method ori~iDaUy ~ed with areat enthusiasm because of the rapid rlaquooenea was later pnerally discarded when fatal caampe$ OCCUlTed (Liebermeister Gildemeister) and permanency ofresults was doubted (Binswanler)

Similar but less severe boredom and a restricted di~t iicre advocated for the trea~nt of hystencal dtSord~l8 by KJetsch~ who ~nded the a~fJl~ton of patte~ts In ltlark~cd rooms The unpresstonof mtltet

lumshment wu to bemiddot avoIded aDd tbe patients were that these measurcs were necesmry ~ to calm their

nerves After a WCIet or two motor phenomena like tic arid tremor subsi~ and had ~ften disatpeared after about Silo WfflL j ~ -

Oiher phYiicians p~eferred rest ~ood food and m benevo~ com~ gtYiItb r~unns and eDcOoragtnl talks After a 1~mPle explanatl~ of the nature of the condition readJusUnalt W81 achieved by aD appeal to patriotism and the aense of duty In lint with this an extensive use of occupational therapy was ma4~ (~ott Adrian and Yeallandi- Pareons Binsw8naet Woltoberg) deafness a~ tbe dem~stratjon of

etjp1ulaijOn Inplralysed Jnnbs Work according to ~rlOnal ~paClliC8 and lDteresti jradually encouraged In ~ses

rather than non~produc1lve m~hamcal rout~ne work slIch patients are vagueiy aware of as matmaklDg paid work ratber thaD unpald work acted symptoms and arc apt 10 develop as a vaJuab1e in~nlve to recovery The patients were friendly laquotalionmip with the employed in th~ poIicinamp of the bospital

l in fann work

and road~making and in workshops In the later stages 8 source of neurotic manitestations war cHpcrimental U$C of these patients was made ~ re~sonale r~nd of common lUon IittOf~ m Germany vafJous methUdS or lA

suggesdon wereemploycq sucOessfuHy including the )f mild faradism graduated exercises and direct hypnOlt HtllCSflon Remarkably rapid rauns Wete obtained

suucstion in hysterical molor disorders but of the recovery was shown by Nonne who C1

easily reproduce the $yrnptoms under hypnosis apparent restoration of function Sham carried out under aenerat anaesthesia although successful in ca~ were generally rejected on

(Hurst Rothmann Goldstein)

1 Much later jn the war a group of physiCians arose

1

behcycd that the neuroses of war were invariably related to reprcsied emotion and lhat for ctlre Ihis must expressed in the form of abreaction either in the waking

lle or under hypnosis Some confined Ihemselves ~ ~Ial Ulltl rcpro(juction under hypnosis of the stLppre~~d prltHlllCel lolate or ~ i repressed cmoliolbll incidents for which there w~s Ii being to for~et the war Wllhout

~ r )ubsequent complete oIlmnesia (Rivers Brown Hadfield I~ Oul of It for gOOd

middot~-middotBrerur Sauer) Whereas othelS (Ed~1 Cui in Nicoll jndhlililnls Ph bull bull IInmel) b a c~mbl~atlo~ of anal tical ~at artlc ~yp~ feminine companionship provcd

I nosls with analytiC diSCUSSion an~ dream ut~rp~C(alion ~ endeavoured to underStllOd and rtheve the underfymg corl- In

UJl utuatjQnbull Acco~~U~jj~5~~~~_~~~~~~L~ oJ ~~~~~~_~~~e~t__ ~

iv v --( rt1~h~ N7~6IW )(fVlY~ (1~) ~ J

Propos

NEUROSES IN WAit

rturned to fmat-1iM duty A=rding to authoritative opinion wac based Oft amp wide very low Only 11 aDd 17 per cent 01 ca German base boopital returned to rrOQtmiddot (Willmans StcmJ-_On this JIaOWIt ithas heenclo jf a return to front-line duty should inariatKy be It has heen argued that tb few sheU-ibocked returned to froatfine duty otten jMtficient and hardly bal the large maTlber of mental receipt of a pension Early rubarJe after n

As in peace time the prognosis of Qeucosis in war time of their aymPt~ to ~ivitian QQupadOll io dllpmds on the alllI1tinteUigeme of the patient aDd OIl caD reodcr - vltco to the try hasoeen the duration nature and severity of the dtsorder Actual psted (MacCurdy Gaupp) breakdown or pronounced ebaracter difficulties before NearlY 66000 were accepled for peasi enlistment and a preponderance of endogenous over Ministry of Pensions on account of functional d exogenous factors were of bad prognostic significance of the nervous system alone 29000 of tbew still Under severe stress almost anyone may break down The pensiooa tn 1938 Wounds and amputations significance of a pwtive family history is debated Cases _ tional netvoUi dilOlden ran aecood in the beginning on home serice on leave or during discharge disorders for which pensions- wue being were unfavourable Early treatment and Ihe place and tional diseasa of the heart are included nature of treatment are important faC1ors Prematuro even clceedina tuberculosis discharge often led to a recurrence of symptoms Not The most comprehensive survey of readjU5tment infrequently during the last yaf the announcement of civiJian life Wu made in the psychiatric service of imminent discharge from hospLtal produced a ~eturn of American Army A fonow-up of 830 CUCI of typical symploms If in spite of this the patient was dl~harged neuroses was undertaken io 1919-20 and J924- to his unit the symptom$ werc agg~ala~ dunng the earljer survey showed that coacussion and PI cases transport when he tinally refOlO~d hi$ re~m~nt he was very high in the percet1taF of successful r~ oflcn in such a state that Immediate readms~lOn to hosshy while campKI with bull attona constitutional elem pital was unavoidable Thereafter he OCCUpted hOSPital hypocbondriasis psychasthenia and timorous beds for ~5 or months and rela~ed after dlSChar~ readjust themselves nearly so well ]t is pain It is generally he~d that the prognosIs IS falourable In u many of the men who never saw action have a regard to the removal of symptoms doubtful 10 regard to ~rious aftermath in symptoms than those who complete recovery ami l once the patIent has been removed actually in the thick of it In the J919 surley a 1 to the ba~ aJmost ~opeJess ~o far as permanent fitness of hystmes were having ditlkulty io getting along for rront~hne ~rVTce lS conce~ned life and di~played numerous nturotic residues I~u~e

Analysis of the figures avatlable reveals that m spite of than unehalf of them were able to earn thelr llVlDg A an apparent lack of uniformity ~ prognosis as regard$ great number of anxiety and effort syqrome cases t~eI return to duty bears a dose relation to the place of treat to be permanently affected The clencal and professlOnal mcnt ~nd the nature of the disorder Concussion cxhausshy groups made the best readjustment those in agriculture lion and bullbull hypcremotivity head the Iist of percentagca he poorest In 1924 practically all the diagnostic amproup of those returned to duty conve~slOn byslena sas showed a higher percentage of readaptation butfu nell~o~is and neurasthenia fo~hJw In that order ~ ~hlle neurosis and effort syndrome remained uncbanged ~nxlcty states are even less faiourab1e and obseSSional [TMt tmd ~ preenin IliO mtkits flU printed in I

1-___ -hl~JlLru)fL ~fffUt ~Yfl~rOm~ ~J~ ~fiLJh~ ~UQm_8[ ~~~ middotmiddotmiddotmiddot1oumai~by-pttmtilIimtmiddotmiddotmiddottJI~ ~-MTIfmfI~-tHJtJ~wm-~ iCLlte Offiter p8lients present IC$S favourable material for inrllHlu in 4 hook shortly to publishtd return W dUly 25 per cent r~tllrned as cumpllid witb liill oj Nl(IIo~$ It ~Furlimtmiddotmiddot 51 fkr cellI of men (United Stlltes Army RCpolt) he tIlt ItltltlIl1re wl1 be gnn]

~4 194lt1

gt ~ shy bullbullbullbull 10

WORK OF MEDICAL BOARD~ 311

pooI also to put every tat if there il any

apperattly harmless any rapidity of PUlse or any history of rheumatillm I do not

utemiddot the eurci1C-tolerance test in rrmiddota No I I~ asked-IO snggm twulIJIIdings--mte _ 50lely based 00 the work enlailed in his own section and another when he noeiyenltd tbe grdings suggested by

best done 1 believe by with his examiners Ho

io detail should b attempt do he remoft somcMmuLmpolllibilily

He should xamimiddotany alteration from H should I think mine hi$tory of rheum~tic fever

He hould take Ih blOOd preasure in c of albuminuria if that la not already heen done by No4

a apecialists opinion I sather there is a great dUference in various medical board

It hasoow heen found surgIcal opiniotf is rarely

It i laid down that a consultation should not is Utdy to be an eflkient

consultation ismiddot not to take For instance any

almost certainlY bar a man from rvice and Ithouch a diagnosis could not be arriyed

consultation is not permissibleargued ht bull better 11 would tomiddot Ophthalmic examination bullbullre neccssary hen the sight doctor did tbe whole of the examination are worn 10 that the amount instead 01 the sectional method being ~I correction by glasses may be known Bar bullminashy

by which each man ibullbullxamined by lour doctors Ions are required when foul discharslt or granulalions are IUoIl ~ interviewed and if necessary examined by the middotIf the services of a pathologist are to dlirman Withmiddot thismiddot I disagree entirely There is in he had the numher of consultations with a physician is my opinion safety in his being examined by several Before this was sanctioned we bad to refer people Take for -instanee the ease of one whose heart cases of glycosuri~ anaemia and albuminuria which pre-may be affected No 2 doctor examines the lungs and clinical signs-the palhologises opinion being records the PDtse (3le~ among other duties II he counts -the PI1Ie by tH stethoscope when he ~amp examiDinl the the conclusion that aU cases with Jungs he can make a mark if be detects anyth[n~ and with very poor chest -bnormal ~nd pass the recruJt to No J whose province it with any history of Dleurlsy -should be 11 to exanun~ the heart ~o 4 has ~e remarks of Nos by the tuberculQsis officer besides (hose with 1 2 and 3ID ffout of bJm re--examme lor any defect bad family history of tuberculosis found and In hJS report sugots a rradmg to the chalr~ cases to defer eatnination for one man who then grades the ~ finally and If hiS opinion officer a chance of a dtffers from the other examiners they consult with him We have had the help of a psychoshy 14) OWn criticism of the sectjonal mcrbod oLeumiIlb __L~~wh~c~[tlC~Mmental conshy -

ton IS that slow doctor holds up the wbole team _ - -_ -~ it IS the chairmans duty~ however to see that an even flomiddot of men is passing through tbe bays When a block c Difficult to Grade

Illnnof or Ihtl~~ rclllrnJlti 10 duty JI lil mvcrjL 10 the ulstun~e of lhe place of treatment fron) line This may be due in part to the soninlt) wher~by mild cases are successfully ~e3tt with at advanced posts und never rcnth the base Ninety-one per cent of those treated at a French (leri) 66 per cent at a British (W Umwnl and 65 per cent at an American casuahy

~~I~ur~r ~~t h~~i~t~~r~lnut an~2 b~ys-No 2 has I will now deal with some of the cases lhal are prlicu~ War-Cime nneTY oenlrn are to be cqablishcd in reception on to No ~ ~ith a paper U L~nnot degexm~~eg~~N~c~

a~~ to ~~vjde evaeualcd childml under the are of 5 witb then e~lDlng tbe hmgs tnstead of No2 until the EC(~C-Th~rtcemch~gc 10 t~e r~aulnhon~clanficJ~OClttt trarnng and occupation during the day A circular block IS overiome The obvious way of lightening the dlfticutJes arcse chiefly wllh

tinn were returned to front-line dUly after It

treatment Accurale agteSSOl nt of the if dence of relapses was made difficult by the nlOenlCJlt divisions since Iht men did not return to the same centre Tentative aSSe5$n1cnls vary between -+ per cent (American) and 10 per cent Holmes) The a~rage laquoture of Ihose

IS~~ by the ~ of ampJucati~ and Ministry of Health work of No2 is to bave ~h~ vei~hing and measuring lgtpeclades It 19 ObVIOUS that a man Ihat for children under 1 a Simple day nursery or creche done hy an orderly~ My chief CfltUIsm however i~ that With (60 In each eye must be reterred t$ a be ~Hmdent Children tletwecn and 5 ycnrs should (her~ is too much time spent by the chairman in filling up ~ible that he can be funy o~rCled an~ II

OIeet ~t ccntn In feuro0tlP of tell to Ilny for ltons correshy duplicate form1i u~o ha 624-636 (that IS one eye With t

opondrng to those m ordinary infanllll Mhoollgt Each centre Divlsloa of Duties dcfieJ(n~ of dloptro 10 mt~e him Grade n to adhere tnchY -mould be ithin euy walking di~tance of the children billets to tfie reguiallono ~ould rctf~llre an examination but il hardiy nd the children amphouJd relum for their midday meal unIe$$ O~her modl~c~tlons that ~ have found uscfut are to almo~ certainly be graded as communal meals aR provided Single empty rooms would uht~lln a beth I hlst~ry by getung No1 to mqUJre speed)shy The reaUy ltbfficult candldate an those who have provide ~he acommodation prQvfJed that each chiJd cally f~r lits J011iSSI Q nS ~o hospital and if a man has full vision in one eye and lelia than 660 in the othcr- with had a rlllnimlllH of 15 ~ fl (he rhildren ohouid t~c-n deh~c~ rom the IQrces~ the reason for discharge Jlraetica~ loso of onC eye the practical IO$$gt 1 intermiddot he under the dwrge a uarden nnt netlt~fil a qualified bull e lind tnal cpllepucs 50nlilIlneS conceal the facl~ anu If the board 15 oal~ficd as to the rcason teacher hut somc~ne specially selected for her suitability for hhat Id soldH(o wtshmg to rccnhst conccal their past tleen middotmiddot~liJied j1 of _~ bullv~~_ bo to ru-Vy ca woul UldcuakA_~lUUk lilcr whICh becomes avallable when they have JOIned a v-ho have had a useless eye from nfancS and cases as rarm of national xrvice without [Yo)mcnt A superin~ h hit iIj ptucd--ut-pcs-cu-vlSif--~ cr_ bten-~~attrL_an_accidtnt____ tcndent who should tJe a trained and etpcrienced nllroery p~sent when h e~amll1es Ihe plantar response because We ha~e not been sOltitled where there 11 any sJgn of cataract shool or infanh teacher mu he appointed 10 sl1pervise the mlfio~ de~rces cf thIS are 31t ~Q be missed by No 3 when in young men or where the eye has heen remond at a con~ work of the wardenlt ~fl II PfJIelvlh to the c1f(Ular contains cNxanunalcn lakes place chiefly with Ihe rccruit standing because we could not be

_J~aJe~Cd~Jpounde 9Q _pp~~t~pnunt hnd Ihe conduct of 0 2 rcC(rd Ihc pulse ~) he usc or the tdhosopc 3nd free from diSe3se the c(nrc~ ~ta~ a flHt-fk-~1middotmiddot~middot~middotor9---peJtei---nOHmiddotmiddot~fU(emiddotPpoundtss- u~nlln-iXlgt~=~~_

lit- hm ~n hI -0 3 ~o~ is a lu to Jill in rhy~al

bullCY Zmiddot ~ -o~ ltj~

development as sood fair or case- dlrouah an eJercitc-toleraDCo kidd of murmur middotwlllcb is

considci it necessary to

the previous doctor The work of the chairman jg

interfering as little as possible cannot possibly examine all

from the othert the 1l0Imll1 reported to him

particularly any cases with a or pleurisy

He dectdes upon tbe need for

to the freq cy 01 this step necessary in few cases A necessary be arranged unless the man soldier Thil JneaIlS that a place merely to clear up a diagnosis abdomlnal tumour would

at by the board a

IS deficient 8Ih1 no glaases

present in the ear

minimiud

sented no the necessary one

We have come to doubtful signs in the IUDgs development or examined a JUSonal h~story or It IS useful In these month to give thetuberculosis second examination

__)~~gipoundalJ~Hni~~Ee__Or~~()(~~~~dillon has lgtCCii untavourabTe

larly dficult to grade

the pOSItion conskterably I he m~n w~o ~Q not wear

With a man

seem~ ntlaquossar-y lDCC h~ Win Ua YLSlon

lo~s or pret as Ion of ~ilhr he j fit to ~rve We have men

as

~iderdhlt time after nn accident a~urel1 Ih3t the Olher eye i

I 2ti4 F 17 19040 THI FORGOtTEN SWAB shywmcuOU1

Early in the operatton (m openins made in the peritoneum that an -amination of the fundus is in many cases the was rrom)I) dosed hut only afler sW~lh btd bc~n best jJuiltk to mediad dIagnoSIS they should know that

~lHoycd When the operation was to be completed a certajn eye drops certain lotions which a clever publiCity swab was nlissed The pentoncum was opened apin showers on them are undoubtedly harmless but that in search of it but it laquoouJd not be found The pahent much precious time is 1011 when they are used in certalll died and at the post-mortem exanUaatioD the swab eye diSeases Amon the other contenls there ia an wu found bdtind the petitCtnCtUD to the left of the interesting ~rti~ on oph~~dm~a neo~orulD in the Near_ middle line whereas the pyOllqlbtooi boltI boon I~- East by Dr 8 DeTanoe- Slie confirms the rarity of th ~1de In a third case bat of a woman ased 40 disease in these reampfoos and gives some explanation of thia operated on for a large fibroma of the uterus the Iwabs -were counted belore and after the operation and the numbers Ullhed About ampj~ months alet the patient

tcturncd with a swelling at the leyel of tbC umbHicus from fever and pain An iocisioo yielded a

__ 1llltJYal wa followed by rtOOCpoundy Menshy-middot-tM Patient had been obliged to dose her little mop

tt iii ycar Waa the to be told Dr Fenaer con a lawyer who counselled honesty as 1M best poticy

When tokl the truth the patient WtlS overjoyed for she had suspected mali31lant disease as the indication for the second operation She assessed her economic loss at kr 600 which were paid by an insurance company_ delighted to get oft so cbeaply After referrinl to yet other cases in his perSoOllal experience Dr Fenger challenged tbe opinion common with doctors as well as with the public lhat this accident always justifies a verdict of negligence against the surgeon He also -referred to the investigation set on foot in Germany by Gulcke who sounded ninety university surgical hospitals on the subject and obtained answers from sixty Only five of these sixty protested their compiete innocence ( yoUjge FehJer freiheit but as it happened Gulde knew that one at least of these five did not have a blaIDCless record in this respcct He concluded that this accident may be

anticipated once in every 2000 to 5000 operations Dr Fengers dry comment on this calculation is that In Denmark alone over 100000 operations are performed annWllly A sirupie essuy in arithmltic and one can cal~

~_tUlate to a nicet) how many Danes acquire forgotten swabs in any given year

SXLL OPHYHALMOL06Y ~-~-~~- nte first number of the third volume of the JouFIlal of

OphliUJlmlJY well maintains the high standard jOliS issues and again 1hc publialion is issued

III ~~l~Lfn~mh and -Englidll The first paper is by the -i-c_--prcsident of the International ASM)(lalion for thl PIfshy

vention of Blindot--1 Dr P ~amiart He give an ouf~ hne (~r a pi llgrilnllnc for the b6h in ciVil life IOU in Ir

---oT)phlhalnw]ogi-ls of 1IumiddotrtI practiloll~rs and of ublicent authorilics A pamgrIIJh in the sCltion regarding the work tlf gencral prrutilinncrs is well worthy of QU(liatiun He wrih~ bull Whilc ev in ctuntries where there are

----~-m-an) ophlhalmoJoJi it i 011( thlt- gencral practilion~r who is first consuitlll by ihc pllicnl with a diseased eye or a failing eyesight Ihlre are ilill countries where owing to the absence of spcialisl the p~titnts have 10 apply to the general praliuoner 1ft most cases owing to the

I crnnmQn sense of th~)C Ilh)ojcians cat31OIrophes are avoided yet they should have 11 minimum acquainlane

------~-middot---witb ophthtlmological facls with our recenl discoveries tney should know for insllt1ncc that lo-day detachment

NlHE BIRD OF 4 B4BY

The spon of this film presented by tIu National BabY-shyWelfiie coUncii~ emphasize that it can in no way be regarded as entertainment hut that it opens up a new and powerful medium for aduh education The main theme is the ante-nalal care and confinement at home of an American primipara Her mOfher~in~law and her imshymensely impressive doctor seize opportunities in response to questions to deliver short lectures well iIIustral~-d on reproductive physiology and the dangers Whhh be1 Ihe parlurient The drama reaches climax in a quiet and easy delivery under anaesthesia The Ucst shot of the picture is a close-up of the baby immediately after delivery lying inert nd motionless except for the pulsa tions of hs cord till suddenly and amazingly it scream its expostulation Tbis is entertainment pure and simple and always will he A weU-dclivered commentary at the beginnini of the piclure warns us of differencu between American and English obstetric lechnique but it was surprising to find complete omission of any hint that the p1acenta remained to be delivered after the baby Pnnllel with the main story the dat1y life of -the doctor is used to iUustrate incidents of obstetric interest-the (lSC of rre~eclampsia the rich lady seekins to escape maternity and t~ inconsiderate husband The whole )(tting of the film is opulent and perhaps will convey an impression of uURahly to the majority of molben in this COUOlry The actin and the accent are best American In spito of this the educative vaJue of the film is high~ Some Ioho attend this film may expect in~cncy and the manifod and unnecessary restrictions of the licensin authorities may encourage visitations from the prurient but there is nothins here that would shock even a congregation of churcbwardens

Wc regret 10 announce the dlth (If Sir Willilm Hodgson la clailnlan of Ihe (hcgtllirl unly IIHlhil

and Ior si YCtflt d nhUlhr I~r lilt I~~ tant ~t- ( jll~ miucente of lh Britlgth MttJjtal Aplalion t also or Dr H OtmpbeU Thomson consulllllg physician 10 inc departshyment for nervous diseases gtrnd emeritus klnrer in ncurology Middtesex HOSPlltll~ and formcdy dCUl of ~lle medical school

Sir Farquhar Buzlard regius professor of medicine in the University of Oxford is one of the twc)e trustees appoin1ed hy Lord NufficJd to be rCllponsihle for the administration of his trust rtlt the provindal huspitals (Sec Jurnal December 9 1939 p 1148)

~~e r~tina i~ curtbi~ Ihllt ghHl~orna IS a trcachbullfous Dr A J OrynsteJn fnmrlj_cbief~-~ritoshyand mSldlOUS dl~asc tha~ _~~~~~Il_~m9Jlrswhl~-llUY middotC01lifoCampardmiddotmiddotand--Oi~i author of M05quita Control in

iliiwly the eyC and may he curable Panama has ben relppointed Direclor~Gencral of the c Socil ()p4tlun 66 lJQuievar4 SriotNiIlWI tit Union of South Africa defcnce medical servicC8

~~ ~ t

N1UROSlS IN WAR ~u 26S

MEDICAL PROBLEMS IN WAR TlUs U 1114 cimd Of 1M artclu sltyl1ll the lilnatu of lIlturosu I

--NEUROSES-IN wAIf 1ft

F WnTKOWER MD PiJ)5kian (JM Hollf7 5Ie R~$e(clt F~low

lltft Toysoc Clink Londoll - I P SPILlANE BSc MB BOo DPM

RfJbullAele1kr Res~mclt Fftlow lite Tovinoct Clink

Ps)dIopodlology

1hree oats of thousbl can be clilCelaood amltlIIg tho numerous aetioJogical views advanced in the literature of the last war They 8llributed war neuroses to (I) anatomical lesions of the nervous system- (2) inborn biological and psychological inferiority-the psychopathic constitution and (3) psychologita reactions to war experiences in individuals previously sensitized to erno-shytional disturbances sub~idy similar although objectively different in tbeir naiure

Early writers on the subjeet noted tho purposive natur~ of many of the neurodt symptoms of soldiers but failed to differentiate between consciou~ preconscious and unshyconscious aims No distinction was made between malingerjng and hysteria and the patients were treated accordingly Authors of that period stre9sed the desire for removal from the fremt line and tbe wish for material compensation as ulterior motives of neurotic manifestashylions The absence of neurosis in severeJy wounded and war prisoners wal noted and was interpreted in the xnse that middotin both caaes a U flight into illness middotwu ttO longer ncedeci u the aim of removal from aeute danger was already attained Terms like neuroses of covetousness and defence and protection neuroses were coined To other observers the desire for gain wal of minor actioshylogical importance but came into action once the neurosIs was established In their view the neurosis itself originated

conflict one

middotmiddot-exampI A bey------ the light of a mangled body of a comrade win arouse horror in anyonC~ but will provoke a disproportionate reaction in individuals in whom there are preltXistent unrecognized conOiets onr vioJmce and aaaresslveness During peace time many such individuals were able by subIimatiOOJ reacdOD formation or environmental manipulation to avoid situation Ukely to provoke their own alampresaive impulses During war on the other hand f not only was the generat taboo on violCnce diminished bUl they were forced by military service into

bullituadons wbich would inevitably have stimulated their aggreuivenest and have provoked anxiety This anxiety i a signal of a threatened breakdown of defences againstmiddot aggressive impulses If further Jlimulatlon of aggressive impulsel took place a complete breakdown ensued

Psytho-anaJytic writers describe in neuroses of war a basit personality tructure characterized by- $ejf~centredshyness over--conscientiousness lack of sociability and lact of affection for relatives and friends Such individuals iutter from a feelinl that their per$OIlality has been neglected aDd that their importance is not 8ufficiently recognized Many of these mea were unable to carry out their tub in practical life othen capable of doing this sbowed little initiative or BY (Abniliam) This group often revealed an effeminatt dispos~tion were dependent on their wives and frequently were akly potent Life in the trenches exposedmiddot them to a danger of death which constituted amiddot threat to their Cxcessive se)fmiddotove Community life ran counter to their asocial tendencies and the unconditionaldemand for self-sacrifice in war caflCd for a renunciation of narciS$isttt priviTeges More so than othen individuals of thia type-middot were prone~ to confticts about aggressiveness~ and through ther latent homosexual tendencies the exclusive association with men constituted a special stress Under such stresses these individuals increasingly regressed to a narcissistic IcyCl of development leading to a state of infantile helplCSsness with a complete surrender to their suffering and a need to be pam~Ll~lLQr_aruLpe1led like oIIi1d - Iltlt-shy ~ wliliOriWif of )bject libido (diminished capacity for Cxterna interests and emotional ties results in an inRation of ego libido (setf~centredness) which is erresied in abnormlil hypochi1ndriacai sensations and a further diminution of genital potency_

S)ll1Promotoiogy

To say thlll the psychological structure of the war neurltnes does not diller (rom that of traumatic neurogtes in peace lime implies that despite the speciftc colooring given by the secial clrcumstanc~ of onset there is no fundamental difference in the symptomatotosy of hcse neurOses A description of such ~yndrome as simple terror) anXiety ~tes conversion hysteria including stupor statesand obsessional states i5 given elsewherC A few points of spetial interestmiddot emerge from a study of the literature

experiences on the other With regard to the initilting tcrrifying experience it was sugg~lcd Ihat durin [he lfaniLOry disturbance of ((nSCiousn(~1O 011 I pncding the onMt of the neurotic dissociation phenomena a splitting oft of the affect from ideational content look pla~t resulting in fixatienl or ps)~honutotjc symptoms ~ BonhlHfer) In military neuroses thc display o( helplessness the need for care and in some gross cases childish behaviour and speecb were taken as si~ns of a reactwtion or defence mechanisms of infantile pitttem (Gaupp and Schmidt) The5e findings recorded by psychiatrists laDy with those of psychoshyanalysts (Jones Abraham Eder Fercnczi Simme1) and uuthors with allied views (Crichton-Miller Hadfield Nicalle They acknowicdt the vulitioDal nature of ~)Ptoms in both dilinn nnd military neurosis but ilrate such almost Ionscioumiddot motives as removal from danger llnd craving for sympathy from those which are

variation in the nature and incidence of the nCuroses This may be due to the personalities of the observers the places of

siooto infantile patterns of behaviour Deep conflicts o~rvation and the variabi1ity of Ihe materiaL Gukkd over unrecognized sadistic i~~_1~__a_~0_~~~e~-~-~-~~~ ~heir pcacc-til1le training and tbeirmiddot-~middot~1merest

w~~ (~~) ~1

I

NEUROSES IN WAR

f shy ~ ~~ ~y -~~ ~~~~J d~poundUllOSlll ~J h

~g- 167

reported syndromes which as in the Caioe H reflex disordersmiddotmiddot were rarely seen by

Aluiety SUlus-The first sign was a (eeling of fatiaue abnormal in ill capricious Ililture Bnd therdore inter reted abullbull form of anxiety There was also a felina

lMY boOk be ptced under one hcadinl or lother Oir orrcd lKuoa 0 he heclrl ito most often a neurosis bullbull (Ctllpin)

IlKOIMiistem viowJ wer hold with regard to anwnability 10 tJClltmertf j ~ng- 10 1lOI~ afJthort ca_ of Cllfort

casualties seen at a casualty clearing 8laHon F----- ~fom1llase at base hospitals Minor ualti

sucb as terror states never reached the base hospltal Gross nysterkal disorders often developed after transfer behind the firing line (Roussy and LHermiue Motl Schneider)

disorders such as elfort syndrome dys laquo rheumatism were orten misdiagnosed

frequently admitted to medical or other wards ~-Jaleif~er under the observation of psych imiddot

5 bullbull More neurOlCS lay in the medical wards than in psychiatric hospitalsmiddot (Culpin)

Fallacies arose [rom bull study o[ seleltted groups Olficera are said to be more often affected than men and in a different way (H Head~ Of the admissions to a British casualty cleann station over a period of thirteen montm there was one officer patient to every fourteen patients of other ranks whereas the actual proportion of officers to other ranks in combatant formations was about 1 in 30 ACCOrding to the official American history neurasthenia Wal five times as common in off)Cers 83 in men and bad so a len favourable prognosis as regards return to the front since only 25 per emt of the oflicers

~__ret~ed to duty compared with 61 per cent or the men

r~ii-----~~uaJ lieprivation anli lack of privacy led to bull blfbedshy

Less than a quarter of British officer patients gave a history of being buried or blown over by shells in contrast to one-balf of the other ranks Conversion hysteria was almost entirely confined to privates and NCOs and occurred for example only five times in 353 officers with psycholoSical di1lOrders_ 00 be olher hand the vast majority of patients with anxiety states were officen-o

The severely wounded hardly ever displayed neurotic ~~Mihiftsla(ions which orten dev~lop aftcr physical he~lth

has been restoroo According to some authors psycho neuroses are eXlremely rare amons war prisoners (Claude

MBrchen Wilmanns His) whereas others admitting the dlJe(ence trom symptoms wen in combatant ~()ldjcJs de$cribe a specific syndrome occurring in those conditions BonhBffer Vischer and others described how the confine~

_ ment and monotony of life in prison camps acccntuated

~ iiIS d~1~MThemiddot mam-syenmploms ~jncreascljrrUa-~L~~_J)ilitY inteme difficulty in concentration ilIlli

Failure of memory was frequcnt and nWlly ~howcli _depre~ion to Which the hench authors gl~ the name (ard

Prodr1 Signs

Neurotic synlplOOlS in wlr time somelimes appear quite suddenly but there arc IIMllHy prooj )nlal signs The most COJlIIHOn of thltse arc OJ fatigue C) increased indulshygence in alcohol or 10btuCo~ (3) a tendency to become tlOsocjable or irrittble (4) a loss of interest and disiruhna tion for effort and (5) emotional crisci-for example

crying fits or states of anxiety and terror Chamcter changes Were found The bellicose incitviduai OecolflC$

moody lhe solemn sullen talkative the clremiddotfree the wdl-bchacd takes to

in the rrodromal stale

of weariness and tenseo~ wjlh a restless desire for action or d~~tracti~ ofteD ~pani~ by irritabiliiY and diftic culty in concenirlmiddottori--aildmiddot a lendemy toStaTt- -atany sudden sound Allbouaht in contrast to ordinary fatigue the (eeling of weariness usually improved towards night there was greal difficulty in getting to sleep and a lona period of hypnagogic hallucinations in which lhe main events of the day appeared in troublesome visions When it did com 1IlP frltqucntly interrupted by bailiemiddot dreams When this situation had progressed for some time the soldier developed fear and horror of the sighlll around him and was unabJe to keep his mind away from the pouibility of injury PioUlily cquired judgrnent coocernina the drection of shells was lost and con sequently evcentry sheU seemed aimed at him pers-onany~ By this time there began the second prodromol pIwio charaltterized by the tear of failure to conceal anxiety which is known to be there Three practiea avenues of escape are then considered tbe soldier may receive an incapacitatin wounda he may be taken prisoner or be may be kiDed Torn belween (ear and tb fea of showbull ins fear neurotie officers in particular often display great courage and on the whole received more decorations lhan non~neurotlc oncs (Schneider) A stuporous state may ~onally usher in a neurosis Traumatic 19$$ of conshysclOusneu is followed by a period of contusion and delirium durms which consdousness is regained for short intervals On the other hand~ the prodromal bullbull functional stuporous state is one of a~ute terror with dilated pupils a cld sweat violent trembJing shallow breathing and inability to perform any voluntary movement It IS succeeded by a period -of contusion and amnesia during which voluntary movement is possible Myrs suggests that the ~IIlconsciousness whicb figllred so frequently in the histories of maoy patients may be idenUcal wiLb this stuporous slate

ConveJsiufl HYlI-eri-Although in conversion hysteria as in anIiety states fatigue was the initial symptom it was nearly always Jess severe Sleeplessness was infre

and nightmares were rare more common was a l ofC~ ~ousing an~ r~~~~t of the need to --i1umpln-ess--wasTcmiddotssmiddot prOntlUn-cea-anUmiddot-m~tiWas-

a relative absence ot the consciou mental canfhcUl hcwcen duty and ideals whih lOU suth ~ rrl1mill~nt rart in the prodromal anlcty ~Iate in ofiltcn I th 1 ocy

bull n c i of pracucall~ ~vcry h)~lcrllal taM cxammcd by l~d( u[Iy there W8$ elJClt~ the ~ope that they would be tn~apltlCl~ ttted from active serVIce h-y bemg wounded In cunmiddot sequence such on event as C(lOCUSSItIfl provilled 1he occasion for the development of definite symplOms Alternatively as with anxiety cases the infiillion of lttn actual wounlt did not pneipiluc hYiicrical symptom~ and these deveJoped later ouring convulescelKc aflcr a bullbull ad d 0 _

pcrt e e me Itatloo Charcot RoussYt 1 HermlHe Wm Brown)

Psy_tic Disorders

cO bull ~~ 0- Jalntionool by __ 1114 Da Coal In tho riCia (XVi) Warlaquomdi1iofCwumiddotofmI -seen dtiriftltt bullbull

taampt war e~ by a type of earoiac symptom without any ltAampturalmiddot1eaiot TfRDlI mentioning the heart (1OIdiermiddotheart irritable heart DAH) proved obvioullymiddot dan8trous ilnd It Is DOW qreed that they shOUld be replaced u Sir Thomal Lewis gaIed~ by tbe tafer and more accurate label of dfort ~raquo bull T1x upi6cance of the dhOrder will beraIiLiCI~ _-req_ 0lt1 IncapacitaU ell cOn~ No ~bIolutO Il_ of the llCide~cbullbull Cpsychltt neuEOlCl- Ii acncrat and of effort syndrome in partiCular are avllilable butmiddot 1ft 1I)I31S$3 Britith _ admllted to medical Units frOm 1916 1921 there wore 11408 co_ of fuOClionaI __ otmiddot tbe heart compared with 21~ of functJouJ disease of the oervOUI y~that is two of funcWol bout iii to lt11 three of fomctooat no dim_bull 329113 patient with functional Mn0IIl di admtled to A_n hospitals from April 1917 w May 1919 only 4)16 cua of OCU1OCirculatory 8S1henia were fOUDd tho __ beinC poibly due to the deetloD of recruits and the Ibottu period of active lervice Accordin to Britbb 1114 o-a oboervtioD8 (Lcwi Holmann I_b) only OM patteot in eVer) tcn admitted to eardillc hOlpitak suIIcred from 1lt heart disease

Jbe main f~re of dfwt syoorOJllO is an abnormal pbysic-shy1oaiaU _n to-elort-lgtratlIJeunes1 eaplaquoiaUy on rmiddot = =~m=~~n7= faiotin The aenise toktancc to5t shows an undue increase In pulse note aOltl a delayed retum to norma The blood ~ it aid ro DO aianifleut uriation About ~ hall of the casa 6epn in civiL Ufe under ~nditions wbere pbyaial strain wu UDimPOfl8l1t (Lewis Part1n50Dh and a furtbct 12 pc centenl duriila the period of traiDinamp (Lewis)

The QctioloaY of the ltondirion has been widely debated 11 has becn aUributed 10 heart ilrain infection IObaCCO~_1~ hyperthyroidism P poilOltJnin 1114middot sbcU shock

Altcordinl to Hunt soldier heart ia oaly QDe manitata dOD of the nervOU$ exhaustion or neuratithenia which tesulU from the eombincd effeltts of physical fatiampue mental eshaus lion and toutmia the toxaemia l1lO$t frequently bein of exoaenous oricin (baeterla or tobacco) and ratliy of endo-shyamp~I origin (endoaine secretions) L-wis dismisses heart

~ ~ pointiD~ _ progn(llIS In 80 pet eDt of ~s caSCIl1nfectlOU$ ~15Ca5eS had precedtd the onset of t~ dlso~der ni1hough 1t was onlyIn 30 rer cent that tbey lmmethalely preceded the Onset ~f $ymploms lk iIlreSbCf the frequency of the disorder m soldiers who previously followed $Cdentary occupations and in IIeI1sitivc luIOUJ highly strona or deprcsMd individuals His lToupmiddot of ease$ included an abnormally hiJh numbct of tcctotan~rs and 15 per cent bad morning spermatorrboea

Jn his view tbeni was no uniformity of aetiology and ~nsti ~0flamp1 weakness 0 retarded ~~V~lop~~ eJtpoSUn~ and

mfecho-n played Yaljln parts ~lmdar VUW8 were expreS-~by A Abrahams The psychiatriC effect of effort syndroma

III

was invutiptcd in more detail by Oppenheirner and Roh$dlild Cohn MacCurdy Culpln Th (nqUeDltY or a positive faAlily history or of facton prediSPOlUnj to psychoshyneurosis was stressed (Oppenheimer and Rothschild) Cohn and CUJpin independently ~phasized the psychological implicationa of certain features often found in t1Iort 5yndrorne pallenb such as tttmor of hand r6dy lweatlng disturbed sleep sbakiness on slilht ecitement ready starting and

~-a-netinrof deptcsaion lheF it AQ bttak in tJw Ktilaquo alnin these and otbcn in which a typtltal anxielY coexists with rapid pulampe shortness of breath precordiJl pain and occasiollli faintneSs and glddineu In short witb regard 10 many patients it is clinically J alter of inditTerence whether

I~ uc WjJhly middotraist to any forrn of treaknent (A)ID4I in_) ftIK of reebl pft)iquo whb __ middotciyenlImiddot tile iuditoly to im~ u_tty to maH ~ to1dien witiLtbiLt~pr~Odd (Hu1$t) Out of 55amp cues seen by Sir Thomas Lewts appr~ mately50 per cent were judaed to be unfit for any category of duty of the 239 who were fOllowed up only lhirty~nine returned tothe firing line in eleven tnonlhs These fiure$ do not correspond with thoampcent of tbe official history of the war in whKb it iI stated that of ll408 tiQ of fUnclional dtSCa$ll of the lIltart 11403 refinally disJgt9sed ltgtf byretum to duty Experience of the It of oYltematO PSY~9Oli1 treatment are not avaJlable

G _

~taDy limilar in structure but with a predominance of respiratory Iymptoma were PI neurol5iC$ Ulllion Roers Hulkrt) Gu neurosis was (0 the lunp whal effort IJDdrome ftl to the heartraquo AD epidernic of ps hysteria was described by the official hiltory of th~ A~rican Expeshyditionary For_ Following desultory ps shelling spread over eight days 500 men returned to one field hospilal as ps Qsualtia Tbe symptoms described were a fcelina of faiaue pain in the chat e1ibt dyspnoea COUghinl husky voice an atlOftmeDt of tinalin and bflmiDa senaaHona referred to the throat and IOIDC indefinite eye symptoms PhySical and neuroloPal examination was praerically negative As lhese men came from battJetelted troops it was reprded aa inconshyceivable that the wcte malitlJlaquoina MOre probably a number of facton acted toaer~ al that time to lower morale and reduce inhibition to to au where tNlnYutilized allyen suitable extrancol-S opportunity as a route to escape frorn an unshyduifable situafi9n Simple rea5sorance given and the palieata ltOIIYinc1nl1y wid tbat lhey would be able 10 return to duty on a OlUin day at some specified hour ~u~uentlY tJte ~mptoms were practically ignored and $triet military dhcipline was enforced Rapid recovery followed and the wave of f8ses ceased spontaneously at ~he end of eiSht days

00pi0Ic DIoodon willi a Iarp EmoI-I c-- Warfare gave a unique opportunity for studying certain

otpnic diMases in whkb emotional factors are aUeged to play a prominent part of primarily aettological and aggravating importance A review of the literature is disappointing Most authors unfortunately confine themshy~~_ to a statistical evaluation of certain organic disltgt eases in reJatIon ToemotitmaJ dIStill babtW atd nCJlutS diaorders

Alim~nfar1 Disordcrs-An lncr(a~ in ltyspepl-ia under the stress or warfare wa frequently nOled (Alhu Schmidt Sirnuss Romberg) Individuals- who suifeNd from simrlur disodet~ in peace time were panicularly attected One-half of the patient$ feU ill before they had ~n any front~iine serviC~ and a further onefhird developed symptoms during the first week in lbe firin line Constipation gastric hypersecretion vomiting and diarrhoea and pyloric spasm were commonly seen The personality type of lhe patients affected was definilely different from that in cardiac neuroses (KUllingtky) There was no conclusive evidence to suggest that peptic ulcer emeramped from the syndrome Most authors agreed that lhe incidence of ~ptic U1ccr during war was not higher than durina peace time but relaPH$ of peptic ulcer were repeatedly seen ill those who had suffered from it in peace lime Hi Frequent onset of stress-dyspepsia or peptic ulcer on demoHi~ uuon has been noted (Da ies and Wilson)

Diabets Diabttes was a rare conditton among wldcrs

bull There were only two dIabetiCs lIt ~6~ Ictcd tH~iIAl-----lOidien (Joslin) Strauss found the IJlcld~nee In war ho~pllaa to be 03 per U)OO as compared With 12 per 1000 m clI(llian bospitals A pre-Gistlng diabetes may be aggravated accofd~

Propos

NEUROSES IN WAit

rturned to fmat-1iM duty A=rding to authoritative opinion wac based Oft amp wide very low Only 11 aDd 17 per cent 01 ca German base boopital returned to rrOQtmiddot (Willmans StcmJ-_On this JIaOWIt ithas heenclo jf a return to front-line duty should inariatKy be It has heen argued that tb few sheU-ibocked returned to froatfine duty otten jMtficient and hardly bal the large maTlber of mental receipt of a pension Early rubarJe after n

As in peace time the prognosis of Qeucosis in war time of their aymPt~ to ~ivitian QQupadOll io dllpmds on the alllI1tinteUigeme of the patient aDd OIl caD reodcr - vltco to the try hasoeen the duration nature and severity of the dtsorder Actual psted (MacCurdy Gaupp) breakdown or pronounced ebaracter difficulties before NearlY 66000 were accepled for peasi enlistment and a preponderance of endogenous over Ministry of Pensions on account of functional d exogenous factors were of bad prognostic significance of the nervous system alone 29000 of tbew still Under severe stress almost anyone may break down The pensiooa tn 1938 Wounds and amputations significance of a pwtive family history is debated Cases _ tional netvoUi dilOlden ran aecood in the beginning on home serice on leave or during discharge disorders for which pensions- wue being were unfavourable Early treatment and Ihe place and tional diseasa of the heart are included nature of treatment are important faC1ors Prematuro even clceedina tuberculosis discharge often led to a recurrence of symptoms Not The most comprehensive survey of readjU5tment infrequently during the last yaf the announcement of civiJian life Wu made in the psychiatric service of imminent discharge from hospLtal produced a ~eturn of American Army A fonow-up of 830 CUCI of typical symploms If in spite of this the patient was dl~harged neuroses was undertaken io 1919-20 and J924- to his unit the symptom$ werc agg~ala~ dunng the earljer survey showed that coacussion and PI cases transport when he tinally refOlO~d hi$ re~m~nt he was very high in the percet1taF of successful r~ oflcn in such a state that Immediate readms~lOn to hosshy while campKI with bull attona constitutional elem pital was unavoidable Thereafter he OCCUpted hOSPital hypocbondriasis psychasthenia and timorous beds for ~5 or months and rela~ed after dlSChar~ readjust themselves nearly so well ]t is pain It is generally he~d that the prognosIs IS falourable In u many of the men who never saw action have a regard to the removal of symptoms doubtful 10 regard to ~rious aftermath in symptoms than those who complete recovery ami l once the patIent has been removed actually in the thick of it In the J919 surley a 1 to the ba~ aJmost ~opeJess ~o far as permanent fitness of hystmes were having ditlkulty io getting along for rront~hne ~rVTce lS conce~ned life and di~played numerous nturotic residues I~u~e

Analysis of the figures avatlable reveals that m spite of than unehalf of them were able to earn thelr llVlDg A an apparent lack of uniformity ~ prognosis as regard$ great number of anxiety and effort syqrome cases t~eI return to duty bears a dose relation to the place of treat to be permanently affected The clencal and professlOnal mcnt ~nd the nature of the disorder Concussion cxhausshy groups made the best readjustment those in agriculture lion and bullbull hypcremotivity head the Iist of percentagca he poorest In 1924 practically all the diagnostic amproup of those returned to duty conve~slOn byslena sas showed a higher percentage of readaptation butfu nell~o~is and neurasthenia fo~hJw In that order ~ ~hlle neurosis and effort syndrome remained uncbanged ~nxlcty states are even less faiourab1e and obseSSional [TMt tmd ~ preenin IliO mtkits flU printed in I

1-___ -hl~JlLru)fL ~fffUt ~Yfl~rOm~ ~J~ ~fiLJh~ ~UQm_8[ ~~~ middotmiddotmiddotmiddot1oumai~by-pttmtilIimtmiddotmiddotmiddottJI~ ~-MTIfmfI~-tHJtJ~wm-~ iCLlte Offiter p8lients present IC$S favourable material for inrllHlu in 4 hook shortly to publishtd return W dUly 25 per cent r~tllrned as cumpllid witb liill oj Nl(IIo~$ It ~Furlimtmiddotmiddot 51 fkr cellI of men (United Stlltes Army RCpolt) he tIlt ItltltlIl1re wl1 be gnn]

~4 194lt1

gt ~ shy bullbullbullbull 10

WORK OF MEDICAL BOARD~ 311

pooI also to put every tat if there il any

apperattly harmless any rapidity of PUlse or any history of rheumatillm I do not

utemiddot the eurci1C-tolerance test in rrmiddota No I I~ asked-IO snggm twulIJIIdings--mte _ 50lely based 00 the work enlailed in his own section and another when he noeiyenltd tbe grdings suggested by

best done 1 believe by with his examiners Ho

io detail should b attempt do he remoft somcMmuLmpolllibilily

He should xamimiddotany alteration from H should I think mine hi$tory of rheum~tic fever

He hould take Ih blOOd preasure in c of albuminuria if that la not already heen done by No4

a apecialists opinion I sather there is a great dUference in various medical board

It hasoow heen found surgIcal opiniotf is rarely

It i laid down that a consultation should not is Utdy to be an eflkient

consultation ismiddot not to take For instance any

almost certainlY bar a man from rvice and Ithouch a diagnosis could not be arriyed

consultation is not permissibleargued ht bull better 11 would tomiddot Ophthalmic examination bullbullre neccssary hen the sight doctor did tbe whole of the examination are worn 10 that the amount instead 01 the sectional method being ~I correction by glasses may be known Bar bullminashy

by which each man ibullbullxamined by lour doctors Ions are required when foul discharslt or granulalions are IUoIl ~ interviewed and if necessary examined by the middotIf the services of a pathologist are to dlirman Withmiddot thismiddot I disagree entirely There is in he had the numher of consultations with a physician is my opinion safety in his being examined by several Before this was sanctioned we bad to refer people Take for -instanee the ease of one whose heart cases of glycosuri~ anaemia and albuminuria which pre-may be affected No 2 doctor examines the lungs and clinical signs-the palhologises opinion being records the PDtse (3le~ among other duties II he counts -the PI1Ie by tH stethoscope when he ~amp examiDinl the the conclusion that aU cases with Jungs he can make a mark if be detects anyth[n~ and with very poor chest -bnormal ~nd pass the recruJt to No J whose province it with any history of Dleurlsy -should be 11 to exanun~ the heart ~o 4 has ~e remarks of Nos by the tuberculQsis officer besides (hose with 1 2 and 3ID ffout of bJm re--examme lor any defect bad family history of tuberculosis found and In hJS report sugots a rradmg to the chalr~ cases to defer eatnination for one man who then grades the ~ finally and If hiS opinion officer a chance of a dtffers from the other examiners they consult with him We have had the help of a psychoshy 14) OWn criticism of the sectjonal mcrbod oLeumiIlb __L~~wh~c~[tlC~Mmental conshy -

ton IS that slow doctor holds up the wbole team _ - -_ -~ it IS the chairmans duty~ however to see that an even flomiddot of men is passing through tbe bays When a block c Difficult to Grade

Illnnof or Ihtl~~ rclllrnJlti 10 duty JI lil mvcrjL 10 the ulstun~e of lhe place of treatment fron) line This may be due in part to the soninlt) wher~by mild cases are successfully ~e3tt with at advanced posts und never rcnth the base Ninety-one per cent of those treated at a French (leri) 66 per cent at a British (W Umwnl and 65 per cent at an American casuahy

~~I~ur~r ~~t h~~i~t~~r~lnut an~2 b~ys-No 2 has I will now deal with some of the cases lhal are prlicu~ War-Cime nneTY oenlrn are to be cqablishcd in reception on to No ~ ~ith a paper U L~nnot degexm~~eg~~N~c~

a~~ to ~~vjde evaeualcd childml under the are of 5 witb then e~lDlng tbe hmgs tnstead of No2 until the EC(~C-Th~rtcemch~gc 10 t~e r~aulnhon~clanficJ~OClttt trarnng and occupation during the day A circular block IS overiome The obvious way of lightening the dlfticutJes arcse chiefly wllh

tinn were returned to front-line dUly after It

treatment Accurale agteSSOl nt of the if dence of relapses was made difficult by the nlOenlCJlt divisions since Iht men did not return to the same centre Tentative aSSe5$n1cnls vary between -+ per cent (American) and 10 per cent Holmes) The a~rage laquoture of Ihose

IS~~ by the ~ of ampJucati~ and Ministry of Health work of No2 is to bave ~h~ vei~hing and measuring lgtpeclades It 19 ObVIOUS that a man Ihat for children under 1 a Simple day nursery or creche done hy an orderly~ My chief CfltUIsm however i~ that With (60 In each eye must be reterred t$ a be ~Hmdent Children tletwecn and 5 ycnrs should (her~ is too much time spent by the chairman in filling up ~ible that he can be funy o~rCled an~ II

OIeet ~t ccntn In feuro0tlP of tell to Ilny for ltons correshy duplicate form1i u~o ha 624-636 (that IS one eye With t

opondrng to those m ordinary infanllll Mhoollgt Each centre Divlsloa of Duties dcfieJ(n~ of dloptro 10 mt~e him Grade n to adhere tnchY -mould be ithin euy walking di~tance of the children billets to tfie reguiallono ~ould rctf~llre an examination but il hardiy nd the children amphouJd relum for their midday meal unIe$$ O~her modl~c~tlons that ~ have found uscfut are to almo~ certainly be graded as communal meals aR provided Single empty rooms would uht~lln a beth I hlst~ry by getung No1 to mqUJre speed)shy The reaUy ltbfficult candldate an those who have provide ~he acommodation prQvfJed that each chiJd cally f~r lits J011iSSI Q nS ~o hospital and if a man has full vision in one eye and lelia than 660 in the othcr- with had a rlllnimlllH of 15 ~ fl (he rhildren ohouid t~c-n deh~c~ rom the IQrces~ the reason for discharge Jlraetica~ loso of onC eye the practical IO$$gt 1 intermiddot he under the dwrge a uarden nnt netlt~fil a qualified bull e lind tnal cpllepucs 50nlilIlneS conceal the facl~ anu If the board 15 oal~ficd as to the rcason teacher hut somc~ne specially selected for her suitability for hhat Id soldH(o wtshmg to rccnhst conccal their past tleen middotmiddot~liJied j1 of _~ bullv~~_ bo to ru-Vy ca woul UldcuakA_~lUUk lilcr whICh becomes avallable when they have JOIned a v-ho have had a useless eye from nfancS and cases as rarm of national xrvice without [Yo)mcnt A superin~ h hit iIj ptucd--ut-pcs-cu-vlSif--~ cr_ bten-~~attrL_an_accidtnt____ tcndent who should tJe a trained and etpcrienced nllroery p~sent when h e~amll1es Ihe plantar response because We ha~e not been sOltitled where there 11 any sJgn of cataract shool or infanh teacher mu he appointed 10 sl1pervise the mlfio~ de~rces cf thIS are 31t ~Q be missed by No 3 when in young men or where the eye has heen remond at a con~ work of the wardenlt ~fl II PfJIelvlh to the c1f(Ular contains cNxanunalcn lakes place chiefly with Ihe rccruit standing because we could not be

_J~aJe~Cd~Jpounde 9Q _pp~~t~pnunt hnd Ihe conduct of 0 2 rcC(rd Ihc pulse ~) he usc or the tdhosopc 3nd free from diSe3se the c(nrc~ ~ta~ a flHt-fk-~1middotmiddot~middot~middotor9---peJtei---nOHmiddotmiddot~fU(emiddotPpoundtss- u~nlln-iXlgt~=~~_

lit- hm ~n hI -0 3 ~o~ is a lu to Jill in rhy~al

bullCY Zmiddot ~ -o~ ltj~

development as sood fair or case- dlrouah an eJercitc-toleraDCo kidd of murmur middotwlllcb is

considci it necessary to

the previous doctor The work of the chairman jg

interfering as little as possible cannot possibly examine all

from the othert the 1l0Imll1 reported to him

particularly any cases with a or pleurisy

He dectdes upon tbe need for

to the freq cy 01 this step necessary in few cases A necessary be arranged unless the man soldier Thil JneaIlS that a place merely to clear up a diagnosis abdomlnal tumour would

at by the board a

IS deficient 8Ih1 no glaases

present in the ear

minimiud

sented no the necessary one

We have come to doubtful signs in the IUDgs development or examined a JUSonal h~story or It IS useful In these month to give thetuberculosis second examination

__)~~gipoundalJ~Hni~~Ee__Or~~()(~~~~dillon has lgtCCii untavourabTe

larly dficult to grade

the pOSItion conskterably I he m~n w~o ~Q not wear

With a man

seem~ ntlaquossar-y lDCC h~ Win Ua YLSlon

lo~s or pret as Ion of ~ilhr he j fit to ~rve We have men

as

~iderdhlt time after nn accident a~urel1 Ih3t the Olher eye i

I 2ti4 F 17 19040 THI FORGOtTEN SWAB shywmcuOU1

Early in the operatton (m openins made in the peritoneum that an -amination of the fundus is in many cases the was rrom)I) dosed hut only afler sW~lh btd bc~n best jJuiltk to mediad dIagnoSIS they should know that

~lHoycd When the operation was to be completed a certajn eye drops certain lotions which a clever publiCity swab was nlissed The pentoncum was opened apin showers on them are undoubtedly harmless but that in search of it but it laquoouJd not be found The pahent much precious time is 1011 when they are used in certalll died and at the post-mortem exanUaatioD the swab eye diSeases Amon the other contenls there ia an wu found bdtind the petitCtnCtUD to the left of the interesting ~rti~ on oph~~dm~a neo~orulD in the Near_ middle line whereas the pyOllqlbtooi boltI boon I~- East by Dr 8 DeTanoe- Slie confirms the rarity of th ~1de In a third case bat of a woman ased 40 disease in these reampfoos and gives some explanation of thia operated on for a large fibroma of the uterus the Iwabs -were counted belore and after the operation and the numbers Ullhed About ampj~ months alet the patient

tcturncd with a swelling at the leyel of tbC umbHicus from fever and pain An iocisioo yielded a

__ 1llltJYal wa followed by rtOOCpoundy Menshy-middot-tM Patient had been obliged to dose her little mop

tt iii ycar Waa the to be told Dr Fenaer con a lawyer who counselled honesty as 1M best poticy

When tokl the truth the patient WtlS overjoyed for she had suspected mali31lant disease as the indication for the second operation She assessed her economic loss at kr 600 which were paid by an insurance company_ delighted to get oft so cbeaply After referrinl to yet other cases in his perSoOllal experience Dr Fenger challenged tbe opinion common with doctors as well as with the public lhat this accident always justifies a verdict of negligence against the surgeon He also -referred to the investigation set on foot in Germany by Gulcke who sounded ninety university surgical hospitals on the subject and obtained answers from sixty Only five of these sixty protested their compiete innocence ( yoUjge FehJer freiheit but as it happened Gulde knew that one at least of these five did not have a blaIDCless record in this respcct He concluded that this accident may be

anticipated once in every 2000 to 5000 operations Dr Fengers dry comment on this calculation is that In Denmark alone over 100000 operations are performed annWllly A sirupie essuy in arithmltic and one can cal~

~_tUlate to a nicet) how many Danes acquire forgotten swabs in any given year

SXLL OPHYHALMOL06Y ~-~-~~- nte first number of the third volume of the JouFIlal of

OphliUJlmlJY well maintains the high standard jOliS issues and again 1hc publialion is issued

III ~~l~Lfn~mh and -Englidll The first paper is by the -i-c_--prcsident of the International ASM)(lalion for thl PIfshy

vention of Blindot--1 Dr P ~amiart He give an ouf~ hne (~r a pi llgrilnllnc for the b6h in ciVil life IOU in Ir

---oT)phlhalnw]ogi-ls of 1IumiddotrtI practiloll~rs and of ublicent authorilics A pamgrIIJh in the sCltion regarding the work tlf gencral prrutilinncrs is well worthy of QU(liatiun He wrih~ bull Whilc ev in ctuntries where there are

----~-m-an) ophlhalmoJoJi it i 011( thlt- gencral practilion~r who is first consuitlll by ihc pllicnl with a diseased eye or a failing eyesight Ihlre are ilill countries where owing to the absence of spcialisl the p~titnts have 10 apply to the general praliuoner 1ft most cases owing to the

I crnnmQn sense of th~)C Ilh)ojcians cat31OIrophes are avoided yet they should have 11 minimum acquainlane

------~-middot---witb ophthtlmological facls with our recenl discoveries tney should know for insllt1ncc that lo-day detachment

NlHE BIRD OF 4 B4BY

The spon of this film presented by tIu National BabY-shyWelfiie coUncii~ emphasize that it can in no way be regarded as entertainment hut that it opens up a new and powerful medium for aduh education The main theme is the ante-nalal care and confinement at home of an American primipara Her mOfher~in~law and her imshymensely impressive doctor seize opportunities in response to questions to deliver short lectures well iIIustral~-d on reproductive physiology and the dangers Whhh be1 Ihe parlurient The drama reaches climax in a quiet and easy delivery under anaesthesia The Ucst shot of the picture is a close-up of the baby immediately after delivery lying inert nd motionless except for the pulsa tions of hs cord till suddenly and amazingly it scream its expostulation Tbis is entertainment pure and simple and always will he A weU-dclivered commentary at the beginnini of the piclure warns us of differencu between American and English obstetric lechnique but it was surprising to find complete omission of any hint that the p1acenta remained to be delivered after the baby Pnnllel with the main story the dat1y life of -the doctor is used to iUustrate incidents of obstetric interest-the (lSC of rre~eclampsia the rich lady seekins to escape maternity and t~ inconsiderate husband The whole )(tting of the film is opulent and perhaps will convey an impression of uURahly to the majority of molben in this COUOlry The actin and the accent are best American In spito of this the educative vaJue of the film is high~ Some Ioho attend this film may expect in~cncy and the manifod and unnecessary restrictions of the licensin authorities may encourage visitations from the prurient but there is nothins here that would shock even a congregation of churcbwardens

Wc regret 10 announce the dlth (If Sir Willilm Hodgson la clailnlan of Ihe (hcgtllirl unly IIHlhil

and Ior si YCtflt d nhUlhr I~r lilt I~~ tant ~t- ( jll~ miucente of lh Britlgth MttJjtal Aplalion t also or Dr H OtmpbeU Thomson consulllllg physician 10 inc departshyment for nervous diseases gtrnd emeritus klnrer in ncurology Middtesex HOSPlltll~ and formcdy dCUl of ~lle medical school

Sir Farquhar Buzlard regius professor of medicine in the University of Oxford is one of the twc)e trustees appoin1ed hy Lord NufficJd to be rCllponsihle for the administration of his trust rtlt the provindal huspitals (Sec Jurnal December 9 1939 p 1148)

~~e r~tina i~ curtbi~ Ihllt ghHl~orna IS a trcachbullfous Dr A J OrynsteJn fnmrlj_cbief~-~ritoshyand mSldlOUS dl~asc tha~ _~~~~~Il_~m9Jlrswhl~-llUY middotC01lifoCampardmiddotmiddotand--Oi~i author of M05quita Control in

iliiwly the eyC and may he curable Panama has ben relppointed Direclor~Gencral of the c Socil ()p4tlun 66 lJQuievar4 SriotNiIlWI tit Union of South Africa defcnce medical servicC8

~~ ~ t

N1UROSlS IN WAR ~u 26S

MEDICAL PROBLEMS IN WAR TlUs U 1114 cimd Of 1M artclu sltyl1ll the lilnatu of lIlturosu I

--NEUROSES-IN wAIf 1ft

F WnTKOWER MD PiJ)5kian (JM Hollf7 5Ie R~$e(clt F~low

lltft Toysoc Clink Londoll - I P SPILlANE BSc MB BOo DPM

RfJbullAele1kr Res~mclt Fftlow lite Tovinoct Clink

Ps)dIopodlology

1hree oats of thousbl can be clilCelaood amltlIIg tho numerous aetioJogical views advanced in the literature of the last war They 8llributed war neuroses to (I) anatomical lesions of the nervous system- (2) inborn biological and psychological inferiority-the psychopathic constitution and (3) psychologita reactions to war experiences in individuals previously sensitized to erno-shytional disturbances sub~idy similar although objectively different in tbeir naiure

Early writers on the subjeet noted tho purposive natur~ of many of the neurodt symptoms of soldiers but failed to differentiate between consciou~ preconscious and unshyconscious aims No distinction was made between malingerjng and hysteria and the patients were treated accordingly Authors of that period stre9sed the desire for removal from the fremt line and tbe wish for material compensation as ulterior motives of neurotic manifestashylions The absence of neurosis in severeJy wounded and war prisoners wal noted and was interpreted in the xnse that middotin both caaes a U flight into illness middotwu ttO longer ncedeci u the aim of removal from aeute danger was already attained Terms like neuroses of covetousness and defence and protection neuroses were coined To other observers the desire for gain wal of minor actioshylogical importance but came into action once the neurosIs was established In their view the neurosis itself originated

conflict one

middotmiddot-exampI A bey------ the light of a mangled body of a comrade win arouse horror in anyonC~ but will provoke a disproportionate reaction in individuals in whom there are preltXistent unrecognized conOiets onr vioJmce and aaaresslveness During peace time many such individuals were able by subIimatiOOJ reacdOD formation or environmental manipulation to avoid situation Ukely to provoke their own alampresaive impulses During war on the other hand f not only was the generat taboo on violCnce diminished bUl they were forced by military service into

bullituadons wbich would inevitably have stimulated their aggreuivenest and have provoked anxiety This anxiety i a signal of a threatened breakdown of defences againstmiddot aggressive impulses If further Jlimulatlon of aggressive impulsel took place a complete breakdown ensued

Psytho-anaJytic writers describe in neuroses of war a basit personality tructure characterized by- $ejf~centredshyness over--conscientiousness lack of sociability and lact of affection for relatives and friends Such individuals iutter from a feelinl that their per$OIlality has been neglected aDd that their importance is not 8ufficiently recognized Many of these mea were unable to carry out their tub in practical life othen capable of doing this sbowed little initiative or BY (Abniliam) This group often revealed an effeminatt dispos~tion were dependent on their wives and frequently were akly potent Life in the trenches exposedmiddot them to a danger of death which constituted amiddot threat to their Cxcessive se)fmiddotove Community life ran counter to their asocial tendencies and the unconditionaldemand for self-sacrifice in war caflCd for a renunciation of narciS$isttt priviTeges More so than othen individuals of thia type-middot were prone~ to confticts about aggressiveness~ and through ther latent homosexual tendencies the exclusive association with men constituted a special stress Under such stresses these individuals increasingly regressed to a narcissistic IcyCl of development leading to a state of infantile helplCSsness with a complete surrender to their suffering and a need to be pam~Ll~lLQr_aruLpe1led like oIIi1d - Iltlt-shy ~ wliliOriWif of )bject libido (diminished capacity for Cxterna interests and emotional ties results in an inRation of ego libido (setf~centredness) which is erresied in abnormlil hypochi1ndriacai sensations and a further diminution of genital potency_

S)ll1Promotoiogy

To say thlll the psychological structure of the war neurltnes does not diller (rom that of traumatic neurogtes in peace lime implies that despite the speciftc colooring given by the secial clrcumstanc~ of onset there is no fundamental difference in the symptomatotosy of hcse neurOses A description of such ~yndrome as simple terror) anXiety ~tes conversion hysteria including stupor statesand obsessional states i5 given elsewherC A few points of spetial interestmiddot emerge from a study of the literature

experiences on the other With regard to the initilting tcrrifying experience it was sugg~lcd Ihat durin [he lfaniLOry disturbance of ((nSCiousn(~1O 011 I pncding the onMt of the neurotic dissociation phenomena a splitting oft of the affect from ideational content look pla~t resulting in fixatienl or ps)~honutotjc symptoms ~ BonhlHfer) In military neuroses thc display o( helplessness the need for care and in some gross cases childish behaviour and speecb were taken as si~ns of a reactwtion or defence mechanisms of infantile pitttem (Gaupp and Schmidt) The5e findings recorded by psychiatrists laDy with those of psychoshyanalysts (Jones Abraham Eder Fercnczi Simme1) and uuthors with allied views (Crichton-Miller Hadfield Nicalle They acknowicdt the vulitioDal nature of ~)Ptoms in both dilinn nnd military neurosis but ilrate such almost Ionscioumiddot motives as removal from danger llnd craving for sympathy from those which are

variation in the nature and incidence of the nCuroses This may be due to the personalities of the observers the places of

siooto infantile patterns of behaviour Deep conflicts o~rvation and the variabi1ity of Ihe materiaL Gukkd over unrecognized sadistic i~~_1~__a_~0_~~~e~-~-~-~~~ ~heir pcacc-til1le training and tbeirmiddot-~middot~1merest

w~~ (~~) ~1

I

NEUROSES IN WAR

f shy ~ ~~ ~y -~~ ~~~~J d~poundUllOSlll ~J h

~g- 167

reported syndromes which as in the Caioe H reflex disordersmiddotmiddot were rarely seen by

Aluiety SUlus-The first sign was a (eeling of fatiaue abnormal in ill capricious Ililture Bnd therdore inter reted abullbull form of anxiety There was also a felina

lMY boOk be ptced under one hcadinl or lother Oir orrcd lKuoa 0 he heclrl ito most often a neurosis bullbull (Ctllpin)

IlKOIMiistem viowJ wer hold with regard to anwnability 10 tJClltmertf j ~ng- 10 1lOI~ afJthort ca_ of Cllfort

casualties seen at a casualty clearing 8laHon F----- ~fom1llase at base hospitals Minor ualti

sucb as terror states never reached the base hospltal Gross nysterkal disorders often developed after transfer behind the firing line (Roussy and LHermiue Motl Schneider)

disorders such as elfort syndrome dys laquo rheumatism were orten misdiagnosed

frequently admitted to medical or other wards ~-Jaleif~er under the observation of psych imiddot

5 bullbull More neurOlCS lay in the medical wards than in psychiatric hospitalsmiddot (Culpin)

Fallacies arose [rom bull study o[ seleltted groups Olficera are said to be more often affected than men and in a different way (H Head~ Of the admissions to a British casualty cleann station over a period of thirteen montm there was one officer patient to every fourteen patients of other ranks whereas the actual proportion of officers to other ranks in combatant formations was about 1 in 30 ACCOrding to the official American history neurasthenia Wal five times as common in off)Cers 83 in men and bad so a len favourable prognosis as regards return to the front since only 25 per emt of the oflicers

~__ret~ed to duty compared with 61 per cent or the men

r~ii-----~~uaJ lieprivation anli lack of privacy led to bull blfbedshy

Less than a quarter of British officer patients gave a history of being buried or blown over by shells in contrast to one-balf of the other ranks Conversion hysteria was almost entirely confined to privates and NCOs and occurred for example only five times in 353 officers with psycholoSical di1lOrders_ 00 be olher hand the vast majority of patients with anxiety states were officen-o

The severely wounded hardly ever displayed neurotic ~~Mihiftsla(ions which orten dev~lop aftcr physical he~lth

has been restoroo According to some authors psycho neuroses are eXlremely rare amons war prisoners (Claude

MBrchen Wilmanns His) whereas others admitting the dlJe(ence trom symptoms wen in combatant ~()ldjcJs de$cribe a specific syndrome occurring in those conditions BonhBffer Vischer and others described how the confine~

_ ment and monotony of life in prison camps acccntuated

~ iiIS d~1~MThemiddot mam-syenmploms ~jncreascljrrUa-~L~~_J)ilitY inteme difficulty in concentration ilIlli

Failure of memory was frequcnt and nWlly ~howcli _depre~ion to Which the hench authors gl~ the name (ard

Prodr1 Signs

Neurotic synlplOOlS in wlr time somelimes appear quite suddenly but there arc IIMllHy prooj )nlal signs The most COJlIIHOn of thltse arc OJ fatigue C) increased indulshygence in alcohol or 10btuCo~ (3) a tendency to become tlOsocjable or irrittble (4) a loss of interest and disiruhna tion for effort and (5) emotional crisci-for example

crying fits or states of anxiety and terror Chamcter changes Were found The bellicose incitviduai OecolflC$

moody lhe solemn sullen talkative the clremiddotfree the wdl-bchacd takes to

in the rrodromal stale

of weariness and tenseo~ wjlh a restless desire for action or d~~tracti~ ofteD ~pani~ by irritabiliiY and diftic culty in concenirlmiddottori--aildmiddot a lendemy toStaTt- -atany sudden sound Allbouaht in contrast to ordinary fatigue the (eeling of weariness usually improved towards night there was greal difficulty in getting to sleep and a lona period of hypnagogic hallucinations in which lhe main events of the day appeared in troublesome visions When it did com 1IlP frltqucntly interrupted by bailiemiddot dreams When this situation had progressed for some time the soldier developed fear and horror of the sighlll around him and was unabJe to keep his mind away from the pouibility of injury PioUlily cquired judgrnent coocernina the drection of shells was lost and con sequently evcentry sheU seemed aimed at him pers-onany~ By this time there began the second prodromol pIwio charaltterized by the tear of failure to conceal anxiety which is known to be there Three practiea avenues of escape are then considered tbe soldier may receive an incapacitatin wounda he may be taken prisoner or be may be kiDed Torn belween (ear and tb fea of showbull ins fear neurotie officers in particular often display great courage and on the whole received more decorations lhan non~neurotlc oncs (Schneider) A stuporous state may ~onally usher in a neurosis Traumatic 19$$ of conshysclOusneu is followed by a period of contusion and delirium durms which consdousness is regained for short intervals On the other hand~ the prodromal bullbull functional stuporous state is one of a~ute terror with dilated pupils a cld sweat violent trembJing shallow breathing and inability to perform any voluntary movement It IS succeeded by a period -of contusion and amnesia during which voluntary movement is possible Myrs suggests that the ~IIlconsciousness whicb figllred so frequently in the histories of maoy patients may be idenUcal wiLb this stuporous slate

ConveJsiufl HYlI-eri-Although in conversion hysteria as in anIiety states fatigue was the initial symptom it was nearly always Jess severe Sleeplessness was infre

and nightmares were rare more common was a l ofC~ ~ousing an~ r~~~~t of the need to --i1umpln-ess--wasTcmiddotssmiddot prOntlUn-cea-anUmiddot-m~tiWas-

a relative absence ot the consciou mental canfhcUl hcwcen duty and ideals whih lOU suth ~ rrl1mill~nt rart in the prodromal anlcty ~Iate in ofiltcn I th 1 ocy

bull n c i of pracucall~ ~vcry h)~lcrllal taM cxammcd by l~d( u[Iy there W8$ elJClt~ the ~ope that they would be tn~apltlCl~ ttted from active serVIce h-y bemg wounded In cunmiddot sequence such on event as C(lOCUSSItIfl provilled 1he occasion for the development of definite symplOms Alternatively as with anxiety cases the infiillion of lttn actual wounlt did not pneipiluc hYiicrical symptom~ and these deveJoped later ouring convulescelKc aflcr a bullbull ad d 0 _

pcrt e e me Itatloo Charcot RoussYt 1 HermlHe Wm Brown)

Psy_tic Disorders

cO bull ~~ 0- Jalntionool by __ 1114 Da Coal In tho riCia (XVi) Warlaquomdi1iofCwumiddotofmI -seen dtiriftltt bullbull

taampt war e~ by a type of earoiac symptom without any ltAampturalmiddot1eaiot TfRDlI mentioning the heart (1OIdiermiddotheart irritable heart DAH) proved obvioullymiddot dan8trous ilnd It Is DOW qreed that they shOUld be replaced u Sir Thomal Lewis gaIed~ by tbe tafer and more accurate label of dfort ~raquo bull T1x upi6cance of the dhOrder will beraIiLiCI~ _-req_ 0lt1 IncapacitaU ell cOn~ No ~bIolutO Il_ of the llCide~cbullbull Cpsychltt neuEOlCl- Ii acncrat and of effort syndrome in partiCular are avllilable butmiddot 1ft 1I)I31S$3 Britith _ admllted to medical Units frOm 1916 1921 there wore 11408 co_ of fuOClionaI __ otmiddot tbe heart compared with 21~ of functJouJ disease of the oervOUI y~that is two of funcWol bout iii to lt11 three of fomctooat no dim_bull 329113 patient with functional Mn0IIl di admtled to A_n hospitals from April 1917 w May 1919 only 4)16 cua of OCU1OCirculatory 8S1henia were fOUDd tho __ beinC poibly due to the deetloD of recruits and the Ibottu period of active lervice Accordin to Britbb 1114 o-a oboervtioD8 (Lcwi Holmann I_b) only OM patteot in eVer) tcn admitted to eardillc hOlpitak suIIcred from 1lt heart disease

Jbe main f~re of dfwt syoorOJllO is an abnormal pbysic-shy1oaiaU _n to-elort-lgtratlIJeunes1 eaplaquoiaUy on rmiddot = =~m=~~n7= faiotin The aenise toktancc to5t shows an undue increase In pulse note aOltl a delayed retum to norma The blood ~ it aid ro DO aianifleut uriation About ~ hall of the casa 6epn in civiL Ufe under ~nditions wbere pbyaial strain wu UDimPOfl8l1t (Lewis Part1n50Dh and a furtbct 12 pc centenl duriila the period of traiDinamp (Lewis)

The QctioloaY of the ltondirion has been widely debated 11 has becn aUributed 10 heart ilrain infection IObaCCO~_1~ hyperthyroidism P poilOltJnin 1114middot sbcU shock

Altcordinl to Hunt soldier heart ia oaly QDe manitata dOD of the nervOU$ exhaustion or neuratithenia which tesulU from the eombincd effeltts of physical fatiampue mental eshaus lion and toutmia the toxaemia l1lO$t frequently bein of exoaenous oricin (baeterla or tobacco) and ratliy of endo-shyamp~I origin (endoaine secretions) L-wis dismisses heart

~ ~ pointiD~ _ progn(llIS In 80 pet eDt of ~s caSCIl1nfectlOU$ ~15Ca5eS had precedtd the onset of t~ dlso~der ni1hough 1t was onlyIn 30 rer cent that tbey lmmethalely preceded the Onset ~f $ymploms lk iIlreSbCf the frequency of the disorder m soldiers who previously followed $Cdentary occupations and in IIeI1sitivc luIOUJ highly strona or deprcsMd individuals His lToupmiddot of ease$ included an abnormally hiJh numbct of tcctotan~rs and 15 per cent bad morning spermatorrboea

Jn his view tbeni was no uniformity of aetiology and ~nsti ~0flamp1 weakness 0 retarded ~~V~lop~~ eJtpoSUn~ and

mfecho-n played Yaljln parts ~lmdar VUW8 were expreS-~by A Abrahams The psychiatriC effect of effort syndroma

III

was invutiptcd in more detail by Oppenheirner and Roh$dlild Cohn MacCurdy Culpln Th (nqUeDltY or a positive faAlily history or of facton prediSPOlUnj to psychoshyneurosis was stressed (Oppenheimer and Rothschild) Cohn and CUJpin independently ~phasized the psychological implicationa of certain features often found in t1Iort 5yndrorne pallenb such as tttmor of hand r6dy lweatlng disturbed sleep sbakiness on slilht ecitement ready starting and

~-a-netinrof deptcsaion lheF it AQ bttak in tJw Ktilaquo alnin these and otbcn in which a typtltal anxielY coexists with rapid pulampe shortness of breath precordiJl pain and occasiollli faintneSs and glddineu In short witb regard 10 many patients it is clinically J alter of inditTerence whether

I~ uc WjJhly middotraist to any forrn of treaknent (A)ID4I in_) ftIK of reebl pft)iquo whb __ middotciyenlImiddot tile iuditoly to im~ u_tty to maH ~ to1dien witiLtbiLt~pr~Odd (Hu1$t) Out of 55amp cues seen by Sir Thomas Lewts appr~ mately50 per cent were judaed to be unfit for any category of duty of the 239 who were fOllowed up only lhirty~nine returned tothe firing line in eleven tnonlhs These fiure$ do not correspond with thoampcent of tbe official history of the war in whKb it iI stated that of ll408 tiQ of fUnclional dtSCa$ll of the lIltart 11403 refinally disJgt9sed ltgtf byretum to duty Experience of the It of oYltematO PSY~9Oli1 treatment are not avaJlable

G _

~taDy limilar in structure but with a predominance of respiratory Iymptoma were PI neurol5iC$ Ulllion Roers Hulkrt) Gu neurosis was (0 the lunp whal effort IJDdrome ftl to the heartraquo AD epidernic of ps hysteria was described by the official hiltory of th~ A~rican Expeshyditionary For_ Following desultory ps shelling spread over eight days 500 men returned to one field hospilal as ps Qsualtia Tbe symptoms described were a fcelina of faiaue pain in the chat e1ibt dyspnoea COUghinl husky voice an atlOftmeDt of tinalin and bflmiDa senaaHona referred to the throat and IOIDC indefinite eye symptoms PhySical and neuroloPal examination was praerically negative As lhese men came from battJetelted troops it was reprded aa inconshyceivable that the wcte malitlJlaquoina MOre probably a number of facton acted toaer~ al that time to lower morale and reduce inhibition to to au where tNlnYutilized allyen suitable extrancol-S opportunity as a route to escape frorn an unshyduifable situafi9n Simple rea5sorance given and the palieata ltOIIYinc1nl1y wid tbat lhey would be able 10 return to duty on a OlUin day at some specified hour ~u~uentlY tJte ~mptoms were practically ignored and $triet military dhcipline was enforced Rapid recovery followed and the wave of f8ses ceased spontaneously at ~he end of eiSht days

00pi0Ic DIoodon willi a Iarp EmoI-I c-- Warfare gave a unique opportunity for studying certain

otpnic diMases in whkb emotional factors are aUeged to play a prominent part of primarily aettological and aggravating importance A review of the literature is disappointing Most authors unfortunately confine themshy~~_ to a statistical evaluation of certain organic disltgt eases in reJatIon ToemotitmaJ dIStill babtW atd nCJlutS diaorders

Alim~nfar1 Disordcrs-An lncr(a~ in ltyspepl-ia under the stress or warfare wa frequently nOled (Alhu Schmidt Sirnuss Romberg) Individuals- who suifeNd from simrlur disodet~ in peace time were panicularly attected One-half of the patient$ feU ill before they had ~n any front~iine serviC~ and a further onefhird developed symptoms during the first week in lbe firin line Constipation gastric hypersecretion vomiting and diarrhoea and pyloric spasm were commonly seen The personality type of lhe patients affected was definilely different from that in cardiac neuroses (KUllingtky) There was no conclusive evidence to suggest that peptic ulcer emeramped from the syndrome Most authors agreed that lhe incidence of ~ptic U1ccr during war was not higher than durina peace time but relaPH$ of peptic ulcer were repeatedly seen ill those who had suffered from it in peace lime Hi Frequent onset of stress-dyspepsia or peptic ulcer on demoHi~ uuon has been noted (Da ies and Wilson)

Diabets Diabttes was a rare conditton among wldcrs

bull There were only two dIabetiCs lIt ~6~ Ictcd tH~iIAl-----lOidien (Joslin) Strauss found the IJlcld~nee In war ho~pllaa to be 03 per U)OO as compared With 12 per 1000 m clI(llian bospitals A pre-Gistlng diabetes may be aggravated accofd~

I 2ti4 F 17 19040 THI FORGOtTEN SWAB shywmcuOU1

Early in the operatton (m openins made in the peritoneum that an -amination of the fundus is in many cases the was rrom)I) dosed hut only afler sW~lh btd bc~n best jJuiltk to mediad dIagnoSIS they should know that

~lHoycd When the operation was to be completed a certajn eye drops certain lotions which a clever publiCity swab was nlissed The pentoncum was opened apin showers on them are undoubtedly harmless but that in search of it but it laquoouJd not be found The pahent much precious time is 1011 when they are used in certalll died and at the post-mortem exanUaatioD the swab eye diSeases Amon the other contenls there ia an wu found bdtind the petitCtnCtUD to the left of the interesting ~rti~ on oph~~dm~a neo~orulD in the Near_ middle line whereas the pyOllqlbtooi boltI boon I~- East by Dr 8 DeTanoe- Slie confirms the rarity of th ~1de In a third case bat of a woman ased 40 disease in these reampfoos and gives some explanation of thia operated on for a large fibroma of the uterus the Iwabs -were counted belore and after the operation and the numbers Ullhed About ampj~ months alet the patient

tcturncd with a swelling at the leyel of tbC umbHicus from fever and pain An iocisioo yielded a

__ 1llltJYal wa followed by rtOOCpoundy Menshy-middot-tM Patient had been obliged to dose her little mop

tt iii ycar Waa the to be told Dr Fenaer con a lawyer who counselled honesty as 1M best poticy

When tokl the truth the patient WtlS overjoyed for she had suspected mali31lant disease as the indication for the second operation She assessed her economic loss at kr 600 which were paid by an insurance company_ delighted to get oft so cbeaply After referrinl to yet other cases in his perSoOllal experience Dr Fenger challenged tbe opinion common with doctors as well as with the public lhat this accident always justifies a verdict of negligence against the surgeon He also -referred to the investigation set on foot in Germany by Gulcke who sounded ninety university surgical hospitals on the subject and obtained answers from sixty Only five of these sixty protested their compiete innocence ( yoUjge FehJer freiheit but as it happened Gulde knew that one at least of these five did not have a blaIDCless record in this respcct He concluded that this accident may be

anticipated once in every 2000 to 5000 operations Dr Fengers dry comment on this calculation is that In Denmark alone over 100000 operations are performed annWllly A sirupie essuy in arithmltic and one can cal~

~_tUlate to a nicet) how many Danes acquire forgotten swabs in any given year

SXLL OPHYHALMOL06Y ~-~-~~- nte first number of the third volume of the JouFIlal of

OphliUJlmlJY well maintains the high standard jOliS issues and again 1hc publialion is issued

III ~~l~Lfn~mh and -Englidll The first paper is by the -i-c_--prcsident of the International ASM)(lalion for thl PIfshy

vention of Blindot--1 Dr P ~amiart He give an ouf~ hne (~r a pi llgrilnllnc for the b6h in ciVil life IOU in Ir

---oT)phlhalnw]ogi-ls of 1IumiddotrtI practiloll~rs and of ublicent authorilics A pamgrIIJh in the sCltion regarding the work tlf gencral prrutilinncrs is well worthy of QU(liatiun He wrih~ bull Whilc ev in ctuntries where there are

----~-m-an) ophlhalmoJoJi it i 011( thlt- gencral practilion~r who is first consuitlll by ihc pllicnl with a diseased eye or a failing eyesight Ihlre are ilill countries where owing to the absence of spcialisl the p~titnts have 10 apply to the general praliuoner 1ft most cases owing to the

I crnnmQn sense of th~)C Ilh)ojcians cat31OIrophes are avoided yet they should have 11 minimum acquainlane

------~-middot---witb ophthtlmological facls with our recenl discoveries tney should know for insllt1ncc that lo-day detachment

NlHE BIRD OF 4 B4BY

The spon of this film presented by tIu National BabY-shyWelfiie coUncii~ emphasize that it can in no way be regarded as entertainment hut that it opens up a new and powerful medium for aduh education The main theme is the ante-nalal care and confinement at home of an American primipara Her mOfher~in~law and her imshymensely impressive doctor seize opportunities in response to questions to deliver short lectures well iIIustral~-d on reproductive physiology and the dangers Whhh be1 Ihe parlurient The drama reaches climax in a quiet and easy delivery under anaesthesia The Ucst shot of the picture is a close-up of the baby immediately after delivery lying inert nd motionless except for the pulsa tions of hs cord till suddenly and amazingly it scream its expostulation Tbis is entertainment pure and simple and always will he A weU-dclivered commentary at the beginnini of the piclure warns us of differencu between American and English obstetric lechnique but it was surprising to find complete omission of any hint that the p1acenta remained to be delivered after the baby Pnnllel with the main story the dat1y life of -the doctor is used to iUustrate incidents of obstetric interest-the (lSC of rre~eclampsia the rich lady seekins to escape maternity and t~ inconsiderate husband The whole )(tting of the film is opulent and perhaps will convey an impression of uURahly to the majority of molben in this COUOlry The actin and the accent are best American In spito of this the educative vaJue of the film is high~ Some Ioho attend this film may expect in~cncy and the manifod and unnecessary restrictions of the licensin authorities may encourage visitations from the prurient but there is nothins here that would shock even a congregation of churcbwardens

Wc regret 10 announce the dlth (If Sir Willilm Hodgson la clailnlan of Ihe (hcgtllirl unly IIHlhil

and Ior si YCtflt d nhUlhr I~r lilt I~~ tant ~t- ( jll~ miucente of lh Britlgth MttJjtal Aplalion t also or Dr H OtmpbeU Thomson consulllllg physician 10 inc departshyment for nervous diseases gtrnd emeritus klnrer in ncurology Middtesex HOSPlltll~ and formcdy dCUl of ~lle medical school

Sir Farquhar Buzlard regius professor of medicine in the University of Oxford is one of the twc)e trustees appoin1ed hy Lord NufficJd to be rCllponsihle for the administration of his trust rtlt the provindal huspitals (Sec Jurnal December 9 1939 p 1148)

~~e r~tina i~ curtbi~ Ihllt ghHl~orna IS a trcachbullfous Dr A J OrynsteJn fnmrlj_cbief~-~ritoshyand mSldlOUS dl~asc tha~ _~~~~~Il_~m9Jlrswhl~-llUY middotC01lifoCampardmiddotmiddotand--Oi~i author of M05quita Control in

iliiwly the eyC and may he curable Panama has ben relppointed Direclor~Gencral of the c Socil ()p4tlun 66 lJQuievar4 SriotNiIlWI tit Union of South Africa defcnce medical servicC8

~~ ~ t

N1UROSlS IN WAR ~u 26S

MEDICAL PROBLEMS IN WAR TlUs U 1114 cimd Of 1M artclu sltyl1ll the lilnatu of lIlturosu I

--NEUROSES-IN wAIf 1ft

F WnTKOWER MD PiJ)5kian (JM Hollf7 5Ie R~$e(clt F~low

lltft Toysoc Clink Londoll - I P SPILlANE BSc MB BOo DPM

RfJbullAele1kr Res~mclt Fftlow lite Tovinoct Clink

Ps)dIopodlology

1hree oats of thousbl can be clilCelaood amltlIIg tho numerous aetioJogical views advanced in the literature of the last war They 8llributed war neuroses to (I) anatomical lesions of the nervous system- (2) inborn biological and psychological inferiority-the psychopathic constitution and (3) psychologita reactions to war experiences in individuals previously sensitized to erno-shytional disturbances sub~idy similar although objectively different in tbeir naiure

Early writers on the subjeet noted tho purposive natur~ of many of the neurodt symptoms of soldiers but failed to differentiate between consciou~ preconscious and unshyconscious aims No distinction was made between malingerjng and hysteria and the patients were treated accordingly Authors of that period stre9sed the desire for removal from the fremt line and tbe wish for material compensation as ulterior motives of neurotic manifestashylions The absence of neurosis in severeJy wounded and war prisoners wal noted and was interpreted in the xnse that middotin both caaes a U flight into illness middotwu ttO longer ncedeci u the aim of removal from aeute danger was already attained Terms like neuroses of covetousness and defence and protection neuroses were coined To other observers the desire for gain wal of minor actioshylogical importance but came into action once the neurosIs was established In their view the neurosis itself originated

conflict one

middotmiddot-exampI A bey------ the light of a mangled body of a comrade win arouse horror in anyonC~ but will provoke a disproportionate reaction in individuals in whom there are preltXistent unrecognized conOiets onr vioJmce and aaaresslveness During peace time many such individuals were able by subIimatiOOJ reacdOD formation or environmental manipulation to avoid situation Ukely to provoke their own alampresaive impulses During war on the other hand f not only was the generat taboo on violCnce diminished bUl they were forced by military service into

bullituadons wbich would inevitably have stimulated their aggreuivenest and have provoked anxiety This anxiety i a signal of a threatened breakdown of defences againstmiddot aggressive impulses If further Jlimulatlon of aggressive impulsel took place a complete breakdown ensued

Psytho-anaJytic writers describe in neuroses of war a basit personality tructure characterized by- $ejf~centredshyness over--conscientiousness lack of sociability and lact of affection for relatives and friends Such individuals iutter from a feelinl that their per$OIlality has been neglected aDd that their importance is not 8ufficiently recognized Many of these mea were unable to carry out their tub in practical life othen capable of doing this sbowed little initiative or BY (Abniliam) This group often revealed an effeminatt dispos~tion were dependent on their wives and frequently were akly potent Life in the trenches exposedmiddot them to a danger of death which constituted amiddot threat to their Cxcessive se)fmiddotove Community life ran counter to their asocial tendencies and the unconditionaldemand for self-sacrifice in war caflCd for a renunciation of narciS$isttt priviTeges More so than othen individuals of thia type-middot were prone~ to confticts about aggressiveness~ and through ther latent homosexual tendencies the exclusive association with men constituted a special stress Under such stresses these individuals increasingly regressed to a narcissistic IcyCl of development leading to a state of infantile helplCSsness with a complete surrender to their suffering and a need to be pam~Ll~lLQr_aruLpe1led like oIIi1d - Iltlt-shy ~ wliliOriWif of )bject libido (diminished capacity for Cxterna interests and emotional ties results in an inRation of ego libido (setf~centredness) which is erresied in abnormlil hypochi1ndriacai sensations and a further diminution of genital potency_

S)ll1Promotoiogy

To say thlll the psychological structure of the war neurltnes does not diller (rom that of traumatic neurogtes in peace lime implies that despite the speciftc colooring given by the secial clrcumstanc~ of onset there is no fundamental difference in the symptomatotosy of hcse neurOses A description of such ~yndrome as simple terror) anXiety ~tes conversion hysteria including stupor statesand obsessional states i5 given elsewherC A few points of spetial interestmiddot emerge from a study of the literature

experiences on the other With regard to the initilting tcrrifying experience it was sugg~lcd Ihat durin [he lfaniLOry disturbance of ((nSCiousn(~1O 011 I pncding the onMt of the neurotic dissociation phenomena a splitting oft of the affect from ideational content look pla~t resulting in fixatienl or ps)~honutotjc symptoms ~ BonhlHfer) In military neuroses thc display o( helplessness the need for care and in some gross cases childish behaviour and speecb were taken as si~ns of a reactwtion or defence mechanisms of infantile pitttem (Gaupp and Schmidt) The5e findings recorded by psychiatrists laDy with those of psychoshyanalysts (Jones Abraham Eder Fercnczi Simme1) and uuthors with allied views (Crichton-Miller Hadfield Nicalle They acknowicdt the vulitioDal nature of ~)Ptoms in both dilinn nnd military neurosis but ilrate such almost Ionscioumiddot motives as removal from danger llnd craving for sympathy from those which are

variation in the nature and incidence of the nCuroses This may be due to the personalities of the observers the places of

siooto infantile patterns of behaviour Deep conflicts o~rvation and the variabi1ity of Ihe materiaL Gukkd over unrecognized sadistic i~~_1~__a_~0_~~~e~-~-~-~~~ ~heir pcacc-til1le training and tbeirmiddot-~middot~1merest

w~~ (~~) ~1

I

NEUROSES IN WAR

f shy ~ ~~ ~y -~~ ~~~~J d~poundUllOSlll ~J h

~g- 167

reported syndromes which as in the Caioe H reflex disordersmiddotmiddot were rarely seen by

Aluiety SUlus-The first sign was a (eeling of fatiaue abnormal in ill capricious Ililture Bnd therdore inter reted abullbull form of anxiety There was also a felina

lMY boOk be ptced under one hcadinl or lother Oir orrcd lKuoa 0 he heclrl ito most often a neurosis bullbull (Ctllpin)

IlKOIMiistem viowJ wer hold with regard to anwnability 10 tJClltmertf j ~ng- 10 1lOI~ afJthort ca_ of Cllfort

casualties seen at a casualty clearing 8laHon F----- ~fom1llase at base hospitals Minor ualti

sucb as terror states never reached the base hospltal Gross nysterkal disorders often developed after transfer behind the firing line (Roussy and LHermiue Motl Schneider)

disorders such as elfort syndrome dys laquo rheumatism were orten misdiagnosed

frequently admitted to medical or other wards ~-Jaleif~er under the observation of psych imiddot

5 bullbull More neurOlCS lay in the medical wards than in psychiatric hospitalsmiddot (Culpin)

Fallacies arose [rom bull study o[ seleltted groups Olficera are said to be more often affected than men and in a different way (H Head~ Of the admissions to a British casualty cleann station over a period of thirteen montm there was one officer patient to every fourteen patients of other ranks whereas the actual proportion of officers to other ranks in combatant formations was about 1 in 30 ACCOrding to the official American history neurasthenia Wal five times as common in off)Cers 83 in men and bad so a len favourable prognosis as regards return to the front since only 25 per emt of the oflicers

~__ret~ed to duty compared with 61 per cent or the men

r~ii-----~~uaJ lieprivation anli lack of privacy led to bull blfbedshy

Less than a quarter of British officer patients gave a history of being buried or blown over by shells in contrast to one-balf of the other ranks Conversion hysteria was almost entirely confined to privates and NCOs and occurred for example only five times in 353 officers with psycholoSical di1lOrders_ 00 be olher hand the vast majority of patients with anxiety states were officen-o

The severely wounded hardly ever displayed neurotic ~~Mihiftsla(ions which orten dev~lop aftcr physical he~lth

has been restoroo According to some authors psycho neuroses are eXlremely rare amons war prisoners (Claude

MBrchen Wilmanns His) whereas others admitting the dlJe(ence trom symptoms wen in combatant ~()ldjcJs de$cribe a specific syndrome occurring in those conditions BonhBffer Vischer and others described how the confine~

_ ment and monotony of life in prison camps acccntuated

~ iiIS d~1~MThemiddot mam-syenmploms ~jncreascljrrUa-~L~~_J)ilitY inteme difficulty in concentration ilIlli

Failure of memory was frequcnt and nWlly ~howcli _depre~ion to Which the hench authors gl~ the name (ard

Prodr1 Signs

Neurotic synlplOOlS in wlr time somelimes appear quite suddenly but there arc IIMllHy prooj )nlal signs The most COJlIIHOn of thltse arc OJ fatigue C) increased indulshygence in alcohol or 10btuCo~ (3) a tendency to become tlOsocjable or irrittble (4) a loss of interest and disiruhna tion for effort and (5) emotional crisci-for example

crying fits or states of anxiety and terror Chamcter changes Were found The bellicose incitviduai OecolflC$

moody lhe solemn sullen talkative the clremiddotfree the wdl-bchacd takes to

in the rrodromal stale

of weariness and tenseo~ wjlh a restless desire for action or d~~tracti~ ofteD ~pani~ by irritabiliiY and diftic culty in concenirlmiddottori--aildmiddot a lendemy toStaTt- -atany sudden sound Allbouaht in contrast to ordinary fatigue the (eeling of weariness usually improved towards night there was greal difficulty in getting to sleep and a lona period of hypnagogic hallucinations in which lhe main events of the day appeared in troublesome visions When it did com 1IlP frltqucntly interrupted by bailiemiddot dreams When this situation had progressed for some time the soldier developed fear and horror of the sighlll around him and was unabJe to keep his mind away from the pouibility of injury PioUlily cquired judgrnent coocernina the drection of shells was lost and con sequently evcentry sheU seemed aimed at him pers-onany~ By this time there began the second prodromol pIwio charaltterized by the tear of failure to conceal anxiety which is known to be there Three practiea avenues of escape are then considered tbe soldier may receive an incapacitatin wounda he may be taken prisoner or be may be kiDed Torn belween (ear and tb fea of showbull ins fear neurotie officers in particular often display great courage and on the whole received more decorations lhan non~neurotlc oncs (Schneider) A stuporous state may ~onally usher in a neurosis Traumatic 19$$ of conshysclOusneu is followed by a period of contusion and delirium durms which consdousness is regained for short intervals On the other hand~ the prodromal bullbull functional stuporous state is one of a~ute terror with dilated pupils a cld sweat violent trembJing shallow breathing and inability to perform any voluntary movement It IS succeeded by a period -of contusion and amnesia during which voluntary movement is possible Myrs suggests that the ~IIlconsciousness whicb figllred so frequently in the histories of maoy patients may be idenUcal wiLb this stuporous slate

ConveJsiufl HYlI-eri-Although in conversion hysteria as in anIiety states fatigue was the initial symptom it was nearly always Jess severe Sleeplessness was infre

and nightmares were rare more common was a l ofC~ ~ousing an~ r~~~~t of the need to --i1umpln-ess--wasTcmiddotssmiddot prOntlUn-cea-anUmiddot-m~tiWas-

a relative absence ot the consciou mental canfhcUl hcwcen duty and ideals whih lOU suth ~ rrl1mill~nt rart in the prodromal anlcty ~Iate in ofiltcn I th 1 ocy

bull n c i of pracucall~ ~vcry h)~lcrllal taM cxammcd by l~d( u[Iy there W8$ elJClt~ the ~ope that they would be tn~apltlCl~ ttted from active serVIce h-y bemg wounded In cunmiddot sequence such on event as C(lOCUSSItIfl provilled 1he occasion for the development of definite symplOms Alternatively as with anxiety cases the infiillion of lttn actual wounlt did not pneipiluc hYiicrical symptom~ and these deveJoped later ouring convulescelKc aflcr a bullbull ad d 0 _

pcrt e e me Itatloo Charcot RoussYt 1 HermlHe Wm Brown)

Psy_tic Disorders

cO bull ~~ 0- Jalntionool by __ 1114 Da Coal In tho riCia (XVi) Warlaquomdi1iofCwumiddotofmI -seen dtiriftltt bullbull

taampt war e~ by a type of earoiac symptom without any ltAampturalmiddot1eaiot TfRDlI mentioning the heart (1OIdiermiddotheart irritable heart DAH) proved obvioullymiddot dan8trous ilnd It Is DOW qreed that they shOUld be replaced u Sir Thomal Lewis gaIed~ by tbe tafer and more accurate label of dfort ~raquo bull T1x upi6cance of the dhOrder will beraIiLiCI~ _-req_ 0lt1 IncapacitaU ell cOn~ No ~bIolutO Il_ of the llCide~cbullbull Cpsychltt neuEOlCl- Ii acncrat and of effort syndrome in partiCular are avllilable butmiddot 1ft 1I)I31S$3 Britith _ admllted to medical Units frOm 1916 1921 there wore 11408 co_ of fuOClionaI __ otmiddot tbe heart compared with 21~ of functJouJ disease of the oervOUI y~that is two of funcWol bout iii to lt11 three of fomctooat no dim_bull 329113 patient with functional Mn0IIl di admtled to A_n hospitals from April 1917 w May 1919 only 4)16 cua of OCU1OCirculatory 8S1henia were fOUDd tho __ beinC poibly due to the deetloD of recruits and the Ibottu period of active lervice Accordin to Britbb 1114 o-a oboervtioD8 (Lcwi Holmann I_b) only OM patteot in eVer) tcn admitted to eardillc hOlpitak suIIcred from 1lt heart disease

Jbe main f~re of dfwt syoorOJllO is an abnormal pbysic-shy1oaiaU _n to-elort-lgtratlIJeunes1 eaplaquoiaUy on rmiddot = =~m=~~n7= faiotin The aenise toktancc to5t shows an undue increase In pulse note aOltl a delayed retum to norma The blood ~ it aid ro DO aianifleut uriation About ~ hall of the casa 6epn in civiL Ufe under ~nditions wbere pbyaial strain wu UDimPOfl8l1t (Lewis Part1n50Dh and a furtbct 12 pc centenl duriila the period of traiDinamp (Lewis)

The QctioloaY of the ltondirion has been widely debated 11 has becn aUributed 10 heart ilrain infection IObaCCO~_1~ hyperthyroidism P poilOltJnin 1114middot sbcU shock

Altcordinl to Hunt soldier heart ia oaly QDe manitata dOD of the nervOU$ exhaustion or neuratithenia which tesulU from the eombincd effeltts of physical fatiampue mental eshaus lion and toutmia the toxaemia l1lO$t frequently bein of exoaenous oricin (baeterla or tobacco) and ratliy of endo-shyamp~I origin (endoaine secretions) L-wis dismisses heart

~ ~ pointiD~ _ progn(llIS In 80 pet eDt of ~s caSCIl1nfectlOU$ ~15Ca5eS had precedtd the onset of t~ dlso~der ni1hough 1t was onlyIn 30 rer cent that tbey lmmethalely preceded the Onset ~f $ymploms lk iIlreSbCf the frequency of the disorder m soldiers who previously followed $Cdentary occupations and in IIeI1sitivc luIOUJ highly strona or deprcsMd individuals His lToupmiddot of ease$ included an abnormally hiJh numbct of tcctotan~rs and 15 per cent bad morning spermatorrboea

Jn his view tbeni was no uniformity of aetiology and ~nsti ~0flamp1 weakness 0 retarded ~~V~lop~~ eJtpoSUn~ and

mfecho-n played Yaljln parts ~lmdar VUW8 were expreS-~by A Abrahams The psychiatriC effect of effort syndroma

III

was invutiptcd in more detail by Oppenheirner and Roh$dlild Cohn MacCurdy Culpln Th (nqUeDltY or a positive faAlily history or of facton prediSPOlUnj to psychoshyneurosis was stressed (Oppenheimer and Rothschild) Cohn and CUJpin independently ~phasized the psychological implicationa of certain features often found in t1Iort 5yndrorne pallenb such as tttmor of hand r6dy lweatlng disturbed sleep sbakiness on slilht ecitement ready starting and

~-a-netinrof deptcsaion lheF it AQ bttak in tJw Ktilaquo alnin these and otbcn in which a typtltal anxielY coexists with rapid pulampe shortness of breath precordiJl pain and occasiollli faintneSs and glddineu In short witb regard 10 many patients it is clinically J alter of inditTerence whether

I~ uc WjJhly middotraist to any forrn of treaknent (A)ID4I in_) ftIK of reebl pft)iquo whb __ middotciyenlImiddot tile iuditoly to im~ u_tty to maH ~ to1dien witiLtbiLt~pr~Odd (Hu1$t) Out of 55amp cues seen by Sir Thomas Lewts appr~ mately50 per cent were judaed to be unfit for any category of duty of the 239 who were fOllowed up only lhirty~nine returned tothe firing line in eleven tnonlhs These fiure$ do not correspond with thoampcent of tbe official history of the war in whKb it iI stated that of ll408 tiQ of fUnclional dtSCa$ll of the lIltart 11403 refinally disJgt9sed ltgtf byretum to duty Experience of the It of oYltematO PSY~9Oli1 treatment are not avaJlable

G _

~taDy limilar in structure but with a predominance of respiratory Iymptoma were PI neurol5iC$ Ulllion Roers Hulkrt) Gu neurosis was (0 the lunp whal effort IJDdrome ftl to the heartraquo AD epidernic of ps hysteria was described by the official hiltory of th~ A~rican Expeshyditionary For_ Following desultory ps shelling spread over eight days 500 men returned to one field hospilal as ps Qsualtia Tbe symptoms described were a fcelina of faiaue pain in the chat e1ibt dyspnoea COUghinl husky voice an atlOftmeDt of tinalin and bflmiDa senaaHona referred to the throat and IOIDC indefinite eye symptoms PhySical and neuroloPal examination was praerically negative As lhese men came from battJetelted troops it was reprded aa inconshyceivable that the wcte malitlJlaquoina MOre probably a number of facton acted toaer~ al that time to lower morale and reduce inhibition to to au where tNlnYutilized allyen suitable extrancol-S opportunity as a route to escape frorn an unshyduifable situafi9n Simple rea5sorance given and the palieata ltOIIYinc1nl1y wid tbat lhey would be able 10 return to duty on a OlUin day at some specified hour ~u~uentlY tJte ~mptoms were practically ignored and $triet military dhcipline was enforced Rapid recovery followed and the wave of f8ses ceased spontaneously at ~he end of eiSht days

00pi0Ic DIoodon willi a Iarp EmoI-I c-- Warfare gave a unique opportunity for studying certain

otpnic diMases in whkb emotional factors are aUeged to play a prominent part of primarily aettological and aggravating importance A review of the literature is disappointing Most authors unfortunately confine themshy~~_ to a statistical evaluation of certain organic disltgt eases in reJatIon ToemotitmaJ dIStill babtW atd nCJlutS diaorders

Alim~nfar1 Disordcrs-An lncr(a~ in ltyspepl-ia under the stress or warfare wa frequently nOled (Alhu Schmidt Sirnuss Romberg) Individuals- who suifeNd from simrlur disodet~ in peace time were panicularly attected One-half of the patient$ feU ill before they had ~n any front~iine serviC~ and a further onefhird developed symptoms during the first week in lbe firin line Constipation gastric hypersecretion vomiting and diarrhoea and pyloric spasm were commonly seen The personality type of lhe patients affected was definilely different from that in cardiac neuroses (KUllingtky) There was no conclusive evidence to suggest that peptic ulcer emeramped from the syndrome Most authors agreed that lhe incidence of ~ptic U1ccr during war was not higher than durina peace time but relaPH$ of peptic ulcer were repeatedly seen ill those who had suffered from it in peace lime Hi Frequent onset of stress-dyspepsia or peptic ulcer on demoHi~ uuon has been noted (Da ies and Wilson)

Diabets Diabttes was a rare conditton among wldcrs

bull There were only two dIabetiCs lIt ~6~ Ictcd tH~iIAl-----lOidien (Joslin) Strauss found the IJlcld~nee In war ho~pllaa to be 03 per U)OO as compared With 12 per 1000 m clI(llian bospitals A pre-Gistlng diabetes may be aggravated accofd~

I

NEUROSES IN WAR

f shy ~ ~~ ~y -~~ ~~~~J d~poundUllOSlll ~J h

~g- 167

reported syndromes which as in the Caioe H reflex disordersmiddotmiddot were rarely seen by

Aluiety SUlus-The first sign was a (eeling of fatiaue abnormal in ill capricious Ililture Bnd therdore inter reted abullbull form of anxiety There was also a felina

lMY boOk be ptced under one hcadinl or lother Oir orrcd lKuoa 0 he heclrl ito most often a neurosis bullbull (Ctllpin)

IlKOIMiistem viowJ wer hold with regard to anwnability 10 tJClltmertf j ~ng- 10 1lOI~ afJthort ca_ of Cllfort

casualties seen at a casualty clearing 8laHon F----- ~fom1llase at base hospitals Minor ualti

sucb as terror states never reached the base hospltal Gross nysterkal disorders often developed after transfer behind the firing line (Roussy and LHermiue Motl Schneider)

disorders such as elfort syndrome dys laquo rheumatism were orten misdiagnosed

frequently admitted to medical or other wards ~-Jaleif~er under the observation of psych imiddot

5 bullbull More neurOlCS lay in the medical wards than in psychiatric hospitalsmiddot (Culpin)

Fallacies arose [rom bull study o[ seleltted groups Olficera are said to be more often affected than men and in a different way (H Head~ Of the admissions to a British casualty cleann station over a period of thirteen montm there was one officer patient to every fourteen patients of other ranks whereas the actual proportion of officers to other ranks in combatant formations was about 1 in 30 ACCOrding to the official American history neurasthenia Wal five times as common in off)Cers 83 in men and bad so a len favourable prognosis as regards return to the front since only 25 per emt of the oflicers

~__ret~ed to duty compared with 61 per cent or the men

r~ii-----~~uaJ lieprivation anli lack of privacy led to bull blfbedshy

Less than a quarter of British officer patients gave a history of being buried or blown over by shells in contrast to one-balf of the other ranks Conversion hysteria was almost entirely confined to privates and NCOs and occurred for example only five times in 353 officers with psycholoSical di1lOrders_ 00 be olher hand the vast majority of patients with anxiety states were officen-o

The severely wounded hardly ever displayed neurotic ~~Mihiftsla(ions which orten dev~lop aftcr physical he~lth

has been restoroo According to some authors psycho neuroses are eXlremely rare amons war prisoners (Claude

MBrchen Wilmanns His) whereas others admitting the dlJe(ence trom symptoms wen in combatant ~()ldjcJs de$cribe a specific syndrome occurring in those conditions BonhBffer Vischer and others described how the confine~

_ ment and monotony of life in prison camps acccntuated

~ iiIS d~1~MThemiddot mam-syenmploms ~jncreascljrrUa-~L~~_J)ilitY inteme difficulty in concentration ilIlli

Failure of memory was frequcnt and nWlly ~howcli _depre~ion to Which the hench authors gl~ the name (ard

Prodr1 Signs

Neurotic synlplOOlS in wlr time somelimes appear quite suddenly but there arc IIMllHy prooj )nlal signs The most COJlIIHOn of thltse arc OJ fatigue C) increased indulshygence in alcohol or 10btuCo~ (3) a tendency to become tlOsocjable or irrittble (4) a loss of interest and disiruhna tion for effort and (5) emotional crisci-for example

crying fits or states of anxiety and terror Chamcter changes Were found The bellicose incitviduai OecolflC$

moody lhe solemn sullen talkative the clremiddotfree the wdl-bchacd takes to

in the rrodromal stale

of weariness and tenseo~ wjlh a restless desire for action or d~~tracti~ ofteD ~pani~ by irritabiliiY and diftic culty in concenirlmiddottori--aildmiddot a lendemy toStaTt- -atany sudden sound Allbouaht in contrast to ordinary fatigue the (eeling of weariness usually improved towards night there was greal difficulty in getting to sleep and a lona period of hypnagogic hallucinations in which lhe main events of the day appeared in troublesome visions When it did com 1IlP frltqucntly interrupted by bailiemiddot dreams When this situation had progressed for some time the soldier developed fear and horror of the sighlll around him and was unabJe to keep his mind away from the pouibility of injury PioUlily cquired judgrnent coocernina the drection of shells was lost and con sequently evcentry sheU seemed aimed at him pers-onany~ By this time there began the second prodromol pIwio charaltterized by the tear of failure to conceal anxiety which is known to be there Three practiea avenues of escape are then considered tbe soldier may receive an incapacitatin wounda he may be taken prisoner or be may be kiDed Torn belween (ear and tb fea of showbull ins fear neurotie officers in particular often display great courage and on the whole received more decorations lhan non~neurotlc oncs (Schneider) A stuporous state may ~onally usher in a neurosis Traumatic 19$$ of conshysclOusneu is followed by a period of contusion and delirium durms which consdousness is regained for short intervals On the other hand~ the prodromal bullbull functional stuporous state is one of a~ute terror with dilated pupils a cld sweat violent trembJing shallow breathing and inability to perform any voluntary movement It IS succeeded by a period -of contusion and amnesia during which voluntary movement is possible Myrs suggests that the ~IIlconsciousness whicb figllred so frequently in the histories of maoy patients may be idenUcal wiLb this stuporous slate

ConveJsiufl HYlI-eri-Although in conversion hysteria as in anIiety states fatigue was the initial symptom it was nearly always Jess severe Sleeplessness was infre

and nightmares were rare more common was a l ofC~ ~ousing an~ r~~~~t of the need to --i1umpln-ess--wasTcmiddotssmiddot prOntlUn-cea-anUmiddot-m~tiWas-

a relative absence ot the consciou mental canfhcUl hcwcen duty and ideals whih lOU suth ~ rrl1mill~nt rart in the prodromal anlcty ~Iate in ofiltcn I th 1 ocy

bull n c i of pracucall~ ~vcry h)~lcrllal taM cxammcd by l~d( u[Iy there W8$ elJClt~ the ~ope that they would be tn~apltlCl~ ttted from active serVIce h-y bemg wounded In cunmiddot sequence such on event as C(lOCUSSItIfl provilled 1he occasion for the development of definite symplOms Alternatively as with anxiety cases the infiillion of lttn actual wounlt did not pneipiluc hYiicrical symptom~ and these deveJoped later ouring convulescelKc aflcr a bullbull ad d 0 _

pcrt e e me Itatloo Charcot RoussYt 1 HermlHe Wm Brown)

Psy_tic Disorders

cO bull ~~ 0- Jalntionool by __ 1114 Da Coal In tho riCia (XVi) Warlaquomdi1iofCwumiddotofmI -seen dtiriftltt bullbull

taampt war e~ by a type of earoiac symptom without any ltAampturalmiddot1eaiot TfRDlI mentioning the heart (1OIdiermiddotheart irritable heart DAH) proved obvioullymiddot dan8trous ilnd It Is DOW qreed that they shOUld be replaced u Sir Thomal Lewis gaIed~ by tbe tafer and more accurate label of dfort ~raquo bull T1x upi6cance of the dhOrder will beraIiLiCI~ _-req_ 0lt1 IncapacitaU ell cOn~ No ~bIolutO Il_ of the llCide~cbullbull Cpsychltt neuEOlCl- Ii acncrat and of effort syndrome in partiCular are avllilable butmiddot 1ft 1I)I31S$3 Britith _ admllted to medical Units frOm 1916 1921 there wore 11408 co_ of fuOClionaI __ otmiddot tbe heart compared with 21~ of functJouJ disease of the oervOUI y~that is two of funcWol bout iii to lt11 three of fomctooat no dim_bull 329113 patient with functional Mn0IIl di admtled to A_n hospitals from April 1917 w May 1919 only 4)16 cua of OCU1OCirculatory 8S1henia were fOUDd tho __ beinC poibly due to the deetloD of recruits and the Ibottu period of active lervice Accordin to Britbb 1114 o-a oboervtioD8 (Lcwi Holmann I_b) only OM patteot in eVer) tcn admitted to eardillc hOlpitak suIIcred from 1lt heart disease

Jbe main f~re of dfwt syoorOJllO is an abnormal pbysic-shy1oaiaU _n to-elort-lgtratlIJeunes1 eaplaquoiaUy on rmiddot = =~m=~~n7= faiotin The aenise toktancc to5t shows an undue increase In pulse note aOltl a delayed retum to norma The blood ~ it aid ro DO aianifleut uriation About ~ hall of the casa 6epn in civiL Ufe under ~nditions wbere pbyaial strain wu UDimPOfl8l1t (Lewis Part1n50Dh and a furtbct 12 pc centenl duriila the period of traiDinamp (Lewis)

The QctioloaY of the ltondirion has been widely debated 11 has becn aUributed 10 heart ilrain infection IObaCCO~_1~ hyperthyroidism P poilOltJnin 1114middot sbcU shock

Altcordinl to Hunt soldier heart ia oaly QDe manitata dOD of the nervOU$ exhaustion or neuratithenia which tesulU from the eombincd effeltts of physical fatiampue mental eshaus lion and toutmia the toxaemia l1lO$t frequently bein of exoaenous oricin (baeterla or tobacco) and ratliy of endo-shyamp~I origin (endoaine secretions) L-wis dismisses heart

~ ~ pointiD~ _ progn(llIS In 80 pet eDt of ~s caSCIl1nfectlOU$ ~15Ca5eS had precedtd the onset of t~ dlso~der ni1hough 1t was onlyIn 30 rer cent that tbey lmmethalely preceded the Onset ~f $ymploms lk iIlreSbCf the frequency of the disorder m soldiers who previously followed $Cdentary occupations and in IIeI1sitivc luIOUJ highly strona or deprcsMd individuals His lToupmiddot of ease$ included an abnormally hiJh numbct of tcctotan~rs and 15 per cent bad morning spermatorrboea

Jn his view tbeni was no uniformity of aetiology and ~nsti ~0flamp1 weakness 0 retarded ~~V~lop~~ eJtpoSUn~ and

mfecho-n played Yaljln parts ~lmdar VUW8 were expreS-~by A Abrahams The psychiatriC effect of effort syndroma

III

was invutiptcd in more detail by Oppenheirner and Roh$dlild Cohn MacCurdy Culpln Th (nqUeDltY or a positive faAlily history or of facton prediSPOlUnj to psychoshyneurosis was stressed (Oppenheimer and Rothschild) Cohn and CUJpin independently ~phasized the psychological implicationa of certain features often found in t1Iort 5yndrorne pallenb such as tttmor of hand r6dy lweatlng disturbed sleep sbakiness on slilht ecitement ready starting and

~-a-netinrof deptcsaion lheF it AQ bttak in tJw Ktilaquo alnin these and otbcn in which a typtltal anxielY coexists with rapid pulampe shortness of breath precordiJl pain and occasiollli faintneSs and glddineu In short witb regard 10 many patients it is clinically J alter of inditTerence whether

I~ uc WjJhly middotraist to any forrn of treaknent (A)ID4I in_) ftIK of reebl pft)iquo whb __ middotciyenlImiddot tile iuditoly to im~ u_tty to maH ~ to1dien witiLtbiLt~pr~Odd (Hu1$t) Out of 55amp cues seen by Sir Thomas Lewts appr~ mately50 per cent were judaed to be unfit for any category of duty of the 239 who were fOllowed up only lhirty~nine returned tothe firing line in eleven tnonlhs These fiure$ do not correspond with thoampcent of tbe official history of the war in whKb it iI stated that of ll408 tiQ of fUnclional dtSCa$ll of the lIltart 11403 refinally disJgt9sed ltgtf byretum to duty Experience of the It of oYltematO PSY~9Oli1 treatment are not avaJlable

G _

~taDy limilar in structure but with a predominance of respiratory Iymptoma were PI neurol5iC$ Ulllion Roers Hulkrt) Gu neurosis was (0 the lunp whal effort IJDdrome ftl to the heartraquo AD epidernic of ps hysteria was described by the official hiltory of th~ A~rican Expeshyditionary For_ Following desultory ps shelling spread over eight days 500 men returned to one field hospilal as ps Qsualtia Tbe symptoms described were a fcelina of faiaue pain in the chat e1ibt dyspnoea COUghinl husky voice an atlOftmeDt of tinalin and bflmiDa senaaHona referred to the throat and IOIDC indefinite eye symptoms PhySical and neuroloPal examination was praerically negative As lhese men came from battJetelted troops it was reprded aa inconshyceivable that the wcte malitlJlaquoina MOre probably a number of facton acted toaer~ al that time to lower morale and reduce inhibition to to au where tNlnYutilized allyen suitable extrancol-S opportunity as a route to escape frorn an unshyduifable situafi9n Simple rea5sorance given and the palieata ltOIIYinc1nl1y wid tbat lhey would be able 10 return to duty on a OlUin day at some specified hour ~u~uentlY tJte ~mptoms were practically ignored and $triet military dhcipline was enforced Rapid recovery followed and the wave of f8ses ceased spontaneously at ~he end of eiSht days

00pi0Ic DIoodon willi a Iarp EmoI-I c-- Warfare gave a unique opportunity for studying certain

otpnic diMases in whkb emotional factors are aUeged to play a prominent part of primarily aettological and aggravating importance A review of the literature is disappointing Most authors unfortunately confine themshy~~_ to a statistical evaluation of certain organic disltgt eases in reJatIon ToemotitmaJ dIStill babtW atd nCJlutS diaorders

Alim~nfar1 Disordcrs-An lncr(a~ in ltyspepl-ia under the stress or warfare wa frequently nOled (Alhu Schmidt Sirnuss Romberg) Individuals- who suifeNd from simrlur disodet~ in peace time were panicularly attected One-half of the patient$ feU ill before they had ~n any front~iine serviC~ and a further onefhird developed symptoms during the first week in lbe firin line Constipation gastric hypersecretion vomiting and diarrhoea and pyloric spasm were commonly seen The personality type of lhe patients affected was definilely different from that in cardiac neuroses (KUllingtky) There was no conclusive evidence to suggest that peptic ulcer emeramped from the syndrome Most authors agreed that lhe incidence of ~ptic U1ccr during war was not higher than durina peace time but relaPH$ of peptic ulcer were repeatedly seen ill those who had suffered from it in peace lime Hi Frequent onset of stress-dyspepsia or peptic ulcer on demoHi~ uuon has been noted (Da ies and Wilson)

Diabets Diabttes was a rare conditton among wldcrs

bull There were only two dIabetiCs lIt ~6~ Ictcd tH~iIAl-----lOidien (Joslin) Strauss found the IJlcld~nee In war ho~pllaa to be 03 per U)OO as compared With 12 per 1000 m clI(llian bospitals A pre-Gistlng diabetes may be aggravated accofd~

~~~ 1

AIRCRAff PRODUCTION AND EYESIGHT NEUROSES IN WAR TioOuu 223 -----------shy ------- MDKuJouuuL

CARCINOGENIC EffECJS OF THORIUM DIOXIDE

fshy lJm art confirmed by clinical experience Thus evcn - --after ~everal years of obsergtation Y(lter Olcll and

Hus~lY flliild to noh~ any injurious eJre~t eilher dinically lr hi~lo)l1~iaIlYJ from lh()rolrat in patients who had had inlra~l1vugt illjlctiollS uf 60 to Oll ttm for the purpl1se of hcpalo-lienography Likewise Moniz nnd Lima Dos Santos Uhr and olhers who have bcen

-~ing thorotra~t for arlcriography in a huge number of over a number of years have never observed a

to the reliculo-enuolheJial

81 kml ltfhl Plaquorls 11l H2 i09 I flm I PI llh lj~ 19 10(1 1 J ((iIftT19I35 111

~~~(J ~ll1r~ltnmiddotI~jlQJ(1 HIl 11 I

fI S(oltI I 11~ 3 i

MEDICAL PROBLEMS IN WAR This ir the prrr-vtrrn W1itIn~e litu -of-_inmiddotmiddot_r

NEUROSES IN WAR IIY

pound WlTIKOWER MD Physitian and Hidley SltW4rt ResHrch Ftllow~

the T QViSlOCk Clinic London

P SPILLANIl BSc~ MB BCb DPM Rcxkerllt Rttsearch Felow

ToiJIOrk CIidc

the conditions of warfare now impose themselves in much greater degree upOn the civilian populatjon~ the

Dumber of psychiatric casualties in current hostilities is likely 10 be even larger than in the war of 1914--18 A survey of the observations and conclusions reached at that or more recently may throw light on potential 1m

It psychiatric problema of the present day in civilian mmiary life

care

in prostitution and has been reported

Katz obltrved bed-wetting in

o~tiom aillable oil clvliamaltitually writetl - Itrm the

infrequency of psycbological disorders in severcly bom~ confirmatory French

10 Redlich) in and capacity

predisposed indishyand hysterical

Dealing with the eff~ of Zeppelin raids R P Smith described conditions similar to those

All inquiry made at various London hospitals about the behaviour of patienllmiddotduriDI air raids

Similarly according 10 Hoche in Germany andt more recently Mira

stood up surprtstngly well to the terrifying experiences of repeated air attacka In Barcelona he air raid shellers althouah adequate for

were by no means Hoche described as the main sources ot anxiety

means of escape or bomb before

pleasures and contrasting lndividuaHsm declines at the outbreak of war and is auditory and visual sensations resulting from the detonamiddot

superseded by mass reactions which show certain variamiddot In those not actually invoived in spite of a general uniformity The feeling of were tbe usual

a common danger leads to a strengthening of commiddot symptoms of anxiety-tremb1ing pallor 50metilllO forced ties and to a leveUing of differences and opposition urinary excretjon and

in social economic religious and political spheres In These symptoms passed off quickly yolunteers particularly the increased community feeling People of advanced age tended to leads to a surrender of priVileges and to self--sacrifice in show an increased tolerance and in some neurotic paticnrs the service of the country Convetsely in some indi~middot diminished tn

quesuoll bull viduals anxious endeavours to protect the ego lead to a In severely bombarded kgtmiddot~h1ess ~jn=- middoti1rmiddotlflsh middotlnmiddotmiddot most-- peopHt--b-_--themiddoteiil-pofgttIIaIiotHklaquolfity -----~__

in~rease in community feeling rcstJlts in a disregard of week~ with disorder or sleep acoustic hyper m1nor physical ailments all hough hypochondriacal rcac sensitivity starting at 1he slighlest sound constant anticishytns Olay be observed in some During the last war ymptt1ms p thmhllirer llOled a dlminution in Ihe number of those amenorrhoea

of anxiety dtcterized r inactivity taenya

neighbourhood of bomb A psychic

epidemic was reported by Wedekind in girls working near frequently visited by

Fil1 of trembling and prolonged loss of con sciousness occurred on the slightest provocation the sight

manifest themselves in sadistic rantasies and alions At noor in convlIlsions he outbreak oj war a decrease in delinquency not wholly N()ggeral and Mira a lujbutablc tl)_JbLellli1un~llL QLpoundriJIljJml~l_~~~L~l~i1~I~llY__ _sLlrilampAiLt~ds ~~~~~~~pound~tpound~il~~~~ _we~C_ ~n~~~llt~t_ observed and may be partly accounted for by the ouUet and anxietY7dxcitement ere observed on1y in families provided for aggression A corresponding increase of

Pfllfe~~or Ern~st W He Groves will (Iilicr lh~ lirsti over 150 per cent was recorded in Berlin during the ylondwn ~hnt~nll j IIll Rt1 ( )llt of ~nod J914 middot16 97 per Ccnt of the j()16 caseo were for _ Sr9~ln()f lntbnd t Inn Field (In Th~JltJV ~-tll1Ctnriitfrrrhmmr-a~ Tractl~ Jin(JenbUfJJr aru1_ TlhliIedIhiLampOkli~~~n~~ ~iJlh 1-1 ltIt 3 pm J findc) The ~It11 irnpotCd upnR 1he fcmde fOPulalion ~t m15S

- - clmranions rcltulttd in experience which alternates between lhe danger of d~tlh

__----------4(11~) d 1g-vd~ 1WQ~0e )0Vt1h~

Some involved in warfare Most Guman

barded Frencb viUages but no observations can be traced According refugees from invaded areas the resistance for adaptation were remarkable In viduals states of depression and anxiety syndromes were seen

found in soldiers

showed be absence of any marted reaction

in Spain the clyman popufation

aniy to per cent of the population crowded (I) forced passivity wiboul any retaliation (2) the whistling of tbe falling the actual detonation (3) the vivid

tion especially in darknessmiddot in the explosion the immediate results

laughing diarrhoea and increased hence marked lhitst in the well-adjusted

anxiety arising from internal conflicts was face of an acute external danger

lasting for

pation of noi~ heart vomijng~ diarrhocJ f

experience Mira

some cases eadinJ to hysterical fits especj Hochets observations As a rule only those in the explosions developed acute nervous symptoms

the front in a munition factory aeroplanes

of over a dozen girls Jying on the was not uncommon According to

where the pare were excited (Siegert) ObsentioM on SoJdlers

_ hbullbull radcriud l1y the cxdtlsion of individualily in

disturbances Babinski and sroup of reflex disordersK which

OCCUPr a ~tion balfway between organic affections and A relI~ contracture foc eample

-~-blt----oca=-JlOOQllSJ~IQOA1lllllb-----i lCqueatly fixed by a psychological mechamsm _shy

E_

Ftig exhaustion whether physical or menial in oriain exposure 10 iDelment welber 10bullbull of sleep lack of food ocmiddotwatctmiddotmay4isturb lhe tense mlIIIlaI state of the frOlltine IIOldicr The conslant tr of eXshyposure 10 lIOffielbinl extremely distaSleful whetber th di_ may be common 10 all mankind or an idiosynshycruy of the pa~~ as well the struill acaillJl sympshytoms already iII oxiotne may lead lo laleS of faligue (MacCurdy) Nearlyn caJeI admitlpoundlt 10 CIISUAIty clearmiddot ing Ilalions were in a stale of fatis $Socialpoundlt sympshytoms described are perspiration palpitation feeling of giddiness and faintipg praecoroial paiD breatblasnns on rtion and wkness of limbs (Jolowicz BrullCh) Mute exhaustion stat diffr from chronic fati Slaes I1kr prolonscltl trench life A true xhaustion stale passes off after a few days rest but patients with neuru~ aod an anxiety state usually gave histories of fatiane reaction in the line that was disproportionate but not te(MCCurdy) A pecial group labelled exhaultion neUrosis is outlined in the American literature

More often than civilian neuroses military neurosa arc preceded by terrifying experin whose action ltan only be unde~ood in conjunction with the mental make~up of the individual and will be considered in detail under Ibe heading Psychopathology

bull bull ~_sItIo

A maJOfIty of posycbultnc authors believed that given sufficient emotional stress neurotic symptoms may appear in anyone and that the existence of neurotic symptoms in Civil Ufe predispos~ to their reappearance in an Increased and aUered form m WI (G Rousy Forsylh Dupony

PSfcll0pathlc personalllles are saId 10 be ~ martial mIslfts (FTUBtj rtvTeiror--tlie facts mlfi~~ light of subsequent knowledge however~ suggests 1hat t~cre wcr~ manyxceplios to thi g~rll~idli7jlon Jndi~ Iduals With prevlOUS anoicly symptnms tkpresscd Mn~l~

and Phobic indivldals wlre as a t tile )of war whereas some psychopathic personality

~n as

return to Systematic statistical A u

predisposition in neuralie soldiers regard to clinical classiticalions gave inconclusive results Studies in small roups seemed to confirm the common belief in family od personal prediposilion (Wolfsohn) but a Comparison of findings obtained in an average regimllllt in the United States (Bowman) with those of a neuropsychiatric base hospital in Frllnee showed bullbull that the preponderance of heredity for the mass of neuroseS alld~-Ts-btrt--a-mae--mtJre --lMn-fet--JIlaJlfll=lIyen)I-middot----1 indhdduaJs t (Us Army Medical Department) Six1yshythree per cent of ncurotlc soldicrs compared With 46 per cent of average soldiers gave combtncd poSitive family

4j~li~~is~c_~___ ~_~~rsona1 _~~~~O~i_~-~Lt~middotJ~ a~d_ 3~_ JK~I cent resp-cttverygave po~llve perMlOal hlstorlCS ~

~T

~MY_4iilMPM~ID2pound_

~ ~ ~~ NEUROSES IN WAR

NEUROSES Df WAR

(Stransky) Aided by community fcelin middotf cssifiltatiolli were lt indiscriminately in the label me of bull pbyoiopalluc and a reliaioul and philosophic outlook the ~t shell shockmiddot U neurasthenia~ and hysterla

H

The Ul- Froment dncribed a vast flaio~ily of the aoIdien manage to adapt themselva ~efined group middotneurasthenia proba~y contain exb to StluatJon Ibt a~a~osl intolrmble Severb ~ uontala Il1IXJety ~teo CW H Rven andH Head) byskl1 ltIi prolonged $Ires may precIpItate a brekdown in almost and ltIlgtre~SiOlW~tltmr~~~-__ everybody Arter e~posure to severe shrapnel fire a whole 1 a traumatic aetJoi08Y is dlfficuJt lR relation to penSlOGS company was noled by Redlich to develop hystericalmiddot bull and has largely been abandoned ~Rporl of War O~ that of bysteria symptoms-ror example crying fitS ano vomiting ~ t Comtnlnee on Shell Shock) As poundt bas becOIDe obvIous

that there IS no fundamental dillerence between peace and war neuroses the generally a~pted terminololY of peacemiddot

Tflf bullbulln_ ~AlJOIItn

Gull _ KlUiog

Normally our aamp8res5lvc or sadistic tendencies are co pressed by our civilizalion mainly through the inOuence of early surroundings In peac these aggressive ten~ dencies may express themselves in a sublimated form in phYiicaI exertion and dangerous exploi1s In war a ~ premium is put upon blood-thirstiness anti he community extols the individual who is most effective in inftictiDI injuries upon the bodies and lies of the members of an opp()sing group This ~mcs in elkct~ a sublimation for noW the soldier can by the ~aml ads give vent to his prtmitivc pasiions and reap the approhalion of his

(MacCurdy) tn $Ome~ howccr~ the conflict early teaching and the demands o( war may

a breakdown

time neuroses is now ~_d fQr both It is difficuJl to middotobt~i~-n accurate estimate of the

incidence of neuroSotJ during the last war (a) Brilish Expeditionary Force-According to the Official

RislQry at Iltt Wtlr the problem in the BEF did not become acute mutt luly 1916 when several thouliand patimts were rapidly passed out of the Somme battle toM An analysis of t 043653 Britih casualties revealed that ntUlOlC1l fGrltled 34 per 1(D) casuaUte$ On occasions neurorei made up 40 per cent of lhe casualties evacuated home In 19)8 out of bull tpoundltal of 160ltn) petlSlonen 32000 or 20 per centbullbull WCIe ceh ing pensions for functional nervous and menta) diseue (Conie) while in 1921 ibls figure had risen to 65000 (Official History cllhe Jyenar)

(b) Canadian Expeditionary Force~-of 180496 casualties occurrinl 24 per J(XKt were mcludcd in the cateJOry of nervoul and mental dia~ (BriUS)middot

(e) American Expeditionary Force-The total number of admissions of enlisted men suffering from functional 1lCTV0UI disea durin tbe period April 1917 10 December 1919 was 32983 equivalent to 9$ per 1000 casualties The attempt to eliminate potentia1 neurotics from the American Expedi lionary Foree and its comparatively Ihort period of active service must be remembered when considering thil figure

Incrased Responsibility Omervations in various armies agreed that (1) the inci~

F uence was relatively greater in fresh troops arriving in or ~~~ enlistment an the Army meant relief from 1j the front line inbattte-tested troops after prolonged trench

responslbthtles but for NCOs and officers especially life without a break tRussell) in men over ~ especially where Ihy were subjeCt 10lralO from the nlaquoJ 10 keep married men (0 Holmes W Brown) and in rapidly up an appearance of courage Ihe~r ncw ~o-llion aclld as a4 trained volunteers as compared wi(h the Regular Army cause Of mental unrest and eontnhuted III no slllali dCgrec ~1 (Bailey) (2) the incidcnce rose considerably aflcr severe to nc~ous breakdown The hurden 01 inerca~cd re~ military operations Actively advancing troops wcre less s~nSlblhty ~y al~o acc~un~ for Ih~ higher incidence apt 10 break down Ihan inactive or rel~ating troops ~ ~neus dord~I In mamed lt (Rltp of War 11) analysis of Ih incidence in variolls branches of service

cc COmmmeltl OIl Shell Shuk) middot~--middothoweltltrat-echnrcins--lting- at extreme hazard-infantry and machine~gunncrs cngiMeB

Sxlml Oc-prl tion and Scgtpanation from Family

TIrrifgting (mill line ep~jIIc lrrll Ih~ 1lJicr sloxuully in two JJn~middotIIH WI)-S 1111 ol11 lllm fh1 a diminution o( s~ual inleleu wa~ ODlIId tWcxhq inJ LllWY) In othcn spermilofrhoca saui~lic seU~l1 llnlenl OCWTCt

proveu em~lcnl and emb of the

anu lank corrs-~rank high ~in themiddot JiMlFenton 11i~ll1fj 01 the WilT ~ and Ayres SheH Shock

AelioWgy

in a few cases led ~arly in war to physical causa

and Von SarOO) including carboa (Mott HUbner Soltau)

molecular changes in lhe ~ but the occurrence of

UUV1l ~UIU nervous symplomsw the groups sharing the same psychothrapy strongly

MacCurdy Eder Viets Wiltshire) fhe COl1Uililln was ushered in by concussion in less than 10 per cent (W Hrown Holmes Hart) or

_ 25 per cent (Graha~ Brown MacCurdy) Concussion id ulmiddotdctii1relIYmiddot1ttcelJT umiddot d nirrC-mmrt n~rrs-wrr--____M --aM concusslmrlRurnsI5bave ~ COmiUcz ed as sepal ate dltlOn~ Imme(hIICly dehrmmcJ by h~ entities the concussion acting as a p~ipitaling factor in cOlHJHlons n~)d~rn II1U Wllh t ~ mploUlilllgy concussion neurosis whIie (lOlnt I~ d1fCClly relIleti 10 Wlf The French school of thought (Roussy Brisleau ~ I~ ~t) [~ ltl l~ lLpplilLlJd t ~fl~~__J uclsnillJHlrl)lilt~1_~~Qu_1rni~~___

01 Ihe Ihl III IIIOlh )lIn I II cummotionne from thcent cmotionn~ Untlcr the bull~Hlbl)rs Athilkj lld ~ iHpm hh~ ~dl

tlI fOAt -IIn_bull Jn1Jgtb)

disturbances Babinski and sroup of reflex disordersK which

OCCUPr a ~tion balfway between organic affections and A relI~ contracture foc eample

-~-blt----oca=-JlOOQllSJ~IQOA1lllllb-----i lCqueatly fixed by a psychological mechamsm _shy

E_

Ftig exhaustion whether physical or menial in oriain exposure 10 iDelment welber 10bullbull of sleep lack of food ocmiddotwatctmiddotmay4isturb lhe tense mlIIIlaI state of the frOlltine IIOldicr The conslant tr of eXshyposure 10 lIOffielbinl extremely distaSleful whetber th di_ may be common 10 all mankind or an idiosynshycruy of the pa~~ as well the struill acaillJl sympshytoms already iII oxiotne may lead lo laleS of faligue (MacCurdy) Nearlyn caJeI admitlpoundlt 10 CIISUAIty clearmiddot ing Ilalions were in a stale of fatis $Socialpoundlt sympshytoms described are perspiration palpitation feeling of giddiness and faintipg praecoroial paiD breatblasnns on rtion and wkness of limbs (Jolowicz BrullCh) Mute exhaustion stat diffr from chronic fati Slaes I1kr prolonscltl trench life A true xhaustion stale passes off after a few days rest but patients with neuru~ aod an anxiety state usually gave histories of fatiane reaction in the line that was disproportionate but not te(MCCurdy) A pecial group labelled exhaultion neUrosis is outlined in the American literature

More often than civilian neuroses military neurosa arc preceded by terrifying experin whose action ltan only be unde~ood in conjunction with the mental make~up of the individual and will be considered in detail under Ibe heading Psychopathology

bull bull ~_sItIo

A maJOfIty of posycbultnc authors believed that given sufficient emotional stress neurotic symptoms may appear in anyone and that the existence of neurotic symptoms in Civil Ufe predispos~ to their reappearance in an Increased and aUered form m WI (G Rousy Forsylh Dupony

PSfcll0pathlc personalllles are saId 10 be ~ martial mIslfts (FTUBtj rtvTeiror--tlie facts mlfi~~ light of subsequent knowledge however~ suggests 1hat t~cre wcr~ manyxceplios to thi g~rll~idli7jlon Jndi~ Iduals With prevlOUS anoicly symptnms tkpresscd Mn~l~

and Phobic indivldals wlre as a t tile )of war whereas some psychopathic personality

~n as

return to Systematic statistical A u

predisposition in neuralie soldiers regard to clinical classiticalions gave inconclusive results Studies in small roups seemed to confirm the common belief in family od personal prediposilion (Wolfsohn) but a Comparison of findings obtained in an average regimllllt in the United States (Bowman) with those of a neuropsychiatric base hospital in Frllnee showed bullbull that the preponderance of heredity for the mass of neuroseS alld~-Ts-btrt--a-mae--mtJre --lMn-fet--JIlaJlfll=lIyen)I-middot----1 indhdduaJs t (Us Army Medical Department) Six1yshythree per cent of ncurotlc soldicrs compared With 46 per cent of average soldiers gave combtncd poSitive family

4j~li~~is~c_~___ ~_~~rsona1 _~~~~O~i_~-~Lt~middotJ~ a~d_ 3~_ JK~I cent resp-cttverygave po~llve perMlOal hlstorlCS ~

~T

~MY_4iilMPM~ID2pound_

~ ~ ~~ NEUROSES IN WAR

NEUROSES Df WAR

(Stransky) Aided by community fcelin middotf cssifiltatiolli were lt indiscriminately in the label me of bull pbyoiopalluc and a reliaioul and philosophic outlook the ~t shell shockmiddot U neurasthenia~ and hysterla

H

The Ul- Froment dncribed a vast flaio~ily of the aoIdien manage to adapt themselva ~efined group middotneurasthenia proba~y contain exb to StluatJon Ibt a~a~osl intolrmble Severb ~ uontala Il1IXJety ~teo CW H Rven andH Head) byskl1 ltIi prolonged $Ires may precIpItate a brekdown in almost and ltIlgtre~SiOlW~tltmr~~~-__ everybody Arter e~posure to severe shrapnel fire a whole 1 a traumatic aetJoi08Y is dlfficuJt lR relation to penSlOGS company was noled by Redlich to develop hystericalmiddot bull and has largely been abandoned ~Rporl of War O~ that of bysteria symptoms-ror example crying fitS ano vomiting ~ t Comtnlnee on Shell Shock) As poundt bas becOIDe obvIous

that there IS no fundamental dillerence between peace and war neuroses the generally a~pted terminololY of peacemiddot

Tflf bullbulln_ ~AlJOIItn

Gull _ KlUiog

Normally our aamp8res5lvc or sadistic tendencies are co pressed by our civilizalion mainly through the inOuence of early surroundings In peac these aggressive ten~ dencies may express themselves in a sublimated form in phYiicaI exertion and dangerous exploi1s In war a ~ premium is put upon blood-thirstiness anti he community extols the individual who is most effective in inftictiDI injuries upon the bodies and lies of the members of an opp()sing group This ~mcs in elkct~ a sublimation for noW the soldier can by the ~aml ads give vent to his prtmitivc pasiions and reap the approhalion of his

(MacCurdy) tn $Ome~ howccr~ the conflict early teaching and the demands o( war may

a breakdown

time neuroses is now ~_d fQr both It is difficuJl to middotobt~i~-n accurate estimate of the

incidence of neuroSotJ during the last war (a) Brilish Expeditionary Force-According to the Official

RislQry at Iltt Wtlr the problem in the BEF did not become acute mutt luly 1916 when several thouliand patimts were rapidly passed out of the Somme battle toM An analysis of t 043653 Britih casualties revealed that ntUlOlC1l fGrltled 34 per 1(D) casuaUte$ On occasions neurorei made up 40 per cent of lhe casualties evacuated home In 19)8 out of bull tpoundltal of 160ltn) petlSlonen 32000 or 20 per centbullbull WCIe ceh ing pensions for functional nervous and menta) diseue (Conie) while in 1921 ibls figure had risen to 65000 (Official History cllhe Jyenar)

(b) Canadian Expeditionary Force~-of 180496 casualties occurrinl 24 per J(XKt were mcludcd in the cateJOry of nervoul and mental dia~ (BriUS)middot

(e) American Expeditionary Force-The total number of admissions of enlisted men suffering from functional 1lCTV0UI disea durin tbe period April 1917 10 December 1919 was 32983 equivalent to 9$ per 1000 casualties The attempt to eliminate potentia1 neurotics from the American Expedi lionary Foree and its comparatively Ihort period of active service must be remembered when considering thil figure

Incrased Responsibility Omervations in various armies agreed that (1) the inci~

F uence was relatively greater in fresh troops arriving in or ~~~ enlistment an the Army meant relief from 1j the front line inbattte-tested troops after prolonged trench

responslbthtles but for NCOs and officers especially life without a break tRussell) in men over ~ especially where Ihy were subjeCt 10lralO from the nlaquoJ 10 keep married men (0 Holmes W Brown) and in rapidly up an appearance of courage Ihe~r ncw ~o-llion aclld as a4 trained volunteers as compared wi(h the Regular Army cause Of mental unrest and eontnhuted III no slllali dCgrec ~1 (Bailey) (2) the incidcnce rose considerably aflcr severe to nc~ous breakdown The hurden 01 inerca~cd re~ military operations Actively advancing troops wcre less s~nSlblhty ~y al~o acc~un~ for Ih~ higher incidence apt 10 break down Ihan inactive or rel~ating troops ~ ~neus dord~I In mamed lt (Rltp of War 11) analysis of Ih incidence in variolls branches of service

cc COmmmeltl OIl Shell Shuk) middot~--middothoweltltrat-echnrcins--lting- at extreme hazard-infantry and machine~gunncrs cngiMeB

Sxlml Oc-prl tion and Scgtpanation from Family

TIrrifgting (mill line ep~jIIc lrrll Ih~ 1lJicr sloxuully in two JJn~middotIIH WI)-S 1111 ol11 lllm fh1 a diminution o( s~ual inleleu wa~ ODlIId tWcxhq inJ LllWY) In othcn spermilofrhoca saui~lic seU~l1 llnlenl OCWTCt

proveu em~lcnl and emb of the

anu lank corrs-~rank high ~in themiddot JiMlFenton 11i~ll1fj 01 the WilT ~ and Ayres SheH Shock

AelioWgy

in a few cases led ~arly in war to physical causa

and Von SarOO) including carboa (Mott HUbner Soltau)

molecular changes in lhe ~ but the occurrence of

UUV1l ~UIU nervous symplomsw the groups sharing the same psychothrapy strongly

MacCurdy Eder Viets Wiltshire) fhe COl1Uililln was ushered in by concussion in less than 10 per cent (W Hrown Holmes Hart) or

_ 25 per cent (Graha~ Brown MacCurdy) Concussion id ulmiddotdctii1relIYmiddot1ttcelJT umiddot d nirrC-mmrt n~rrs-wrr--____M --aM concusslmrlRurnsI5bave ~ COmiUcz ed as sepal ate dltlOn~ Imme(hIICly dehrmmcJ by h~ entities the concussion acting as a p~ipitaling factor in cOlHJHlons n~)d~rn II1U Wllh t ~ mploUlilllgy concussion neurosis whIie (lOlnt I~ d1fCClly relIleti 10 Wlf The French school of thought (Roussy Brisleau ~ I~ ~t) [~ ltl l~ lLpplilLlJd t ~fl~~__J uclsnillJHlrl)lilt~1_~~Qu_1rni~~___

01 Ihe Ihl III IIIOlh )lIn I II cummotionne from thcent cmotionn~ Untlcr the bull~Hlbl)rs Athilkj lld ~ iHpm hh~ ~dl

tlI fOAt -IIn_bull Jn1Jgtb)