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WAR NEUROSES 
 
 By 
 
 JOHN T. MacCURDY, 
 
 Lieut., Medical Officers' Reserve Corps, U. S. A. 
 
 Reprinted from " PSYCHIATRIC BULLETIN " for July, 1917 
 
 UTICA, N. Y. 
 
 STATE HOSPITALS PRESS 
 
 1918 
 

WAR NEUROSES. 
 By Dr. John T. MacCurdy, 
 
 Psychiatric Institute of the New York State Hospitals. 
 
 War neuroses may be defined as those functional nervous 
 conditions arising in soldiers, which are immediately deter- 
 mined by the conditions of modern warfare^ and have a 
 symptomatology whose content is directly related to war. 
 Naturally enough, in any large body of troops, neuroses (as 
 well as psychoses) develop as they do in times of peace, and 
 many of these are determined by factors which are essen- 
 tially those of civilian life. In these latter the symptoms 
 are the same as those occurring in peace times, and can 
 therefore not be called war neuroses with any clinical accu- 
 racy. This group of functional nervous diseases presents 
 no problems that are different from those which have been 
 studied for many years, and they shall therefore receive no 
 attention in the preliminary clinical report which follows. 
 
 The war neuroses, however, offer problems very new and 
 of great importance both from medical and military stand- 
 points. The term ' ' shell shock ' ' has been adopted ofl&cially 
 by the British War Office as the diagnostic term to cover all 
 neuroses arising among officers and soldiers of the armies. 
 This term has an advantage in its picturesqueness that has 
 helped to stimulate popular as well as professional interest, 
 but it is a term which can be defended with difficulty from 
 a purely medical standpoint. There are two reasons why 
 this is so. In the first place it implies a single etiology — the 
 physical effects of high explosive shells on those subjected 
 to bombardment, who suffer no external physical injury — 
 and this is far from being even the main factor in the deter- 
 mination of the symptoms. Secondly, the clinical types 
 covered by this blanket diagnostic term are too various to 
 be safely gathered under one heading. It is therefore more 
 advisable to use the term "war neuroses," which gives the 
 desired latitude in grouping together the different clinical 
 pictures that occur, and focuses the attention on those 
 influences which come directly from warfare. 
 
In most countries, at the outbreak of the present war, a 
 situation was in existence that was distinctly inimical to the 
 careful study of functional nervous diseases. Neurotics, 
 with their tendency to superficial recovery and frequent 
 relapses, were insoluble problems to the bulk of the profes- 
 sion who were not especially trained in their treatment, so 
 that they had become the betes noires of most general prac- 
 titioners and of man}^ neurologists. Being little understood, 
 the general ignorance as to causation led to the adoption of 
 hypotheses concerning the essential nature of these con- 
 ditions, which were more strongly held than scientific 
 accuracy would justify. This was, of course, a natural 
 consequence of the multiplicity of phj'sical and psycholog- 
 ical factors that are probably always at work in the 
 production of peace neuroses. 
 
 Neurotics, too, demand so much time of the physician in 
 treatment that a tendency had developed to regard their 
 symptoms as purely imaginary, somewhat spurious, or at 
 least of less importance than obviously organic medical 
 problems. The average medical practitioner naturally pre- 
 ferred to give his attention to concrete physical disabilities 
 rather than to impalpable and subjective symptoms. When 
 the war appeared, therefore, the medical attitude toward 
 neuroses was one of rather narrow bigotry on the part of 
 most of that small group interested in functional nervous 
 diseases, and of indifference on the part of the bulk of the 
 profession. Naturally then, there were few observers who 
 were really competent to study the great mass of material 
 which the war suddenly produced. 
 
 These thousands of cases presented problems which were 
 no less important from a military than from a medical stand- 
 point, and hypotheses as to their essential nature were put 
 forth with as much enthusiasm and as little accuracy as the 
 importance of the problem, on the one hand, and the lack 
 of preparation on the part of the observers, on the other, 
 would naturally be expected to produce. Those who had 
 had little sympathy with the neurotic looked on these vic- 
 tims of war as mere malingerers and advised treatment by 
 a firing squad — " pour encourager les autres." 
 
Those wTio had been previously interested in hereditary 
 defects asserted that these new patients were practically all 
 inferior individuals. Those who had emphasized physical 
 factors in peace times were able to demonstrate to their sat- 
 isfaction that all the cases were suffering from extreme 
 physical fatigue, concussion from high explosive shells, or 
 poisoning with gases from the explosives. On the other 
 hand, there were those, who had worked with neurotics from 
 a psychological standpoint, who took the ground that the 
 war neuroses were essentially psychic in origin. As a re- 
 sult of this, a large literature has grown up which must be 
 rather chaotic for the average American to whom it is acces- 
 sible, since few publications are to be found which give any 
 broad survey of the clinical material, or a careful study of 
 all possible factors. It therefore seemed advisable to make 
 a survey of these cases, bearing constantly in mind the 
 possibility of all the above mentioned factors coming into 
 play, in order that their relative importance might be gauged 
 as a basis for the further study and treatment of these con- 
 ditions as they arise in the American expeditionary forces. 
 
 The cases now to be reported were observed in seven hos- 
 pitals in England: five of them in London, one in the 
 neighborhood of Liverpool and one near Edinborough. 
 They embrace neuroses occurring both in officers and men, 
 and arising in the extremely varied circumstances of mod- 
 ern warfare. Most of the cases had been out of the firing 
 line for some weeks or months, but a few had been disabled 
 from active service for only a few days. Unfortunately it 
 was not possible in the two months at my disposal to visit the 
 front and examine similar material in its more acute stages. 
 As a result, it is impossible to describe on the basis of per- 
 sonal observation the "stuporous" states that are said to 
 exist for a short time in many of the cases. For the pur- 
 poses of this preliminary account, no neuroses developing 
 during the period of training have been included. What 
 material is presented, as a foundation for statements as to 
 etiology, was gathered by taking careful histories from the 
 patients themselves, and discussing the problems freely with 
 those who had spent months or years in the observation and 
 
treatment of these diseases. This work was not only greatly 
 facilitated, but was made a pleasurable task by the extraor- 
 dinary cooperation and cordiality which was everywhere 
 found in the British hospitals. It is impossible to state too 
 strongly my appreciation of the opportunities that were given 
 me, and of the kindness with which, as an American, I was 
 received. 
 
 In order to orient the reader at the outset with the nature 
 of these neuroses, it may be well to note cases representa- 
 tive of the two main types which are to be found. These 
 are conditions of anxiety on the one hand, and of simple 
 conversion hysteria on the other. 
 
 Case I. The following history is typical of the development and 
 symptoms of an anxiety state. The patient was a man of 27 who had 
 never been ill in his life. He had never shown any neurotic tenden- 
 cies, having been entirely free from night terrors as a child, and had 
 suffered from none of the fears or inhibitions so constantly met with 
 among neurotics in peace times. He had never had any fear of high 
 places, or thunder-storms, or crowds, or entering tunnels, and had had 
 no sensitiveness to bloodshed. He had been a normal, mischievous 
 boy, had played many games, and had been successful in his work, 
 both in school and when he entered business life. The only abnor- 
 mality to be found in his make-up was a certain shyness with the other 
 sex, from which he had never entirely freed himself. It was perhaps 
 for this reason that he was unmarried and had never thought of taking a 
 wife. It is interesting to note that he always despised those who de- 
 veloped neuroses of any kind, and when he went to France had similar 
 disrespect for those suffering from "shell shock." 
 
 He enlisted as a private in October, 1914, and adapted himself pretty 
 well to the training, making many friends among his fellow soldiers 
 and enjoying the work at first, although he became rather bored with 
 the routine before his five months of training were completed. In 
 February, 1915, he went to the firing line in France. In his first 
 experience of shell fire he broke out with a cold sweat with fear, 
 then became rather slow and depressed, without any energy, and 
 felt rather sleepy. This reaction, however, was only temporary. He 
 soon became accustomed to bombardment and the sight of wounds and 
 death, and then began to enjoy his work, particularly the active oper- 
 ations. After eight months in the trenches he was invalided home 
 with nephritis. He was convalescent for four months, and was rec- 
 ommended for a commission, which he received after two months 
 training. Two months more being spent in his regimental depot, he 
 returned to France as a lieutenant in June, 1916. Then followed four 
 months of very heavy fighting on the Somme, during which time he 
 
developed no symptoms whatever. He was wounded very slightly 
 once. One day he was buried three times by earth thrown up from 
 shell explosions. The last time he was unconscious for ten minutes. 
 He was relieved for three days after this experience, although he had 
 no symptoms. He was very frequently knocked out for short periods 
 by the concussion from shells. About the end of October, 1916, he 
 was sent to the Ypres section where he was working with a pioneer 
 battalion and had to bury many dead. This has been, since the outset 
 of the war, the most trying part of the whole British line. Not only 
 has bombardment been practically constant from the beginning, but 
 to add to the other horrors of the situation it has never been possible 
 to bury all the dead. In this disagreeable situation he began, after 
 a month of these new duties, to dislike the work, and became mildly 
 depressed, although he paid no particular attention to his feelings. 
 Then some fatigue set in, and he found himself for the first time since 
 his initial experience of shell fire with a tendency to jump nervously 
 when the shells came. To keep himself in hand he began to drink. 
 After a couple of weeks he found that his sleep was becoming poor. 
 It took him a long time to get to sleep, during which time the scenes 
 on the Somme front were constantly in his mind. He had a feeling 
 that he had to get up to the trenches on the Somme the next day, and 
 that he did not want to go. During this period of half-sleeping, half- 
 waking, he suffered from "hypnagogic" hallucinations; that is, vis- 
 ions of the trenches, shells, and so on, accompanied by insight that 
 they were really not there, but only imaginations. These visions pro- 
 duced no fear. At this time he had no nightmares. Matters grew 
 worse. Every week he became more nervous; fear of the shells grew 
 on him, he lost the ability to tell by the sound where each was going 
 to land, and all of them seemed to be coming at him. In the effort to 
 "quiet his nerves " he got to drinking quite heavily by the beginning 
 of the present year. He struggled constantly to prevent any outward 
 signs of his fear betraying his condition to his men. This effort in- 
 creased his fatigue. The horror that he felt when first confronted 
 with the bloodshed of battle, and to which he had long since become 
 accustomed, reappeared at this time. He became sensitive to all the 
 sights that were forced on his eyes, would think of them when alone 
 and not actively engaged on some duty, and would see them before 
 him on falling off to sleep. He was so discouraged that he began to 
 wish he might be killed. 
 
 He was able to continue, however, until March, when on a raid one 
 day seven men around him were killed and he was immediately after- 
 ward buried himself. After this he felt so much worse that he applied 
 to the doctor, who told him he had some fever and gave him a " pick- 
 me-up. ' ' He ' ' carried on ' ' for two days, but with extreme difficulty; 
 then his condition became so bad that he was forced to report to his 
 physician again, and was sent to a hospital. For two or three weeks 
 he had had bad headaches back of his eyes, his sleep had become very 
 limited as he would constantly awake with a jump. 
 
As soon as he got into the hospital he began having nightmares 
 which were typical of the anxiety state. In them he was back on the 
 Somme front and being shelled mercilessly. Shells would come 
 closer and closer to him, finally one would land right on top of him 
 and he would awake with a shriek of terror. After a long time he 
 would go to sleep again, to be almost immediately reawakened with 
 another of these dreams, the content being always the same and 
 confined to fighting, in which he was invariably getting the worst 
 of it. 
 
 He would awaken in the morning feeling weak, absolutely played 
 out. Any noise would be interpreted as a shell and strike him with 
 terror. He was therefore suffering from a combination of fatigue and 
 extreme nervousness, with the war constantly in his thoughts. At 
 night when falling off to sleep he would have "hypnagogic" hallu- 
 cinations of Germans entering the room, and with these visions, too, 
 there was great terror. 
 
 After being a little over a week in different hospitals in France, hd 
 was transferred to London. There his condition greatly improved, his 
 fatigue lessened, he became less sensitive to noises and his night- 
 mares largely disappeared. He was then sent to a hospital in the 
 country where he had every opportunity for out-door exercise and 
 recreation and continued to improve for two weeks. Then came the 
 news of the death of one of his best friends in France, which de- 
 pressed him considerably. Shortly after this a concert was arranged 
 at the hospital and he tried to sing, but failed. This experience made 
 him much worse. The old dreams began to destroy his sleep with 
 great regularity. He became more disheartened and hypochondriacal, 
 complained that he was in a sweat day and night, that he had lost 
 twelve pounds and that he was never going to get well because his 
 physicians would not give him an opiate. (As a matter of fact, at 
 this time his sleep was fairly good.) He could not be induced to 
 leave the hospital and would not go out of doors for a week at a time. 
 He felt so much weaker that he was no longer able to play golf. He 
 was in general quite convinced that he was physically and nervously 
 a permanent wreck. 
 
 This case is typical, except for the occurrence of the 
 relapse with depression. 
 
 Case II. This case illustrates a simple hysterical conversion. The 
 patient is a private of 20 years of age, who is not quite so normal 
 as the individual whose history has just been cited. Although he 
 had never had any neurotic symptoms, he showed a tendency to 
 abnormality in his make-up. He was rather tender-hearted and 
 never liked to see animals killed. Socially, he was rather self- 
 conscious, inclined to keep to himself, and had not been a perfectly 
 normal, mischievous boy, but was rather more virtuous than his 
 
companions. He had always been shy with girls and had never 
 thought of getting married. All of these seclusive tendencies, 
 however, were quite mild in degree. The one physical trouble from 
 which he ever suffered was a sore throat a year or so before the war 
 began. At this time he was unable to sing or to talk loudly without 
 hurting his throat. He had always had a lisp. 
 
 He enlisted in May, 1916, and spent five months in training. This 
 proved to be distinctly advantageous, for he adapted himself well to 
 it and was mentally more comfortable than before, as was shown by 
 his increasing sociability. On going to the front, October, 1916, he 
 found himself frightened, as is usual, by the first shell fire he encoun- 
 tered, and horror-struck by the sight of wounds and death, but soon 
 became free from fear and quite accustomed to the horrors around him. 
 After five months of fighting, he was sent to Armentieres in March, 
 1917, and had to fight for three days without sleep. He became tired, 
 developed no anxiety or " jumpiriess, " but felt a strong desire to get 
 out of the fatiguing situation in which he found himself. This desire 
 did not show itself, as in the previous case, in a wish to be killed, but 
 rather in the hope that he might receive wounds which would inca- 
 pacitate him from service, for a time at least. 
 
 Then he was suddenly buried by a shell. He did not lose conscious- 
 ness, but when dug out by his companions he was found to be deaf 
 and dumb. On his way to the field dressing station he had a fear of 
 the shells, but this did not persist after his leaving the zone that was 
 under bombardment- 
 Physical examination revealed absolutely no abnormality, of course, 
 to account for his deafness and inability to speak. It was a purely 
 hysterical condition, and persisted unchanged for a month. He was 
 then transferred to a hospital for the treatment of functional cases, 
 where he was completely and permanently cured in less than five 
 minutes. This cure was effected by demonstrating to the patient that 
 he had not really lost his hearing, the method employed being to 
 make him face a mirror and observe the start he gave when hands 
 were clapped behind him. He was spoken to immediately, and told 
 that the jump he had just given, which he had himself observed in 
 the mirror, was evidence that he had heard the hand clapping, and 
 that, as his hearing was not lost, neither was his speech. He 
 promptly replied verbally, and had no relapses during the two months 
 before I saw him. All this time he did not suffer from nightmares 
 or from any other anxiety symptoms. 
 
 This case is typical of the simple conversion hysteria 
 that develops under the stress of warfare. Not only the 
 history and symptoms are typical, but the speedy and 
 apparently permanent recovery under competent treatment 
 is equally representative of this group. 
 
8 
 
 With these two cases in mind we may proceed to a few 
 general considerations. Officers are affected in the propor- 
 tion of five to one as compared with privates and non-com- 
 missioned officers, although in absolute numbers there are 
 more in the latter group, of course. Explanations for this 
 discrepancy will be offered later. As to the total number 
 of neuroses developing in the different armies, there are no 
 statistics available for general publication. But I have been 
 informed that "shell shock" ranks with what were pre- 
 viously considered the more important conditions (excluding 
 wounds) operating to remove men temporarily or permanently 
 from active service. This makes it at once evident that 
 functional nervous troubles are an extremely important 
 medical problem. Unlike other causalities, however, there 
 is a military significance in the nature of these neuroses. 
 These do not merely cause the removal of many men from 
 active service. As can be easily seen in the first case 
 quoted, there may be the development of a state of fear 
 which may last for weeks or months before the symptoms 
 accumulate sufficiently to incapacitate the soldier totally. 
 No matter how much any man may try to hide his fear, he 
 can not but unconsciously betray it, and so weaken, or tend 
 to weaken, the morale of his group. This is not merely a 
 psychological deduction, but has been confirmed by the 
 statements of many officers who have observed these cases, 
 and whom I had the opportunity of questioning on the 
 subject. 
 
 Another point of military importance is that war neuroses 
 are apparently a corollary of modern methods of fighting. 
 The first reports of these conditions came from the Russo- 
 Japanese war, which would indicate that there is something 
 in the modern trench warfare, combined with the appalling 
 artillery fire, which tends to produce a condition of what 
 might loosely be termed neuro-psychic instability. I have 
 had the opportunity of asking several officers who served 
 both in South Africa and in the present war about this 
 matter. The answers are quite consistent. Practically all 
 the officers now in France are familiar with the clinical 
 pictures of the war neuroses, and are therefore competent 
 
to say whether they existed in the Boer war or not. None 
 of them observed anything at all similar. It is impossible 
 to consider that the human race can have deteriorated 
 appreciably in a matter of fifteen years, and therefore we 
 are safe in assuming that it is modern warfare which has 
 produced these conditions. 
 
 Medical interest in these cases should naturally exceed 
 the interest of the professional soldier. It is the responsi- 
 bility of the medical corps to treat the sick and prevent 
 diseases from developing. The responsibility of the army 
 medical ofi&cer must now, however, go further than this, for 
 the all important discrimination between a definite disease 
 and malingering can be made only by him. 
 
 To those who are interested in psychological medicine 
 there is here a new field, and a highly important one, 
 opened up. We find in these cases a great simplicity in 
 the psychic mechanisms operating to produce symptoms and 
 the appearance of severe neuroses in people who were 
 apparently absolutely normal before their exposure to the 
 horrors and hardships of this war. We find wishes, fully 
 conscious to the subject, directly determining symptoms, 
 simple therapeutic measures leading to permanent recovery 
 with astonishing rapidity, and, on the other hand, we see a 
 chronicity of symptoms for which no treatment, or improper 
 treatment, is given. 
 
 In all these respects we discover an extraordinary con- 
 trast to the phenomena exhibited by neurotics in times of 
 peace. It is therefore reasonable to hope that psycho- 
 pathology can profit greatly by a careful study of the war 
 neuroses. Without minimizing the importance of physical 
 factors, it is safe to say that psychic mechanisms always 
 determine the exact nature of the symptoms. Physical 
 disabilities, of course, frequently underlie the faulty psychic 
 processes. We must therefore consider at the outset how 
 our previous psychopathological knowledge can be applied 
 to this novel material. In order to gain our first approach 
 to the problem, account must be taken of what is really, if 
 dispassionately viewed, an extraordinary phenomenon. 
 
 At the present time there are millions of men, previously 
 
10 
 
 sober, humdrum citizens, with no observable traits of reck- 
 lessness or bloodthirstiness in their nature, and with a nor- 
 mal interest in their own comfort and security, not only 
 exposing themselves to extraordinary hazards, but cheer- 
 fully putting up with extreme discomforts, and engaged in 
 inflicting injuries on fellow human beings, without the re- 
 pugnance they would have shown in performing similar 
 operations on the bodies of dogs and cats. It would be im- 
 possible to discuss in any completeness the mental mechan- 
 isms which result in this astonishing change in character. 
 It is, however, extremely important to develop some hypoth- 
 esis, no matter how briefly, to account for this, because 
 one of the phenomena exhibited by the war neuroses is the 
 tendency to return to the mental attitudes of civilian life 
 and to become increasingly obsessed with the horror of 
 warfare. 
 
 Deep down in all of us there is, apparently, a primitive 
 instinct that takes a delight in brutality and savagery for 
 themselves alone. Among civilized peoples these tenden- 
 cies are, in normal circumstances, quite thoroughly re- 
 pressed, and gain an outlet, as William James has suggested, 
 only in physical exertions, dangerous exploits and rough 
 and tumble athletic contests. The origin of this repres- 
 sion is probably to be found in the instinct of gregari- 
 ousness in the human species, which increases in its power 
 with the advance of civilization, and is necessarily in con- 
 flict with all individualistic instincts, whose operation 
 would be inimical to the interests of society. The repug- 
 nance, therefore, of the modern civilized man to cruelty and 
 bloodshed is probably based on the fact that, during cen- 
 turies of development, the race has frowned upon all lawless 
 individual exhibitions of such tendencies, and that this 
 feeling has become part and parcel of the individual's 
 make-up. 
 
 The doctrine of sublimation, as developed by the psycho- 
 analytic school of psychology, furnishes probably the only 
 effective explanation for the lifting of this repression in 
 times of war. A sublimation is an outlet to primitive indi- 
 vidualistic instinct, rarely in a direct, more often in a 
 
11 
 
 symbolic form, but always so constituted as not to be re- 
 pugnant to society or to the social instincts of the subject. 
 Any man is not only a member of the human genus, but 
 also, and more immediately, a member of a smaller group, 
 that is, a tribe or a nation. And it is an interesting fact 
 that this group is apt to be more powerful in its influence 
 on the man than is the interest of mankind as a whole. 
 The more primitive is any people, the more does it tend to 
 regard members of other tribes or nations as belonging to a 
 different species, and therefore to be treated as natural 
 enemies, to whom no sympathy or consideration is due. It 
 follows from this that any man's instinctive morality is 
 much more strongly determined by the general standards of 
 the group with which he lives than by any interest in that 
 vaguer conception of mankind as a whole. The average 
 human being is therefore restrained in large measure from 
 the development of his tendencies to lust and cruelty by the 
 innate feeling he enjoys of the deleterious effect such actions 
 would have on his immediate fellows. When war develops, 
 however, a premium is put upon bloodthirstiness, and the 
 community extols the individual who is most effective in 
 inflicting injuries upon the bodies and lives of the members 
 of an opposing group. 
 
 This becomes, in effect, a sublimation, for now the soldier 
 can, by the same acts, give vent to his primitive passions 
 and reap the approbation of his fellows. Only two factors 
 may, occasionally, stand in the way of a complete develop- 
 ment of this sublimation; the fijrst is the habit of the man's 
 mind, who for years has been educated with ideals of 
 gentleness; the second is that degree of emotional unity, 
 he may possess, that binds him to all mankind, making 
 him sensitive to the sufferings of those outside his group. 
 The combined influence of both these factors is, apparently, 
 insufficient to inhibit an almost universal and fairly free 
 outlet to cruelty in the average modern man, as the present 
 war shows. The soldier is therefore usually able to take 
 delight in the injury he inflicts upon his foe, and to become 
 callously immune to the horrible sights to which he is 
 constantly exposed, since bloodshed, as such, has ceased 
 to be colored with horror for him. 
 
12 
 
 Another feature in the psychology of war is of clinical 
 importance. Individualistic and social, or herd instincts 
 are by their very nature in conflict. The predominance of 
 one over the other at any given time depends upon a num- 
 ber of factors, one of the most important of which is the 
 nature of the immediate stimulus. In time of war, either 
 the existence of the tribe or nation is threatened, or there is 
 a possibility of the power of the group being greatly aug- 
 mented. Either of these possibilities tends to stimulate the 
 social instinct of the individual, rather than his individual- 
 istic cravings. Consequently the citizen becomes less of an 
 individual and more an integral part of the society to which 
 he owes allegiance. He thinks less of himself. Greater 
 personal sacrifices become possible, and he is able to feel 
 his reward in the advantages which accrue to his party in 
 the struggle. This gives him the ability to endure fatigue 
 and deprivation, even cheerfully to face death itself, in a 
 way that would be quite impossible in times of peace. 
 This and the enjoyment of bloodshed probably constitute 
 the two most important factors in the production of the 
 change of character which the civilian undergoes in be- 
 coming a soldier. 
 
 In recent years, those who have been interested in the 
 more minute psychological study of neuroses, particularly 
 those of the psycho-analytic school, have found that before 
 the onset of actual symptoms, there is apt to be a period 
 during which there are changes in the patient's activities 
 or outlook upon life. Very often these changes are the 
 result of environmental accident, but, whether coming 
 from within or without, they consist essentially in a change 
 of his adaptation to the situation in which he is placed, 
 and involve a loss or weakness of sublimations which he 
 has previously enjoyed. A knowledge of this phenomenon 
 is of considerable aid in studying war neuroses, because 
 we find that an analogous change takes place in the adap- 
 tation of the soldier to his task before the appearance of 
 active symptoms. Anyone, who is at all familiar with 
 the phenomena of modern trench warfare, can see that it 
 makes a great demand on the devotion of the belligerents 
 
13 
 
 and offers little personal satisfaction in return. In pre- 
 vious wars the soldiers, it is true, were called upon to suffer 
 fatigue and expose themselves to great danger. In return, 
 however, they were compensated by the excitement of more 
 active operations, the more frequent possibility of gaining 
 some satisfaction in active hand to hand fighting, where 
 they might feel the joy of personal prowess. Now, the sol- 
 dier must remain for days, weeks, even months, in a narrow 
 trench or a stuffy dugout, exposed to a constant danger of 
 the most fearful kind; namely, bombardment with high 
 explosive shells, which come from some unseen source, and 
 against which no personal agility or wit is of any avail. 
 This naturally occasions great fatigue, and, on the other 
 hand, opportunities of active hand to hand fighting are 
 rare, so that a man may be exposed for months to the 
 appalling effects of bombardment and never once have a 
 chance to retaliate in a personal way. Consequently the 
 sublimations described above are more difficult to maintain 
 than in any previous war. The soldier becomes fatigued 
 (developing symptoms which will be discussed later) and 
 not unnaturally finds it difficult to remain satisfied with his 
 situation. His adaptation to warfare is, therefore, soon 
 weakened or lost. His disregard of the carnage and death 
 around him is gone, and he becomes every daj'^ more 
 acutely sensitive to the horrors which surround him. This 
 sensitiveness may develop even to the point of pity for the 
 foe, which is naturally an emotion most incapacitating for 
 a soldier. 
 
 With this dislike for the war there is inevitably some 
 degree of resentment at the State which has sent him to 
 fight, although this is apt to come only vaguely into full 
 consciousness. The bonds uniting him to the common 
 cause are definitely loosened, however, and as a consequence 
 his individual feelings begin to assert themselves. Acci- 
 dents to which he was previously liable, but to which he 
 was indifferent, are now viewed with apprehension. He 
 becomes fearful of the dangers opposing him, so that his 
 courage is no longer automatic but forced. According as 
 he has high or low ideals, is more or less intelligent, he 
 
14 
 
 feels a shame before his fellows as a coward, or feels ill- 
 treated by his superiors in being forced to continue fighting. 
 His feeling of cowardice may lead to superhuman efforts of 
 self-control, but these lead only to a cumulative increase of 
 his fatigue. Naturally he grows mentally and nervously 
 more and more unstable, but is prevented from leaving the 
 line, either by his superior officers or by his own shame at 
 the thought of "going sick," which is frequently looked 
 upon as a sign of weaTcness. Those of lesser intelligence 
 often regard their terrors as indications of approaching 
 insanity, and thus another worry is added to the strains 
 under which they suffer. Once a man has acquired this 
 unhappy condition any trifling accident, such as a mild 
 concussion from an exploding shell, or some particularly 
 unpleasant experience, may cause a final break and lead to 
 such an exaggeration of symptoms already present that he 
 becomes totally incompetent. 
 
 It is not unnatural that anyone in this situation should 
 look for some relief, and, unconsciously at least, this must 
 be a powerful factor in the production of disabling 
 symptoms. In many cases, after more or less of these 
 prodromal difficulties, symptoms appear that seem to be 
 specifically directed against the man's capacity to fight. 
 
 As many physicians in England, previously apathetic or 
 antagonistic to psychoanalysis, now admit, the general 
 mechanisms of repression of emotionally toned ideas with 
 their reappearance when repression fails, are responsible 
 for the production of the symptoms of war neuroses. 
 Psychoanalysts in civilian practice claim that the individ- 
 ualistic tendencies in question are preponderantly related to 
 the sex instinct. In war, however, this does not seem to 
 be the case, these latter tendencies coming into play, 
 apparently, only as a complication. The reason for this is 
 probably to be found in the fact that in warfare the instincts 
 of self-interest and self-preservation, which are equally as 
 primitive and basic as the sex instinct, are involved in a 
 way that they never are in normal civilian life. The 
 psychological factors are consequently much more simple, 
 and it may be that this explains the extraordinary amena- 
 
15 
 
 bility of the war neuroses to treatment. Personality studies 
 of many of the cases, however, show a previous weakness 
 in adaptability that is confined to such demands as are 
 essentially related to sex. These individuals, although 
 they may never manifest symptoms directly related to any 
 erotic tendencies, are nevertheless apt to suffer sooner or 
 more severely than their completely normal fellows. The 
 explanation for these two phenomena is perhaps to be found 
 in the fact that sex adaptation is quite the most difficult of 
 all those which the individual has to make in modern 
 civilization. The same fundamental weakness exhibits 
 itself in his failure to respond fully to the most trying 
 demands of civilian life, namely, those of sex adaptation, 
 and in his inability to meet the demands of war. In other 
 words, the neurotic in times of peace may have his symptoms 
 on account of poor adaptation in the sex sphere, but this is 
 fundamentally dependent on some vague constitutional 
 defect from which he suffers. It is this defect which also 
 makes him liable to lose his efficiency in the unparalleled 
 strain of modern war. One makes inquiry into a patient's 
 past life, therefore, not only in order to discover what there 
 may have been in his previous character which would 
 directly affect his capacity as a soldier, but also to gain 
 some rough idea of how resistant he had previously been to 
 the most disturbing influences of life. 
 
 Anxiety States. 
 
 The term ' ' Anxiety States ' ' is chosen to designate one 
 of the two clinical groups into which the war neuroses fall, 
 for the reason that anxiety is the most prominent and con- 
 sistent feature in the clinical picture. These cases bear 
 most resemblance to what is frequently termed ' ' neuras- 
 thenia " in civil practice, but it is thought better to avoid 
 this term in the present instance on account of the vague- 
 ness which almost universally exists as to what neuras- 
 thenia is. Unfortunately the term has been used to include 
 practically every neurosis. 
 
 The clinical course of an anxiety state is as follows: the 
 patient is a man who may or may not have had a past 
 
16 
 
 history of abnormality. The existence of abnormality 
 affects the clinical course of his neurosis in that it is apt to 
 indicate an earlier onset, more marked symptoms and a 
 longer duration. But there are too many exceptions to 
 this statement to make it more than a generalization. 
 
 When the civilian enlists or is commissioned, he at once 
 enters into a totally new life, and, provided he is a tolerably 
 normal individual, quickly adapts himself to it. This is 
 demonstrated by his eagerness to learn his new duties, his 
 pleasure in his accomplishment as training progresses, and 
 in an increased sociability. It is frequently found that an 
 individual who has been rather shy will make more friends 
 after entering the army then he ever did before. It is, of 
 course, unnecessary to state that training almost invaria- 
 bly has a marked effect on physique in the direction of 
 improvement. 
 
 The mental attitude of the new soldier on leaving for the 
 front is of some interest. The majority of men are eager 
 for their new experiences and look forward to active service 
 without much apprehension. A few, however, of the more 
 introspective type, are unable to keep their thoughts away 
 from wounds and death; some with a distinct fear of fail- 
 ure, that is, a fear that their courage may not be equal 
 to the demands made upon it. With occasional men this 
 apprehension is suflScient to precipitate a neurosis, but the 
 clinical features of this are more apt to resemble the peace, 
 than the war, type, and none are included in this report. 
 It is important to note that some momentary disquietude at 
 this stage is not necessarily indicative of coming failure. 
 There are men who approach the actual battlefield with 
 considerable misgiving, but are surprised to find how 
 indifferent they quickly become to the dangers they meet 
 there. 
 
 The first actual trial which the recruit usually meets is 
 the experience of being shelled. Naturally the intensity 
 of the bombardment varies greatly, and if the shells are 
 falling at long intervals of time and at considerable dis- 
 tance, it is only the most unstable who are particularly 
 affected. Few, if any, as far as one can learn, are abso- 
 
17 
 
 lutely normal on introduction to a heavy bombardment. 
 By far the commonest response is one of fear, usually 
 accompanied with the idea of running away, which the 
 subject himself sees to be absurd. Although the men may 
 make an effort to hide the signs of this fear, they are so 
 frequently evident under initial shelling that the military 
 authorities count on their appearance. Their presence at 
 this time is no indication of the degree of indifference which 
 may later develop. A less common reaction is that of 
 excitement, accompanied even with a kind of spurious 
 elation. The man has a tendency to make facetious 
 remarks about the shells, to laugh at feeble witticisms, and 
 very often feels under considerable motor tension, there 
 being a pressing desire to do something, to do it immedi- 
 ately and do it hard. A still more unusual but very inter- 
 esting reaction is that of slowness or languor (which may 
 succeed primary fear). This may be accompanied by a 
 depressive affect or by lethargy so extreme that the indi- 
 vidual will lie down and go perforce to sleep with a patho- 
 logical indifference to the danger. 
 
 None of these reactions seem, of themselves, to be indica- 
 tive of the future adaptability of the soldier. That is 
 determined much more by the duration of these symptoms. 
 Most men recover quite soon (a matter of a day or so) and 
 then become indifferent to the possibility of being hit, and 
 capable of philosophically considering the chances. This 
 development is usually accompanied by, or is the result of, 
 learning to recognize the location and direction of the 
 shells by the sound they make in traveling through the 
 air. When a man can tell from the sound that a shell is 
 traveling some distance over his head and will fall a hun- 
 dred yards to the rear, that sound has no further terrifying 
 effect on him. 
 
 If the primary bombardment be sufficiently heavy, the 
 soldier sees his first casualties, and it is a rare man who is 
 not struck with horror at the sight of the mangled remains 
 of his comrades. The man who is going to make a good 
 soldier, however, quickly becomes accustomed to this. 
 Similarly, there may be an initial inhibition with horror at 
 
18 
 
 tlie thought of inflicting wounds on, or killing, an opponent, 
 but this, too, is a temporary phase. Individuals who can not 
 recover fully from their initial fear, horror, or reluctance 
 to inflict injury, never build up that sublimation which we 
 have described, and so are poorly adapted to a soldier's 
 life. These men are very quickly fatigued and develop 
 disabling symptoms. 
 
 The first sign of an approaching neurosis is fatigue. The 
 word sign, rather than symptom, is used because fatigue as 
 such is a condition which is completely removed by rest, 
 and rest of quite brief duration. For the neurosis, fatigue 
 is of importance, as it is the almost universal occasion of 
 the dissatisfaction with his work which leads to a breaking 
 down of the soldier's adaptation and the development of more 
 permanent symptoms. The conditions producing fatigue 
 are both physical and mental. Those on the physical side 
 are the obvious ones of long hours of duty, combined often 
 with irregularity of meals, shortness of water, exposure to 
 extremes of temperature, constant wetting, etc. Although 
 these factors need no detailed consideration on account of 
 their obviousness, their importance in producing fatigue 
 can not be too strongly emphasized. Important as they are, 
 however, they are probably of less influence in the produc- 
 tion of neurotic fatigue than are the purely mental in- 
 fluences. The most common and important of these is the 
 strain of continuing in a dull routine that demands a con- 
 stant alertness, a speediness of decision, complete self- 
 confidence and a spontaneous eagerness. And this mental 
 attitude must be maintained hours, even days, on end, with- 
 out sleep, often without the distraction of food, and in the 
 face of constant danger. Other, more personal, factors 
 contribute to the development of fatigue. A man, for 
 instance, may be placed under the authority of some one 
 who is antagonistic to him and makes everything as diffi- 
 cult as possible. This naturally leads to distrust, and once 
 a man's confidence is lost in his superiors it is soon impossi- 
 ble for him to disregard the strain under which he suffers. 
 Many men, too, have peculiarities that make them suscep- 
 tible to particular discomforts. Such things as the presence 
 
19 
 
 of vermin, and the frequency of bad odors, particularly 
 where there are many unburied bodies, are factors of no 
 mean importance in slowly disheartening the soldier. In 
 fact, one can safely say that in view of the many external 
 physical diflSculties, a soldier can be kept in the best men- 
 tal condition only when he is not irritated by things which 
 affect his special sensibilities, and, most important, when 
 he feels sociallj^ comfortable with his mates. Not infre- 
 quently the death of a close friend or comrade may be the 
 signal for the stress of warfare to make its effects known. 
 
 The above views present this neuro-ps^'chic fatigue as a 
 product of environmental, or of mental, factors. It must 
 be mentioned, however, that other views are held on this 
 matter. When these patients are finally brought to a hos- 
 pital, it is often found that they have a low blood- pressure. 
 Temporary symptoms indicative of thyroid disturbance are 
 also seen not infrequently. Some students of ' ' shell shock ' ' 
 have therefore made the claim that the fundamental and 
 primary cause of the neuroses lies in the ductless glands. 
 They consider that the patients have succumbed to the 
 strain of warfare because their endocrinic functions were 
 less stable than those of their fellows. Considering that 
 the vast bulk of these men have never shown any symptoms 
 earlier in their lives of internal secretion disease, this is prob- 
 ably too sweeping a statement to be accepted as such. It 
 must be borne in mind, however, that some chemical change 
 is probably present in neuro-psychic fatigue. The poison — 
 whatever it is that affects the central nervous system — may 
 easily be the product of some endocrinic reaction to abnor- 
 mal conditions. This opens up an important and not un- 
 promising field for research. Civilian life does not favor 
 the development of fatigue to anything like the same extent 
 as does the stress of war. Consequently, any chemical 
 changes must be present in a greater degree than in the 
 milder states of mere ' ' tiredness ' ' which we meet in times 
 of peace. Therefore, what has heretofore remained undis- 
 covered might now be found to the immense benefit of 
 neuropathology . 
 
 It can readily be seen that the more in the mental sphere 
 
20 
 
 a man's responsibilities lie, the more quickly will he be 
 affected, and it is a striking fact that anxiety conditions in 
 the pure state occur almost exclusively among officers. It 
 is their task, not merely to keep their own feelings in sub- 
 jugation, but to inspire the men beneath them with courage 
 and enthusiasm. 
 
 The evidences of fatigue are almost exclusively in the 
 mental sphere. It goes without saying that there is a sub- 
 jective feeling of weariness. This, however, is so common 
 and so easily produced that it is of no especial significance. 
 What one can term fatigue in a clinical sense appears when 
 other symptoms develop. These are a feeling of tenseness, 
 a restless desire for action or distraction, irritability, diffi- 
 culty in concentration, and a tendency to start at any 
 sudden sound (without fear), the sound being usually that 
 of exploding shells. This reaction of nervous starting is so 
 common that it is universally known by the officers and 
 men as "jumpiness." There is usually a slight improve- 
 ment in the feeling of weariness toward night, as a certain 
 degree of excitement accumulates which enables the indi- 
 vidual to disregard his difficulties. 
 
 The nocturnal symptoms are even more distinctive. 
 There is great difficulty in getting to sleep, with a long 
 period of hypnagogic hallucinations. Whatever has been 
 the dominating experience of the day appears in trouble- 
 some vision before the e3^es of the soldier, who although 
 knowing that what he sees is not actually there, is still un- 
 able either to go to sleep or to awaken himself sufficiently 
 to banish the visions. The only emotional reaction is a 
 feeling of irritation with restlessness. Fatigue as such does 
 not seem to produce fear. When sleep does come, it is 
 often troubled by repeated dreams of the occupational type 
 where the soldier is trying to do whatever was his task 
 during the day, is having constant difficulty and meeting 
 with no success in accomplishment. The sleep, too, is fre- 
 quently interrupted by the man suddenly awakening with a 
 jump, although he is not conscious of this wakiug being the 
 result of any incident in his previous dream. As a result, 
 he gets many less hours sleep than he expected, and little 
 
21 
 
 benefit from the sleep he does achieve. He awakes in the 
 morning- more tired than when he lay down, feeling slow 
 and unwilling to assume the duties to which he has to force 
 himself. 
 
 When this situation has continued for some time and 
 become cumulatively worse, fear, as has been said, develops, 
 and also horror of the sights around him. Both of these 
 are signs that the "war sublimation" has failed. The 
 soldier finds himself, when alone and not mentally occupied 
 with his duty, thinking of the horrible sights he has seen. 
 He dwells obsessively on the difficulties which surround 
 him, on the frictions he may have with brother or superior 
 officers, and can not keep his mind away from the possi- 
 bility of injury. It is interesting to note that the British 
 soldiers are singularly free, at this stage, from homesickness, 
 although the Canadian troops are very liable to it. This is 
 presumably the result of the longer distance from home of 
 the latter and the impossibility of return within the near 
 future. 
 
 A man in this condition is very apt to find a certain ex- 
 ternalization of his difficulty in thinking about war in 
 general, and there are probably no more fervid pacifists in 
 existence than many of the men who are conscientiously 
 fighting day after day. Many of them acquire with their 
 reluctance to bloodshed such a pity for the enemy that they 
 find it difficult to fight effectively. At this stage when fear 
 is developing, a man begins to lose his judgment concern- 
 ing the direction of shells. At first, he feels frightened 
 when he hears the shell coming, although he knows it is not 
 going to land where he is. Later, he loses the ability to 
 gauge its direction, and consequently every shell seems 
 aimed at him personally. Naturally in such a situation a 
 heavy bombardment becomes almost intolerable. It is 
 necessary, however, particularly for the officer, that all signs 
 of fear should be hidden, and to his other difficulties is added 
 the fear that he may not be able to hide his fear — another 
 factor in the vicious circle. 
 
 Thus afflicted, the soldier now has ideas of escape, the 
 nature of which has considerable influence on the symp- 
 
22 
 
 toms to follow. There are three practicable avenues of 
 escape; the man may receive an incapacitating wound, he 
 may be taken prisoner, or he may be killed. One who 
 manifests an anxiety state is always one with high ideals 
 of his duty. We find, therefore, that none of them entertain 
 the hope of disabling- wounds. Nor do they consciously 
 seek surrender, but it is interesting that the}'' not infrequently 
 dream of it at this stage. The third possibility is the most 
 alluring, as it offers complete release and is quite compatible 
 with all standards of duty. It is not unnatural, therefore, 
 that many of these unfortunates who are constantly obsessed 
 with fear perform most reckless acts. Almost universally 
 there are thoughts of suicide, and many of the men thus 
 afflicted will plan different methods of accomplishing their 
 own deaths in ways which could not be subsequently 
 regarded as suicidal. 
 
 When once the desire for death has become fixed, a 
 complete breakdown is imminent. This breakdown, as a 
 rule, occurs after some accident, which is either physical or 
 mental. The commonest physical accident is the exposure 
 to the explosion of a shell, which either produces a brief 
 unconsciousness by concussion, or, possibly, poisons the 
 individual with some noxious gas. After this accident, the 
 neurosis is suddenly established in an incapacitating form, 
 or if the fatigue symptoms have just begun, they are 
 suddenly very much worse. 
 
 The mental accidents should properly be called precipi- 
 tating factors. They consist of psychic traumata such as 
 particularly horrible sights, the mangling of some close 
 friend, or the killing of all others in the immediate environ- 
 ment. Occasionally it is an extremely dangerous situation, 
 such as arises when a company is isolated in an advanced 
 trench and subjected to a pitilessly methodical bombard- 
 ment that seems certain to kill every occupant of the trench 
 sooner or later. A very frequent occurrence is burial with 
 earth thrown up by an exploding shell. Some clinicians 
 are inclined to attribute all the results of such burial to 
 concussion, whereas a more thorough examination of many 
 patients, who have been buried, reveals the fact that there 
 
23 
 
 have been no symptoms developed which could not be fully 
 accounted for on the basis of mental shock, and, on the 
 other hand, that there have been none that point definitely 
 to concussion. It is important to note that this quite 
 frequent accident produces little or no effect on the normal 
 individual, but is extremely trying, if not actually incapaci- 
 tating to the soldier who has begun to manifest symptoms. 
 
 Another precipitating factor, that is obviously purely 
 mental, is the disappointment ensuing on a refusal of 
 "leave" from the trenches when that has been expected. 
 The man whose ability to continue fighting has been put 
 to a great strain, is enabled to keep going by the thought 
 that there is a definite end in view. When this end is 
 suddenly and indefinitely postponed, his last remaining 
 source of encouragement is gone and he collapses. Simi- 
 larly, when the soldier is sent back to a rest camp for a 
 short stay and this has proved insufficient to restore his 
 equilibrium, the order to return to the front line may cause 
 the sudden development of incapacitating symptoms. 
 
 It is both theoretically and practically of the first impor- 
 tance to recognize that actual wounding does not disable 
 the soldier neurotically, no matter what his mental and 
 nervous condition may be. This is really not difficult to 
 understand. As we have seen, the man has an urgent 
 desire to escape from an intolerable situation, and a large 
 part of the motivation of the symptoms comes directlj^ from 
 this wish. A wound is obviously an ideal form of relief. 
 So true is this that it is said to be a common occurrence for 
 a soldier who has had a foot or a leg blown off, to dance 
 about on the remaining one shouting with joy that he has 
 got a "Blighty one" (Blighty being the Tommies' slang 
 for England; that is, a wound which will take him home). 
 
 The acute symptoms of the neurosis may be ushered in 
 with a stuporous state. As I have said before, I have not 
 enjoyed an opportunity of examining cases at this stage, 
 and so must rely on what can be gained from the patients' 
 own retrospects, and what is to be learned from others. It 
 seems that these stuporous states that ensue suddenly after 
 concussion or some mental trauma are of two types, organic 
 
24 
 
 and functional, althoug^h the latter may slowly emerge from 
 the former. The organic type is marked by a true loss of 
 consciousness, followed by a period during which conscious- 
 ness reappears and can be maintained for a short time, only 
 to lapse again. This ' ' dipping " may endure for days, even 
 weeks. While conscious, the patient is extremely confused, 
 disoriented, usually complains of violent headache, is 
 frequently incontinent and may have to be catheterized. 
 A delirium is very frequent, the content of which is constant 
 aggression on the part of the enemy, either with bayonets, 
 bombs or shells, against which the patient is largely or 
 completely powerless. 
 
 The functional type of stuporous state may be ushered in 
 by a condition which apparently expresses the acme of fear, 
 the patient lying with dilated pupils, in a cold sweat, with 
 shallow breathing, incapable of any voluntary movement, 
 and often trembling violently. Following this, there is a 
 phase when voluntary movement is possible, during which 
 he is dazed, inactive, confused and amnesic, and may 
 use gestures in place of speech. Myers thinks that the 
 "unconsciousness ' ' of which so many patients subsequently 
 tell may really be this stuporous state. Unfortunately he 
 attempts no discrimination between organic and functional 
 symptoms in these conditions. 
 
 While still in a stuporous state, the patient may suffer 
 from hallucinations concerning which he is amnesic or 
 confused later. It is only the more severe cases, of course, 
 which show marked or prolonged symptoms of stupor. In 
 others, the hypnagogic hallucinations of which we have 
 spoken pass over into somewhat similar visions, which are 
 now accompanied by fear. That is, in place of a repetition 
 of the day's work, in the visions on going to sleep, the 
 patient sees soldiers advancing against him with bayonets, 
 throwing bombs at him, feels mines exploding beneath his 
 feet, or he hears shells coming shrieking toward him. 
 Insight as to the reality of these visions varies. Occasion- 
 ally it is constant. More often it is applied with some effort 
 on the part of the patient, whereas it is quite unusual for it 
 to be consistently absent. Any sudden sound, such as a 
 
25 
 
 door slamming, is interpreted as the explosion of a shell, 
 with consequent terror. The patient jumps with fright, 
 although he usually realizes very quickly the real nature of 
 the sound. 
 
 In his preliminary symptoms, the patient, as a rule, may 
 have been bothered with dreams of the occupational type, 
 but has had few, if any, nightmares. Once the neurosis 
 reaches this acute stage, however, sleep becomes torture 
 owing to the violence of nightmares. These, like the 
 hallucinations have a purely war content, the setting of 
 which is, as a rule, the section of the line in which the 
 patient has last been, or that section in which he may have 
 been subjected to most severe strain. The exact nature of 
 the injuries which seem imminent in the dreams, naturally 
 varies with the type of fighting in which the man has been 
 engaged. The enemy is throwing bombs at him, which 
 explode at his feet, he is about to be bayoneted, he is shot 
 down in an aeroplane or shells are raining upon him. 
 Unlike dreams in times of peace, no amount of cross- 
 questioning can produce any details which would indicate 
 that there is any inaccuracy in the delineation of the normal 
 environment. That is, the soldier is always in France, he 
 is always in a trench, his comrades are always his natural 
 comrades, nothing is distorted except that he is invariably 
 powerless to retaliate, and his fear is infinitely greater than 
 it ever is while he is awake in a situation at all similar. 
 This last point is quite intere.sting psychologically. Patients 
 who have these dreams while still in the trenches may be 
 completely paralyzed with fear in their dreams, and yet be 
 capable of performing their duties diiring the da}^ with few 
 signs of nervousness; occasionally they are even totally free 
 from fear during the day. 
 
 The patient is, of course, awakened, as in the civilian 
 nightmares, in a cold sweat of terror; frequently he awakes 
 screaming. As even a few minutes' sleep means the appear- 
 ance of such a nightmare, there is added to his previous 
 difficulty in falling to sleep, a fear of sleep, and this reduces 
 his actual rest, obtained without sedatives, to a very small 
 amount. In fact, patients may go for some weeks getting 
 only a few minutes actual normal sleep any night. 
 
26 
 
 Naturally then, the fatig-ue from which he previously 
 suffered is greatly increased. It is particularly in evidence 
 in the morning-, improving somewhat as the da^^ goes on, 
 and apt to be much worse again by night. Blood-pressure 
 may be quite low according to some observers. Some have 
 found this so reg-ularly, and have seen it rise again so 
 consistently with improvement, that they have concluded 
 that there is a primary disturbance in the glands of internal 
 secretion. It is not unlikely that a change in endocrinic 
 functions determines the low pressure, but the evidence 
 seems to point toward this change being secondary to 
 fatigue (or concussion). It must be borne in mind that the 
 degree of fatigue developed in active warfare is incompar- 
 ably greater than anything we ever see in times of peace, 
 and that a low blood-pressure is therefore to be expected. 
 Patients in the acute phases of the neurosis are frequently 
 subjected to photophobia. Tremors are, I believe, always 
 present. These occur most frequently in the hands and 
 arms, but may appear in any part of the body. They are 
 present both at rest and on voluntarj^^ movement, the latter 
 being much more marked. There is also sometimes a slight 
 ataxia which is never really disabling. Both tremors and 
 ataxia are prone to be much exaggerated when attention is 
 directed to them. Cyanosis of the hands and feet is 
 frequently observed, but perhaps not more often than in 
 soldiers who have no neurosis, but have been exposed to 
 the inclemencies of the weather during many winter months. 
 
 Symptoms suggestive of disturbance of the thyroid gland 
 are very frequent, but usually of short duration. The ej'-es 
 protrude slightly, and the upper eyelid may lag behind the 
 eyeball on looking downward; the pulse is rapid, excessive 
 sweating is extremely common, and sometimes there is a 
 slight enlargement of the thyroid gland. Headaches, rarely 
 of extreme violence, are common. 
 
 Objective mental symptoms are shown occasionally by 
 tics, such as blinking the eyes, or a grimace accompanied 
 by a withdrawal of the head, suggesting the starting back 
 from something unpleasant. 
 
 Histories of these patients sometimes state that they have 
 
27 
 
 been subject to hysterical "fits, " so that epilepsy has been 
 considered. Although unable to observe any of these at- 
 tacks myself, I have carefully questioned a number of 
 patients who have had them, and from their account I 
 should be inclined to believe that they were not convulsions, 
 in any sense of the word, but much more like tantrum 
 reactions, and similar to the performances of a child who 
 lies on the floor and kicks when particularly upset. 
 
 The facial expression of many anxiety cases is suffi- 
 ciently typical for a diagnosis to be made by mere inspection. 
 The face is drawn, showing signs of fatigue, while the 
 emotional strain is exhibited by chronic frowning with con- 
 siderable wrinkling of the forehead. The patients look as 
 if they were under great strain, and maintaining control of 
 themselves with effort. The expression suggests a chronic 
 mental, rather than physical, pain. 
 
 As most of these patients are kept in bed for some time, 
 they are apt to be weak on getting up, and as a result find 
 themselves unsteady on their feet when they attempt to walk. 
 As a rule, this is recovered from quite quickly. Occasion- 
 ally, however, the staggering, uncertain gait with coarse 
 tremors of the feet and legs, which is natural to a weak- 
 ened patient, becomes with all the symptoms exaggerated, 
 a chronic gait. This is rare in officers but more common 
 among privates. 
 
 There is an interesting feature of the mental state of these 
 patients, not at all obvious, but subjectively painful, and 
 one that has considerable effect on the course of the disease 
 when it is well marked. As has been said, these men, while 
 still in the firing line, are apt to think more of themselves 
 than they previously had thought, and consequently to get out 
 of touch with their fellows. This latter tendency is almost 
 universally present when the neurosis is firmly established. 
 The patient suffers considerably from a lack of sociability, 
 and of spontaneous affection. This is probably due, in part, 
 to a sense of un worthiness which develops with a feeling of 
 cowardice. As in almost any neurosis, there is consider- 
 able introversion. Many a patient wants to be alone, and, 
 although he is always capable of making a good impression 
 
28 
 
 socially in a formal way, he finds it difficult to exhibit any 
 signs of affection. The man who is visited by his mother, 
 his wife, or his sweetheart is a disappointment both to him- 
 self and to his visitor in that it is impossible for him to give 
 any convincing proof of his affection. This finds expres- 
 sion physically in a painfully obvious way through the 
 symptom of impotence, which is, so far as I have been able 
 to learn, universally present in the anxiety state, either as 
 such or in the form of its equivalent, lack of erotic feeling. 
 Even in quite mild cases it occurs, and its demonstration 
 may be a distinct shock to the patient. More frequently no 
 attempt at intercourse is made, through lack of desire. 
 
 These symptoms continue acutely for a few weeks in most 
 cases, sometimes for months in the more severe neuroses. 
 All the more obvious symptoms tend to abate gradually with- 
 out particularly painstaking treatment. The dreams grow 
 less frequent, and usually disappear. Quite frequently the 
 content changes when the patient has been away from the 
 trenches for some time. Distortions occur whereby the set- 
 ting comes to include more of the normal peace environment. 
 For example, the patient may begin to have normal dreams 
 of civilian life which will be suddenly interrupted by the 
 appearance of the enemy with bombs or bayonets. A man 
 may be playing golf, when the foe suddenly appears on the 
 green. A very interesting change of content occurs occa- 
 sionally and marks a radical emotional change. For some 
 time dreams will proceed, in which the enemy is invariably 
 successful and the dreamer powerless. Then the dreamer 
 begins to show fight, and for some nights may struggle, 
 although still defeated. Next, the battle becomes a draw. 
 Finally, the dreamer begins to get the upper hand and is 
 able to enjoy the fight of which he dreams, because he in- 
 variably punishes the enemy. Such a sequence augurs well, 
 of course, for the man's further adaptability in the firing 
 line. When improvement begins, the fatigue lessens suffi- 
 ciently for the patient to leave his bed and indulge in mild 
 activities about the hospital. He is surprised, however, to 
 find how quickly he becomes tired, even exhausted, when 
 he goes through the streets, or attempts to play some game. 
 
29 
 
 But, unless there are other complications, this phase of 
 fatigability, rather than chronic fatigue, is quickly passed. 
 
 The constant apprehensiveness which persists throughout 
 the day in the acute stages, disappears, but in its place there 
 remains a good deal of " jumpiness." In the earlier stages 
 a sudden noise is interpreted as an explosion. Then the real 
 nature of the sound is instantaneously recognized, but the 
 patient is frightened, which suggests that unconsciously the 
 sound is still regarded as a shell. Later the habit of start- 
 ing at any sound persists without any fear. That this is 
 purely a neurotic habit, is demonstrated by such instances 
 as the following: I was talking to a patient when he moved 
 to knock some ashes from a cigarette into a small bowl. 
 While his hand was approaching the bowl, a door slammed. 
 The patient proceeded to execute his movement quite care- 
 fully and then to jump violently, although more than a 
 second had elapsed between the sound and the jump. At 
 this stage the patient can, if he exerts sufficient effort, train 
 himself to remain calm when sudden noises occur. Quite 
 frequently the patients who are more intelligent can remem- 
 ber accurately the phases of development and disappearance 
 of this symptom. 
 
 The patient has now come to appear objectively normal, 
 but grave defects are still subjectively present to interfere 
 with his renewed adaptation to trench warfare. He finds, 
 for instance, that crowded traffic makes him excessively 
 nervous. He is fearful that his taxicab will run over some 
 one in the street, or that there will be collisions. He finds 
 himself fearful if he is in a high place, or looks out of a 
 window some distance from the ground. He can not enter 
 a tunnel, and thunder-storms terrify him. Perhaps his most 
 distressing symptom is his feeling of incompetence and his 
 lack of desire to return to the front. He is a subject of seri- 
 ous mental conflict. He knows that duty calls him to fight 
 again, and that he ought cheerfully to assume these duties, 
 but he recognizes that he is a coward, feels great shame over 
 this, and is even more ashamed of the lack of desire to do 
 his bit. It is this final phase which may be indefinitely 
 prolonged if appropriate psychological treatment is not 
 available. 
 
30 
 
 When acute symptoms subside, complications are prone 
 to appear. It would not be surprising to any one familiar 
 with the psychology of the neurotic to learn that the disap- 
 pearance of obviously incapacitating symptoms may be the 
 signal for others to develop which would make return to 
 the front impossible. Naturally, these complications occur 
 mainly, if not exclusively, in those who have before the 
 war been not quite normal. A man, for instance, who has 
 previously had a neurosis, may produce his old symptoms 
 again. Captain Rivers* thinks that adaptation to war 
 demands a repression of all neurotic tendencies and abnor- 
 malities, which, on account of this repression, increase in 
 intensity, and therefore reappear with unwonted strength 
 when the patient has been absent from the front for some 
 time. 
 
 A frequent complication is depression. This rarely, if 
 ever, reaches the point of retardation. It is much more a 
 subjective feeling of hopelessness and shame for incompe- 
 tence and cowardice. Sometimes the depression is the 
 accompaniment of obsessing thoughts about the horrors the 
 patient has seen, and about the horrors of war in general. 
 Very often he is depressed because he feels that he is not 
 being treated well. This last is probably a development of 
 the lack of contact with his fellows which has been previ- 
 ously enjoyed. The patient, having become interested more 
 in his own welfare than in the needs of the army or the 
 country, is prone to dwell on the sacrifices he has made and 
 the obligations of the state to him. Such patients are there- 
 fore morbidly interested in having attention paid to them. 
 This is somewhat different from ordinary hypochondria, in 
 that it is not a physical symptom for which the patient de- 
 mands attention so much as it is himself, his personality, 
 which he feels to be neglected. 
 
 The diagnosis of this neurosis naturally offers very little 
 difficulty. The only condition with which it could be con- 
 fused is malingering. The history and appearance of these 
 patients should, however, never leave much doubt in the 
 mind of the physician. Some history of slow onset and 
 gradual dissatisfaction is invariably present in those cases 
 
 * Personal communication. 
 
31 
 
 who do not break down after physical trauma. Even those 
 who have suffered from severe concussion will give a similar 
 history, although it may be reduced to the presence of mild 
 symptoms for a short time before the accident. I was 
 unable to find a single case of pure anxiety who did not give 
 a history of some prodromal difficulties. The concussion 
 cases also show signs of organic disturbance of the brain 
 function, which are diagnostic (dipping of consciousness, 
 confusion, disorientation, etc.). The malingerer is not likely 
 to speak frankly about his gradually increasing terror, 
 whereas the man suffering from a true anxiety neurosis is, 
 as a rule, extraordinarily open and frank about the matter. 
 The appearance, too, of drawn face, staring eyes, exhibit- 
 ing obvious distress, combined with a rapid pulse and 
 excessive sweating, is something which it would be very 
 hard to imitate consciously. Difficulty in eliminating 
 malingering occurs almost exclusively with the conversion 
 hysterias rather than with the anxiety neuroses. 
 
 It may be well to describe in somewhat more detail the 
 various factors of importance in the production of the 
 anxiety state with illustrative cases. 
 
 Mental Make-up : There are certain features in the per- 
 sonality study which are more or less directly related to the 
 capacity of the individual for warfare. It goes without 
 saying that one always makes inquiries as to the existence 
 of actual nervous breakdowns. An individual who has 
 once given way to a neurosis is obviously more likelj^ to be 
 unstable than one who has not. What one may term 
 neurotic tendencies rather than neuroses must be searched 
 for diligently. The man who, as a child, has sviffered from 
 night terrors and fear of the dark will probably, under a 
 strain, be more apt to become fearful than one who has not. 
 Similarly an individual who has been either chronically, or 
 as a child, afraid of thunder-storms, is apt to be affected 
 more quickly by shell fire, as the noise of bombardment is 
 extremely like that of a violent thunder-storm. A man with 
 a tendency to claustrophobia, which in times of peace may 
 be indicated only by a slight feeling of faintness in an 
 underground train, or by an unusual sensitiveness to the bad 
 
32 
 
 air in such a situation, or a mild feeling of discomfort, is apt 
 to be fearful of dugouts being blown in, or to be particularly 
 afraid that he may be buried by a shell. The existence of 
 such claustrophobic tendencies may be determined by ques- 
 tioning as to symptoms of all kinds while in a subway, or 
 by finding out whether the patient has suffered from night- 
 mares of premature burial, or of being enclosed in some 
 small space. Great sensitiveness to cruelty, horror of blood- 
 shed and accidents, discomfort at the sight of animals being 
 killed, unusual sensitiveness to pain, either in himself or 
 others, are all indications of more than normal difficulty 
 which the soldier may have in accustoming himself to the 
 horrors of war. Occasionally this abnormality may be 
 expressed in a morbid fascination for the horrible. 
 
 Seclusiveness, as has been said, is important in that it is 
 an indication of general lack of adaptability, and is, of 
 course, more likely to occur in an individual who is not quite 
 up to par in his ability to meet any situation, particularly 
 one such as war, that demands the highest degree of 
 normality. It has, however, another and more direct impor- 
 tance. The soldier who is not naturally sociable has, as a 
 consequence, less of an outlet for his feelings in the trenches, 
 and is less distracted from the thoughts of the painfulness 
 of his situation than is his normal companion. As a result, 
 he becomes more quickly a prey to all the influences that 
 generate fatigue and dissatisfaction. 
 
 The following cases exhibit different types of make-up 
 and the effect of previous abnormalities on the development 
 and symptoms of anxiety neuroses. 
 
 Case III. The patient is a lieutenant, of 25, an artist before 
 he joined the army, who had never had any nervous breakdown, but 
 with the rather high-strung sensitive disposition frequently found in 
 those who adopt this profession. As a child he had frequent night 
 terrors, which disappeared as he grew older, but evidently had made 
 quite an impression on him. In fact he spoke of the dreams which 
 developed in his neurosis as a return of his childish nightmares. 
 He never was able to prevent giddiness when he was in an especially 
 high place, but had no fear of thunder-storms. He was abnormally 
 sensitive to the sight of blood, and more sympathetic than is usual. 
 He had no dreams of premature burial, but as a child remembers 
 having fear of being shut up in a small place. In his adult life he 
 
33 
 
 had an uncomfortable apprehensiveness when on the underground 
 railway, and was positively terrified by the " switchback " — a railway 
 in amusement parks that dashes suddenly into sepulchral caverns. 
 
 All his life he was of a rather retiring and self-conscious disposition, 
 but constantly struggled against it, and was able to make fair adapta- 
 tions. For example, he played the usual games at school, and 
 creditably, too, but never was capable of abandoning his self-con- 
 sciousness and joining in with the usual boyish pranks with any 
 great enthusiasm. He was similarly rather shy with girls, but did 
 not let this prevent him from going out in society, although he had 
 no puppy love affairs. He fell in love with only one girl and married 
 her immediately before entering the army. As practically all of his 
 married life had been spent away from home, it was impossible to see 
 how well he would have adapted himself to marriage. 
 
 He reacted well to his training and became more sociable and self- 
 reliant. When he arrived in France and came under shell fire he 
 was frightened, and although he recovered to a certain extent from 
 his initial terror, he never was capable of wholly ridding himself 
 from fear of shells. 
 
 The horrors of war made a constant impression upon him, and 
 afflicted his sensitive nature to such an extent that he never could 
 bring himself to enjoy the fight The best that he could do was to be 
 unaware, in an advance, that he was killing men. He was not afraid 
 of machine guns, had some slight fears of snipers, but found a con- 
 stant strain in waiting in the trenches for shells to come, the likeli- 
 hood of which was always in his mind. His claustrophobic tendencies 
 appeared in that he was afraid of the dugouts and hated to go into them, 
 although they offered the only protection from bombardment. He 
 always felt that a shell might come and block the entrance so that he 
 would be buried alive. He never dreamed of this, however. 
 
 This man was obviously not adapted for any continued stretch of 
 fighting, and as a result, within a couple of months of reaching the 
 front he began to show symptoms of fatigue in sleeplessness, 
 hypnagogic hallucinations, and a good deal of "jumpiness" in the 
 daytime. Fear quickly appeared, and then his condition got rapidly 
 worse. Being a man of high ideals as to his duty, he made great 
 efforts to keep all signs of fear from his men, and to appear absolutely 
 intrepid before them. In this he succeeded, but only to produce such 
 a strain that he felt after a few weeks that it was only a matter of 
 time before he would have to give up. While in this condition, a 
 shell dropped one day on the parados and threw enough dirt into the 
 trench where he was standing to cover his legs up to the knees. He 
 became absolutely terrified, although physically he felt no effects 
 whatever, did not lose consciousness nor become at all confused. It 
 seems not unlikely that this accident, which was a small enough 
 affair in the light of his daily experiences, represented symbolic 
 burial. At any rate, whatever its psychological significance, he 
 
34 
 
 became completely unstrung and felt that it was absolutely impossible 
 to continue in his duties. He therefore reported sick, and the 
 medical officer, observing his condition, sent him to the hospital. 
 That night he dreamed that he was taken prisoner by the Germans, 
 and had to confess, when he related his dream, that with it there was 
 a certain feeling of relief in that he was by this event free from all 
 responsibilities of " carrying on. " He never had had this idea during 
 the daytime, however, so far as he could remember, but had only 
 wished for death. 
 
 The day following this dream, he felt still worse, more fearful than 
 before (although he was out of danger) and extremely sensitive to 
 noises. That night terrifying dreams began. These were always of 
 some untoward event, the most frequent of which was that the enemy 
 would penetrate his trench, and rush at him, with bayonets, one of 
 which was just about to pierce his chest when he would awake in an 
 agony of terror. He said that in these dreams he always wanted to 
 scream with fright, which was an idea which would never occur to 
 him in the daytime in the trenches, no matter how frightened he 
 might be. 
 
 When he first went into the trenches he had occasional emissions 
 during sleep. Once his symptoms began, these ceased, and he had 
 no erotic thoughts whatever. The latter did not return until he was 
 nearly recovered from his neurosis. 
 
 After about three weeks the dreams began to lessen in their fre- 
 quency, although the content changed not at all. Finally they disap- 
 peared. When they had been absent for about a week, he dreamed one 
 night that he was being tied down by some soldiers on a stretcher, for 
 what purpose he did not know, but he was very much frightened and 
 was trying to scream when he awoke. This, of course, was not 
 related directly to any actual experience at the front, and it remained 
 an isolated dream. 
 
 Physically he showed some fatigability when I examined him 
 about three weeks after leaving the front. He had prominent eyes, 
 a rapid pulse and some sweating. His tremors were not marked, 
 and did not endure for long. His was a case where a few weeks rest 
 in bed, without other treatment, caused all the obvious symptoms 
 to disappear. None of them, in fact, had ever been particularly 
 severe, except the dreams, and of these he had never had more than 
 one or two in any one night. 
 
 This history is rather typical of the patient who is poorly 
 adapted to fightin°f. The struggle begins at the first 
 moment of entering the trenches, and the mental difficulties 
 increase out of all proportion to the physical fatigue. As a 
 result, these patients are apt to give up before they have 
 struggled long enough against their symptoms to exhaust 
 
35 
 
 seriously their fund of nervous energy. The symptoms, 
 therefore, do not become so intense, nor do they last so long 
 as they do with those who are normal enough to become 
 well adapted to the fighting and then spend weeks and 
 even months in a strenuous effort to fight their symptoms 
 after the " break in compensation " has set in. 
 
 To get such a patient as this back to the firing line, is, 
 of course, a good deal more of a problem than to relieve 
 him of his acute symptoms. 
 
 Case IV. The patient is a lieutenant in the artillery, 23 years of 
 age. He was always high strung and sensitive, and thinks that he 
 would have been definitely seclusive if it had not been that he was 
 put to school at 10 and left there until he was nearly 20, and so was 
 forced to adapt himself to boyish life before the habit of retreating to 
 the protection of his mother and family had become fixed. As he 
 grew older he had a few abortive love affairs and became engaged the 
 first year of the war. He is not yet married. As a child he had 
 night terrors and a constant fear of the dark that clouded his child- 
 hood. As he grew older, however, he seems to have become much 
 more normal, for he developed no phobias, had no nightmares, and 
 none of the usual neurotic sensibilities, except for an undue horror of 
 cruelty and bloodshed. 
 
 In the Spring of 1914 he had an attack of "neurasthenia " which he 
 thinks was somewhat the same as his war neurosis. He was very 
 much disappointed about the result of an examination which he had 
 tried. When the telegram arrived announcing his failure he "sort of 
 fainted," and was "hysterical " after that. For some weeks he slept 
 poorly, had occasional nightmares, was easily fatigued, easily startled, 
 and felt no ambition. This continued until the war broke out, shortly 
 after which he joined the army and spent over a year in training for 
 his artillery work. He rather enjoyed this, became quite sociable 
 with his brother officers and looked forward keenly to going to 
 France. He was rather curious to know what it would all be like. 
 In his first shelling, no one was hit in his immediate vicinity. He 
 became excited and enjoyed it in a sense. A few weeks later, when 
 on a road back of the lines, a shell landed in the engine of a passing 
 automobile and mangled the occupants horribly. This upset him a 
 great deal and for a few weeks after the experience he stammered. 
 (He gave a long and unnecessarily lurid account of this incident; in 
 fact, in all his recitals there was evidence of a morbid fascination for 
 him in the carnage of war. ) Following this experience he always 
 had some fear of shells, but as his battery was miles behind the front 
 line trenches he was seldom under heavy or continuous bombardment. 
 
 After seeing what a shell could do, he always had a certain degree 
 of abhorrence to the idea of killing people, but his victims were miles 
 
36 
 
 away and he kept from thinking of that aspect of his work too much, 
 concentrating his mind rather on perfecting his technical skill in 
 gunnery in which he was able to take considerable pride and satis- 
 faction. He was quite sure that he never could be brought to the 
 point of running a man through with a bayonet. He continued in 
 this position for six weeks and then went home to England on leave. 
 On returning, after being shelled again for the first time, he stam- 
 mered for a day or two, but quickly recovered from this, and proceeded 
 with his work comfortably enough for a good many months. He was 
 then sent to Arras (in the Spring of 1917) and was there for nine 
 weeks altogether. The fighting grew gradually heavier. He became 
 tired with the constant strain, and began to be troubled with his fear 
 of the shells. He became so nervous that he had to force himself to 
 go through communication trenches that were under shell fire. He 
 slept less well, having difficulty in driving the thoughts of fighting 
 from his mind, and had occasional dreams of running the battery, but 
 no nightmares. 
 
 For the last four or five weeks the feeling grew that he could not 
 keep on indefinitely and he began to wish that a shell would come 
 and end it all. During this time he had great difficulty in putting 
 from his mind thoughts of the wounds and death he was occasioning 
 in the German lines. Finally, he was sent to an observation post in 
 No-Man's- Land to direct the fire of one of his batteries. He went out 
 a sap about fifty feet long that terminated under a pile of sand-bags 
 through which there was a small loophole for observation. The 
 Germans, evidently suspecting that an observer might be there, 
 began to shell this spot pitilessly. The patient remained for some 
 minutes with the shells bursting all around, and then retired to a 
 dugout for about a quarter of an hour. Having recovered his courage, 
 he returned to his post and made the necessary observations, although 
 a great many shells were still falling. He thought that he might 
 have received some slight concussion because his head ached a little, 
 but otherwise he felt fairly comfortable. He was, however, very 
 much strung up by his efforts, and a half hour later when he returned 
 to his battery he fainted. The unconsciousness, if it was complete, 
 lasted only a minute or so, but when he came to he was extremely 
 fearful and so emotionally upset that he was sent back to a hospital at 
 once. There he began to have the usual terrifying nightmares, in 
 his case always of being shelled. On account of his poor sleep he 
 was given sedatives very freely, the effect of which was to produce 
 some sleep, it is true, but to make his nervous control very much less. 
 As a result he got into a state where he was almost constantly shaking 
 with violent, coarse tremors, and apt to show most dramatic exhi- 
 bitions of fear when the slightest noise occurred. He stammered a 
 good deal, but mainly when excited by examination, for he could 
 speak quite calmly and consistently for several minutes without any 
 hesitation. When under observation he frequently showed a peculiar 
 
37 
 
 tic. His lips wovild shut tight, with the corners of his mouth drawn 
 back and up, his nose would be raised with a "pug" expression, both 
 of which movements were coincident with a good deal of blinking 
 and a slight retraction of the head. He seemed to be unaware of 
 these contortions, but when they were described to him he said that 
 those were the movements of his face and head when a shell burst 
 and threw up earth near him, which seemed as if it would fly in his 
 face. With this explanation, it was at once probable that the 
 symptoms had developed from such actions of shrinking and disgust, 
 for the expression of his face accurately showed these. 
 
 After six weeks in a general hospital, where he was subjected to a 
 good deal of annoyance from the noises of busy wards and the sights 
 of many wounded men, he was transferred to a special hospital in 
 England. Here, under the influence of complete quiet and isolation, 
 his symptoms very largely subsided in a matter of a couple of weeks. 
 His dreams disappeared altogether, but he remained for a month 
 during which time I saw him occasionally, still prone to develop 
 tremors, grimaces and signs of emotional instability when under close 
 observation, or when startled by sudden noises. He was, however, 
 anxious to understand the psychological mechanisms of his symptoms, 
 and made promising efforts to gain complete control over himself. 
 
 Cask V. The following case gives an excellent example of the long 
 fight which a patient may make against his symptoms, a struggle that 
 reflects more credit on the individual than many exhibitions of 
 sudden and unconscious courage. The patient is a lieutenant in the 
 artillery, who joined the army in the Spring of 1915. He was always 
 given to worrying about trifles, and to feeling that he had made 
 mistakes. He was self-conscious, but with effort became steadily 
 more sociable as he grew older. As a child he was painfully shy and 
 fearful of his capacity to do anything. With adolescence he became 
 more normal in this respect and had many puppy love affairs, and 
 more serious ones, too, for he was finally married at the time he 
 joined the army. Having seen little of his wife, he has had no 
 change of outlook as the result of this marriage. 
 
 As a small boy he was afraid of the dark. He began reading when 
 very young, and turned, boy-like, to books of adventure. When 
 night came, he would lie in the dark and people it with imaginations 
 that would become very fearful. He has no memory, however, of actual 
 nightmares. He has always been uncomfortable and disturbed during 
 thunder-storms, although not exactly afraid. He invariably suffered 
 from giddiness in high places, but has had no claustrophobic tenden- 
 cies, and very few nightmares of any kind. Cruelty and bloodshed 
 were always repulsive to him. As a boy, he played "Indian " a great 
 deal with his brothers. The older brothers used to ambuscade him 
 and scare him tremendously, even though he knew what was coming. 
 His shyness kept him from playing team games as a boy, but when he 
 was older he took up tennis, golf and walking, although music and 
 
38 
 
 reading were always his main interests. When he was 16, one of his 
 brothers died of tuberculosis at the age of 23. A couple of years later, 
 another brother died of the same disease at the same age. The patient 
 became so obsessed by the fear that he himself would have tubercu- 
 losis that he was practicall}' incapacitated and developed mild 
 compulsive symptoms. When he passed the "danger period" at 23, 
 however, he regained his confidence and shook off the fear of 
 tuberculosis very largely. 
 
 He joined the army in the Spring of 1915 and remained in England 
 under training for a year and a half. This was distinctly to his ad- 
 vantage, for he gained more confidence in himself and felt that he had 
 become a competent individual. During this period he had no anx- 
 iety, and was philosophically resigned to whatever might happen in 
 France. He went there in January, 1917, and was glad to find that 
 conditions were better than he had been led to expect. When shelled 
 for the first time he became worried rather than frightened, and 
 quickly got used to it It was possible for him to have shells drop 
 quite close to him without his being at all frightened. When he had 
 been fighting for about six weeks he caught cold, had a bad tracheitis 
 and bronchitis and lost his voice. When coughing, he brought up blood 
 several times and of course began at once to worry about tuberculosis. 
 With the natural ph3-sical strain of this infection, added to the worry, 
 he felt very much dragged down and fatigued and continued so for about 
 ten days. Then two 5.9 shells dropped, one ten, the other thirteen feet 
 from him. The concussion did not cause him to lose consciousness, 
 but he became so excited that he could not talk sensibly and was in- 
 coherent for an hour at least. He went to bed, but could sleep very little, 
 and in the morning he found himself horribly afraid and trembling. 
 With great effort he kept himself at work for a few days, and then 
 was fortunate enough to be sent away for a course of study for twelve 
 days. During this time he recovered from his fatigue, but worried 
 constantly about having to return to his batteries and could not con- 
 centrate on his study. He went back to the line apprehensive of 
 what might happen. The difficulty of continuing in his work became 
 cumulatively greater. He was "jumpy" during the day, inconstant 
 fear of the shells, but keyed himself up to the task. At night he was 
 always dreaming of being wounded in a ghastly fashion, and for some 
 time had more fear of being wounded than of being killed. Before 
 long, however, he reached the stage of wishing a shell woiild end his 
 troubles completel}- and began to spend a good deal of time alone in 
 planning some form of suicide that would afterward seem to have 
 been an accident For five or six weeks the struggle continued, 
 although he felt more and more that it would be impossible for him to 
 "carry on " indefinitely. About this time he was in the open one day 
 and a German field gunner spied him and tried to hit him with twenty 
 or thirty shells. This experience almost finished him, and he be- 
 cajne so upset that his battery commander sent him to take charge of 
 
39 
 
 a wagon line in order that he might have less trying work. Although 
 in less clanger here, there were other worries from which he was not 
 free. Always rather sensitive to the horrors of war, he now became 
 obsessed by them, and marveled continually that the whole ghastly 
 business could be possible. He said later that he thought it was not 
 improbable that he may have clenched his hands and shrieked at the 
 horror of anything so cruel existing. When awake, this was his 
 strongest feeling. Another symptom also developed. This was a 
 difificulty in uttering guttural sounds, which soon spread to include 
 all phonation, making him stammer constantly. When it was later 
 suggested to him that this may have been connected psychologically 
 with the loss of his voice and fear of tuberculosis, he admitted that 
 this was probably the case, inasmuch as these fears were much in his 
 mind at the time the speech difficulty began. 
 
 In spite of these troubles he continued working for about a month 
 longer, although the effort must have been great, considering that he 
 had very little sleep, interrupted by nightmares, and that during the 
 day he was both excessively fatigued and obsessed with horror. 
 Altogether he had struggled on, in spite of these harrowing symp- 
 toms for three and a half months! Finally, however, his superior 
 officer sent him to divisional headquarters. There he got so much 
 worse that he had to be sent almost immediately to a hospital. Once 
 there, it seemed to him that if he were ever sent back to the line he 
 would go mad. He was so depressed at the thought of his failure 
 and the conviction that he was a coward that he frequently cried. 
 The hospital he was in for nearly a month was next to a parade 
 ground and at night they practiced gunnery. With his extreme sen- 
 sitiveness to sounds this terrorized him. Then he was removed to a 
 hospital in London, where he improved quite rapidly, so that his 
 main symptoms became not so much anxiety with its accompaniments 
 as depression and an obsession with the wickedness and horror of 
 war. This latter was developed to such a point that he was able to 
 take absolutely no interest in such striking events as the capture of 
 Messines Ridge which occurred while he was in the London hospital. 
 He said that he was able to think of nothing but the carnage that must 
 have taken place there. He felt, however, that this attitude was dis- 
 tinctly abnormal, in fact, that it was one of his difficulties. Wicked 
 and horrible as war might be, he spontaneously admitted that in the 
 present situation one's duty was not to think about it, but to fight, 
 and end the struggle as soon as possible. At the same time he knew 
 that it was his thinking about it which incapacitated him. 
 
 When he was first put in the hospital, the horrible sights at his last 
 station were constantly before his eyes, as well as the immediate hos- 
 pital surroundings. This lasted only a few days and then it became 
 a matter not of seeing but merely of thinking about the bloodshed. 
 Finally, he reached in London the point where he was able to drive 
 these thoughts out of his mind by an effort of will, or where he could 
 read a little and so distract his mind. 
 
40 
 
 His dreams are of interest. In the latter part of his stay in the 
 line, and for the first month in hospital, he dreamed constantly of 
 working with his battery and being under shell fire, and this dream 
 was consistently accompanied with great terror. When he began to 
 recover, he had, with these previous stereotyped dreams, another 
 recurring one. He was in the country near his home, which 
 distantly resembled the country in France where his battery was. 
 He was under shell fire, which he returned, but always with decreas- 
 ing effect, so that his battery was gradually shelled out. In these 
 dreams he would sometimes leave the battery and run, alone. At 
 other times he would run with another oflBcer. Occasionally the 
 brigadier was with him, who looked on and criticized during the 
 fighting. The brigadier, however, always disappeared before he had 
 to run from the guns. The scenery of his home was not the only 
 matter external to war that appeared in the setting of his dreams, for 
 he began to replace his gunners with people he would read of during 
 the day. Finally, dreams occurred that showed a direct regression to 
 childhood, and the relation between the object of fear in his early 
 life and what stimulated that emotion in the war. He began to 
 dream, not that he was fighting against Germans, but that Indians 
 were his foes. 
 
 This case is interesting both clinically and psychologic- 
 ally. We have an individual who showed strong neurotic 
 tendencies before the war, who adapted himself only briefly 
 to it, and then developed symptoms after his resistance was 
 reduced b5^ a worry that originated in times of peace. His 
 dreams, too, showed a tendency to include material outside 
 of war, and finallj^ became a distortion of the great fear of 
 his childhood, namely, that of Indians. He was constitu- 
 tionall}' afQicted with a disgust of bloodshed and violence, 
 and this became in his neurosis the most prominent factor 
 in disabling him from active service. Running parallel to 
 this were certain clinical features. The symptoms of pure 
 and simple fatigue were less prominent in this case than is 
 usual, and his disease was always much more subjective 
 than objective. He had at any time very little nervous 
 starting, and when I examined him, six weeks after his 
 first admission to a hospital, he showed no tendency to jump 
 when noises occurred, but was obviously greatly irritated 
 by them. He had a little restlessness, and stammered 
 pretty constantly in his speech, although the latter was 
 steadily improving. 
 
41 
 
 The next case, that of a lieutenant, ag^ed 20, illustrates the 
 effect of war on one who had always been considered rather 
 below par nervously. Strictly speaking, this is not an 
 anxiety case, in fact all the symptoms he showed were 
 those which are usually merely complications in the anxiety 
 neurosis. It is included here, however, as an example of 
 the very much poorer adaptation made in war time by those 
 who are not completely adapted to the demands of civil 
 life, at the time they enter the army. 
 
 Case VI. As a child he had frequent night terrors and was afraid 
 of the dark. As he grew older he was high strung and could not find 
 himself at an elevation without wanting to throw himself down. He 
 was never horrified by seeing animals killed but took a delight in it. 
 He was shy with both sexes. He played games in moderation only, 
 because he was never able to run any great distance. In fact, his 
 father, who was a physician, took him from school at the age of 15 
 on account of his lack of strength, and discouraged him from the idea 
 of studying medicine because he was too nervous. He was always 
 subject to headaches which were somewhat improved by glasses. 
 
 In training his first symptom developed, which was a sharp pain 
 in the left groin that got better when he lay down. This was appar- 
 ently hysterical, as no physical reason could be found for it. After 
 this he began to have shortness of breath, pain above the heart and 
 palpitations, with occasional attacks of dizziness. He was absent on 
 sick leave for a while. His superior officer did not wish him to go to 
 the front, but he insisted on it, and was finally sent to France in Sep- 
 tember, 1916, after he had been seventeen months in training. He 
 found himself at first somewhat afraid of the shells, but soon got used to 
 them. The horror of the war, however, grew on him, and he came to 
 pity the Germans as much as the British. His weakness, however, 
 was his main difficulty, for he had to lie down half the time. This he 
 regarded as failure and became depressed over it. Then his com- 
 manding officer committed suicide, and the idea of his doing this also 
 obsessed him to such an extent that he thought he was going mad. 
 He drove a knife into his upper lip and smashed a looking-glass 
 because he hated to see himself. An extra long spell of duty in the 
 trenches made him incapable of any further effort and he was sent 
 home. In the hospital in England his chief difficulties were depres- 
 sion and thoughts of suicide and a desire to mutilate himself. As to 
 the latter, he at first feared that he would do himself serious harm; 
 but later he discovered that a slight pain and the drawing of blood 
 gave him the satisfaction he seemed to crave. His chief trouble was 
 the lack of any confidence in himself. His failure, as such, ceased to 
 bother him, and he rationalized that comfortably with the conviction 
 that he should never have been sent to the front. He complained, 
 
42 
 
 too, of lack of memory and concfentration. His reaction was typically 
 neurotic and offered more difficulty in the way of treatment than the 
 usual war neurosis. He insisted that he was physically incapable of 
 outdoor exercise, yet always complained of a headache if he stayed 
 indoors. He said he wanted to go back to the front, but he knew 
 that he couldn't, and refused to consider the possibility of getting 
 well with the idea of doing some work at home. Therefore, he 
 argued, there was nothing left for him but to think of suicide. 
 
 As he showed no signs of organic heart trouble physi- 
 cally, one is safe in assuming that these symptoms were 
 largely, if not entirely, neurotic, and that the patient was 
 an individual not quite capable of meeting the ordinary 
 strain and stress of civil life, consequently far from com- 
 petent to deal with the strain of war. 
 
 The following case is also not typical, but is included here 
 to show how what is essentially a peace neurosis may de- 
 velop syinptoms that are colored by the environment of war. 
 
 Case VII. The patient is a captain in the French Army, attached 
 as a liaison officer to the British staff. At the time I saw him he had 
 returned to duty and was good enough to give me a retrospective 
 account of his neurosis. 
 
 He had a severe attack of meningitis at 3, and as a result, was very 
 delicate as a child. It was not thought by his parents that he ever 
 would be strong enough to be educated, and he was given no school- 
 ing until he had himself demonstrated his intellectual ability. He 
 was always "nervous" but never had any definite symptoms and no 
 breakdowns. He became a barrister and passed successfully many ex- 
 aminations both in France and in England. It is important to note that 
 he had very little anxiety in connection with any of his examinations. 
 He was commissioned immediately at the outbreak of the war, and 
 fought for some months with the French Army. Shortly after the begin- 
 ning of the war he got news of the death of his best friend. At once he 
 began having dreams of examinations, in which failure seemed cer- 
 tain, and he was tormented by great fear of this. There were other 
 dreams of his arguing in court most ineffectively, in fact so poorly 
 that his clients insulted him. He was tired in the morning after these 
 dreams. Under this strain he soon began to be nervous and fearful of 
 shells, but never showed this fear, and in fact felt it less, when he was 
 in the company of others. He had no increase of horror at the car- 
 nage, but could never become accustomed to shell fire. After con- 
 tinuing in this state for eighteen months, and, so far as he could 
 remember, without any particular aggravation of his difficulties, he 
 fell in a " fit" while drilling some men. He was told that he did not 
 have a convulsion, but talked as if he were apologizing to the colonel. 
 
43 
 
 Following this, he was extremely weak and had bad pains in his legs; 
 when he walked it was with a very staggering gait and exaggerated 
 movements. He was, of course, incapable of fighting further, and 
 was sent to the south of France. He stayed there very quietly with 
 his wife for nearly five months, for the first two of which he felt abso- 
 lutely no affection for his wife. All this time he endeavored to rest 
 completely, and did not even read a newspaper. This was apparently 
 successful treatment, for he recovered completely, and on returning 
 to the front felt no more fear and had perfect confidence in himself. 
 Later he obtained leave long enough to go to London for some Eng- 
 lish bar examinations, which he passed without having any anxiety 
 at all. He continued, however, to repress his friend's death, trying 
 never to think about it, and was always disturbed for some time after 
 hearing the friend's name mentioned. 
 
 Fatigue : Perhaps the most important of all the factors 
 that unite in the production of an anxiety state is fatigue. 
 So far as I have been able to learn, either it or concussion 
 is present to greater or less extent in every case of anxiety 
 neurosis, and it seems to be possible to trace its influences 
 directly in the production of symptoms. 
 
 Although the discrimination may be somewhat academic, 
 it is possible to recognize two types of fatigue which are 
 usually combined. These we might call physical and men- 
 tal in origin, although there is probably no place in medicine 
 where it is more difficult to discriminate between what is 
 purely physical and purely mental. We may call fatigue 
 physical in origin that proceeds from physical factors out- 
 side the patient, such as continued exertion on duty, 
 exposure to inclement weather, lack of food and opportu- 
 nity to sleep, or physical disease. Fatigue of mental 
 origin is that which proceeds from difficulties that are more 
 psychological than physical in their operation. This in- 
 cludes the constant stress of exposure to what is extremely 
 distasteful, whether the distaste be common to all mankind, 
 or an idiosyncracy of the patient. It also includes the 
 fatigue coming from the struggle against symptoms already 
 in existence. These influences never demand in times 
 of peace the consideration due them in warfare. The 
 reason for this is that escape from symptoms or from 
 environmental factors which are particularly trying is usu- 
 ally possible to some extent in civil life, but is absolutely 
 impossible in the trenches. 
 
44 
 
 Two cases of the physical type may first be quoted: 
 
 C VSE VIII. The patient is a lieutenant, aged 29, who was a regular 
 soldier for eight years before the present war. He had an extraordi- 
 naril}' normal mental make-up, liked military life extremely, and did 
 well in it, so that he was made a non-commissioned officer almost 
 immediately after enlistment. He went to France as a sergeant with 
 the original expeditionary force, and went through all the severe 
 fighting in the retreat from Mons and the first battle of Ypres, 
 unscathed. 
 
 He exhibited no symptoms whatever with his first shell fire, and en- 
 joyed the fighting hugely. At the first, he did not like to "mess the 
 dead about," but soon became quite indifferent to this part of his 
 duties. He was several times rather saddened by losing all his chums, 
 but he was never unable to continue in his duties, and soon forgot 
 about these incidents. From the standpoint of adaptation he might 
 easily be called a perfect soldier, for he was not only completely de- 
 void of fear, but well disciplined, and took a keen enjoyment in his 
 work and was able to continue fighting quite unaffected by the hor- 
 rors that are trj-ing to all ordinary individuals. In August, 1915, he 
 had a slight touch of rheumatism, not severe enough to send him to 
 the hospital, but enough to drag him down a bit. He thought that he 
 had recovered completely from this. Two or three months later the 
 Germans exploded a mine right in front of the trench in which he was. 
 This is perhaps quite the most fearful event in any soldier's life, as all 
 the ground is shaken and the extent of the damage done may be appall- 
 ing. The patient went pale for the first time in his life, but did not lose 
 his control, and kept his men ' ' standing to ' ' immediately. It was a new 
 experience to him and rather a shock. He began to think for the 
 first time about danger. He was in an area where mining was the chief 
 form of attack, and he would frequently hear the Germans digging 
 beneath his dugout He got too restless to sleep while on active duty, 
 but could sleep well when back in billets. This continued for two 
 months, during which time, he thinks now, he was probably getting 
 worse than he realized at the time. He was getting more and more 
 on edge, although he felt no real fear, and could always tell by the 
 sounds where shells were going to land. About six weeks after the 
 mining incident, he was buried in a dugout. He did not completely 
 lose consciousness, but was so dazed that he had to lie down for a 
 couple of hours. Following this, he was nervous, had a chronic head- 
 ache and could not sleep, even in the billets. He would lie for a long 
 time, trj-ing to get to sleep, his head aching, seeing dugouts being 
 blown out, and the men being bowled over, and imagining himself in 
 the way of shells. Occasionally he could feel these things as well as see 
 them, but could always by an effort of will convince himself that they 
 were only imaginations. With these hallucinations he had no real fear, 
 but was very much bothered and wished they would go away. All this 
 
45 
 
 time he was in a position of the most trying responsibility which any 
 non-commissioned officer can have, since he was company sergeant 
 major. Feeling this responsibility, he continued his work, but got 
 gradually worse and worse. His sleep became poorer. Not that he 
 had nightmares, but he found himself constantly awaking with a start 
 whenever he fell off to sleep. In the daytime he was bothered by a 
 constant tendency to "jump" whenever a shell came, but was able to 
 keep himself perfectly calm as far as any outsider could see. It was 
 only with the greatest effort, however, that he was able to get through 
 each day. He began taking morphia, but was able to secure very 
 little sleep with it. He thought sometimes of suicide. 
 
 After two months of these troublesome symptoms, his officers saw 
 that he was not well and sent him to England. Here he picked tip 
 quickly. He soon began to sleep a little, but he never was able to get 
 more than five hours sleep in any night. After a rest of three 
 months he applied for some light duty, and was given company 
 accountant work. This soon bored him extremely, and, as he insisted 
 on returning to France, he was given a commission and sent back to 
 the front in January, 1917, after he had been nine months in England. 
 On his return, he found the fighting not very active, and was able to 
 go ahead with it very well for a while, with his condition about the 
 same as in England; that is, he felt rather high-strung and was able 
 to get only four or five hours sleep at night. In April he was sent to 
 Arras. A month before this he had a dream that he was going to be 
 bowled over by a shell, buried, and wounded in the neck. He thought 
 a good deal about this, and realized perfectly that he was not 
 thoroughly fit. At Arras, where the fighting was very heavy, his 
 sleep got much poorer. He had, however, no "jumpiness, " nor any 
 idea of suicide. Then in April he led his men in an advance, and 
 almost immediately on leaving the trench was bowled over and buried 
 by a shell and at the same time hit in the neck, knee, and the hand 
 (all superficial wounds). He was not unconscious, but dazed and 
 had to be carried back to the hospital. There he felt first rather 
 pounded and blinded, but slept a little, and was fairly comfortable 
 after ten days. In fact, he felt so much better that he undertook a 
 journey down to his base. This exhausted him and he arrived almost 
 in a collapse. He was in camp at the base for three weeks, during 
 which time he tried to rest, and took tonics, but got steadily worse. 
 He became depressed, thinking that something was going to happen 
 and kill him. It was not exactly a shell, and he could not tell what 
 it was to be, — it was just a restless, vague anxiety. He found that he 
 could not concentrate his thoughts sufficiently to read. Occasionally 
 he contemplated committing suicide in order to finish up quickly 
 what was going to happen anyway. He had practically no sleep, but 
 whenever he would doze, would wake with a start, feeling that some- 
 thing had hit him. 
 
 This was as near as he came to a real nightmare. He had several 
 
46 
 
 dreams of being taken prisoner. This probably expressed an 
 unconscious relief from having to fight, but how far this was from his 
 conscious ideals may be gathered from what took place on waking. 
 He would immediately imagine himself in the situation of prisoner, 
 and then in fancy start a fight and escape back to the British lines. 
 
 He was in various hospitals for two weeks, and then was sent to a 
 special hospital for nervous cases which was very pleasantly situated 
 in the country. Ten days in this quiet situation improved his con- 
 dition considerably and he began to get some sleep. On a day after 
 no sleep, he would have a bad headache, be restless and apprehensive, 
 with a feeling that he would never get better, always being worse 
 when he was alone. The distraction of talking to others did him 
 good. Any exertion, however, would lead to a very bad headache. 
 He thought that if he were left permanently alone he would go mad. 
 At no time had he had real nightmares. It was quite interesting that 
 he discovered when riding on a train that he would become terrorized 
 on passing through every tunnel lest he should be crushed. 
 
 This case shows how incapacitating- pure fatigue without 
 the development of any marked neurotic symptoms may be. 
 Judging from what one gathers in taking the histories of 
 many patients, it might be safe to say that had this lieuten- 
 ant's superiors not sent him back to the hospital after his 
 final burial, he would have developed a typical anxiety 
 state, for all the symptoms were potentially present. We 
 can probably account for his long and successful struggle 
 against a neurosis by the fact that he was so extraordinarily 
 well adapted to fighting. But, as he himself said, "There 
 is no man on earth who can stick this thing forever." 
 
 The following case is interesting and typical in two 
 respects. In the first place, he was a man well adapted to 
 fighting, whose first symptoms were those of fatigue, apart 
 from any neurotic manifestations. Secondly, his neurosis, 
 once established, remained in abeyance for thirteen months 
 while at home only to blossom out immediately on his 
 return to the front. 
 
 Case IX. The patient is a lieutenant, aged 21, who showed no 
 distinctly neurotic tendencies. He was somewhat shy with girls and 
 slightly so with boys, but played many games with them, and seems 
 to have been rather a normal child. His only abnormality, apparently, 
 was a tendency to self-consciousness. He enlisted in September, 1914, 
 and found that the training did him much good, for he became more 
 sociable; it "made a man of him," as he said. He went to France in 
 
47 
 
 February, 1915, and although he was at first somewhat frightened, 
 soon got used to being shelled. He enjoyed the life and was careless 
 of the sight of wounds and death. 
 
 After fighting for seven months, he became somewhat fatigued and 
 had occasional dreams of fighting, with fear. In the daytime, how- 
 ever, he had only a tendency to start when the shells came, and no 
 consciousness of fear whatever. He was then invalided home with a 
 fever, and three months later was given a commission, spending nine 
 months in training. He then returned to France as an officer in Octo- 
 ber, 1916. Heat once joined a company which had just been in severe 
 action and was feeling very shaky. This had some effect on him, and he 
 found himself slightly nervous and a little depressed at the thought 
 of going back to the firing line. He tried to persuade himself tliat 
 he did not care what happened. When examined later, he told me 
 that this initial fear was probably due to the rough time he had before 
 he left the firing line thirteen months earlier. He had never, in all 
 the time he was at home, gained complete possession of his confi- 
 dence. He found now that he could get no enjoyment in the fight- 
 ing, and became sensitive to the horrors. He began to take rum 
 in order to keep fit. The fighting was so active that he had little 
 opportunity to sleep, but when he did have the chance he was not 
 bothered by bad dreams. Gradually he became more and more fright- 
 ened, but was constantly successful in hiding any signs of it The 
 fatigue became so extreme that he felt that it could not last long, and 
 wished fervently that a shell would come along and finish him. 
 
 One night a raid was on, and a heavy barrage. He remembered 
 nothing more until he awoke in a dressing station where he was told 
 that he had been buried. Apparently he had been unconscious for three 
 or four hours. His head ached, as did his back, where the earth had 
 hit it. He had no dizziness, no further loss of consciousness and no diffi- 
 culty in thinking. As there is no evidence of concussion, except from 
 his amnesia, it is probable that it was rather slight. He felt very 
 much frightened, however, but managed to get some control of this as 
 he was carried further from the firing line back to the field ambulance. 
 He remained here ten days, and recovered sufficiently to insist on 
 being sent back. He found on his return to the line, however, that 
 he could not sleep, and was extremely frightened during the day. 
 He realized at once that he could not stick it out, and after a week 
 asked to be sent back. This was done at once, and he was sent direct 
 to England. He was in the hospital for a week where his sleep was 
 very poor and continuously troubled by nightmares, the content of 
 which was exclusively a repetition of previous terrifying incidents at 
 the front He was extremely shaky; in fact, his legs moved so much 
 that he crossed them in bed in order to keep them quiet This ex- 
 treme shakiness he ascribed not only to his nervous strain, but also to 
 the injury to his back, which remained sore for some time, and which 
 he thought included an injury to his spinal cord which was responsible 
 
48 
 
 for the movements of his legs. At the end of the week he got up out 
 of bed in order to return to his home. He then found that he could not 
 uncross his legs, and was so spastic that he had great difficulty in 
 walking. In his home, his family and friends exhausted him by their 
 constant efforts to distract his mind. He was very restless, and his 
 dreams became more insistent at night. He remained at home three 
 and a half months, during which time his fatigue, shakiness, sleep- 
 lessness, all appeared worse. His dreams, however, became less 
 severe, in that they appeared at less frequent intervals. He was then 
 sent to a special hospital where I saw him after two months stay. 
 He had improved in all directions. The dreams had ceased. He 
 had no chronic fatigue, although he was still rather easily fatigable. 
 The shakiness had disappeared except when he was tired or when he 
 tried to stand or walk with his legs apart. His gait, however, was 
 improving very rapidly under the methods of re-education which 
 were employed. 
 
 He said that he kept himself from thinking much about returning 
 to France, but when that idea did come in his mind it was always 
 accompanied with a fear that he would be a coward if he were once 
 back in the firing line again. He worried a good deal about his failure, 
 because he had seen a good deal of prejudice against a man who 
 ' ' goes sick, ' ' whatever the cause. 
 
 It may probably be taken as additional evidence of this patient's 
 essential normality, that he had no trouble whatever in abstaining 
 from alcohol after leaving the line, although he had been afraid that 
 he would have difficulty in this. 
 
 The following two cases are illustrative of fatigue 
 engendered by mental as well as physical diflBculties, and 
 difficulties, too, that would not be at all incapacitating in 
 times of peace with as normal individuals as these patients 
 are. 
 
 Case X. The patient is a major, aged 35, who had spent seven years 
 in the army with the rank of captain, but had resigned some five years 
 previous to the beginning of the present war. During this time he 
 had been living in North Africa, engaged for some years in tribal 
 warfare, and following that had built a plantation miles from civili- 
 zation where he lived very happily. He is a typical representative of 
 the British adventuring, colonizing class. At the beginning of the 
 war he returned to England and was given a commission as major, 
 and fought for two years before his breakdown occurred. In make-up 
 he was apparently an unusually normal individual, and in many talks 
 with him I could discover no abnormality except that he was a con- 
 firmed bachelor, and that he was always unusually antagonistic to 
 inefficiency in any superior. 
 
 On going to France, after a short initial period of fear with the 
 
49 
 
 shells, he became fully adapted to the conditions and enjoyed the 
 fighting hugely. Probably as a result of his many years of life in the 
 open, he knew how to adapt himself to an uncivilized environment, 
 and took considerable pride in making not only himself, but all his 
 men, unusually comfortable. He fought continuously for one and 
 one-half years, with absolutely no symptoms. At one time, when he 
 was feeling particularly fit, he was in a dugout with two other men when 
 a heavy, high explosive shell pierced the roof and exploded. All 
 three men were laid out immediately, and all apparently paralyzed 
 for half an hour. The patient said he thought he might have been 
 unconscious for a second or two. It was difficult to recall his sensa- 
 tions. He remembered being very much frightened, but what occa- 
 sioned that fear he can not remember. He also was unable to say 
 whether he was really paralyzed or unable to try to move, or perhaps 
 afraid to move. At any rate, at the end of the half hour all three 
 men picked themselves up, laughed at each other and went on with 
 their work. The patient felt no after-effects whatever. As such an 
 incident is frequently given as the occasion of a neurosis, it is impor- 
 tant to note how little effect it may have on those who have not been 
 troubled with any symptoms prior to the event 
 
 After a year and a half of fighting, the patient was transferred to a 
 battalion that was under the command of a brigadier whom he felt to 
 be not only very inefiicient but antagonistic to him. They had fre- 
 quent difference on various matters, and finally when they disagreed 
 on tactics, the brigadier had him sent home on sick leave, although 
 he was perfectly well. He returned to the front after a few months' 
 stay at home, and was very much disappointed to be transferred to 
 the same division and come under the authority of his old enemy ten 
 months after leaving him. 
 
 Up to this time he felt perfectly well, but the strain of constantly 
 following orders of which he did not approve, began to tell on him. 
 He became sleepless at night, and "jumpy" during the day. This 
 " jumpiness " at first was not accompanied by fear, but later on he 
 became fearful of the shells. Much irritated by this failure, he made 
 strong efforts to control his emotion, and did succeed in hiding it from 
 his brother officers and from his men. The brigadier, however, con- 
 tinued to bother him in every possible way, so the patient thought. 
 He was continually pestered for reports, so that he had to spend much 
 time in purely clerical work. He began to dream of this. Night 
 after night he would be making endless inventories which he never 
 was able to finish, so that he would wake in the morning more tired than 
 when he had gone to sleep. Finally the patient and his brigadier came 
 to an open quarrel about a case of court martial when the patient accused 
 his superior of attempting to coerce the court illegally. The brigadier 
 over- ruled him, but was possibly in the wrong as he made no com- 
 plaint of the patient's actions to headquarters. As the patient had 
 begun to have occasional terrifying dreams of fighting at night, he 
 
50 
 
 felt that his resistance was steadily decreasing. He tried taking 
 bromides in ten grain doses every night for some weeks, but finally 
 discontinued the use of this drug because he found it was failing to 
 give any benefit at this dosage. He had been on active service for 
 many months, so felt justified in applying for leave. This was granted 
 and he came to London. There he consulted a neurologist who 
 advised him to go to a hospital, which he did at once. He showed 
 some tremulousness, but no other obvious abnormality, and his sub- 
 jective symptoms were not so intense as is often the case. His 
 nightmares occurred regularly every night, only for about a week, 
 after which they became fewer in number, and after two weeks dis- 
 appeared entirely. Sleeplessness, however, continued to bother him, 
 and sometimes he would lie awake practically the whole night 
 rehearsing in his mind the past quarrels with the brigadier, or imagi- 
 nary defiances. 
 
 After two or three weeks stay in the hospital he began to go out for 
 occasional walks or rides in a motor, and he was then disgusted to find 
 how easily he was fatigued and how fearful he was of the traffic. 
 After a month of hospital residence he went to a convalescent home in 
 the country, from which he wrote me a month later to state that, 
 although he had no obvious symptoms, his convalescence was pro- 
 ceeding much more slowly than he had expected. He found himself 
 still nervous with any sudden noise, terribly giddy if he were in a 
 high place, and much upset by thunder-storms. In addition, he could 
 not entirely shake himself of the obsession concerning the brigadier. 
 Unfortunately there was no opportunity for any psychological analysis 
 of this antagonism to his superior, but judging from the experience of 
 others with such cases, it seems probable that it would have been a 
 comparatively simple matter to give this patient insight into and 
 control over his trouble. 
 
 It is probabl}^ safe to say in this case that the main factor 
 in this patient's breakdown was his constitutional inability 
 to act subserviently and take orders from one whom he did 
 not respect. This spirit is, of course, an asset in times of 
 peace. In military life, however, it is a distinct dis- 
 advantage. 
 
 Case XI. The history of this patient presents a somewhat similar 
 situation to that just described. He was commissioned in the regular 
 army in 1906, became an officer in the artillery, and enjoyed the army 
 life. When the war broke out he was home on sick leave from India 
 and joined the expeditionary force in France in November, 1914. His 
 make-up showed that he had not been a completely normal individual. 
 As a child he had many nightmares of falling and was also afraid of 
 the dark. This latter fear never entirely left him, for he stated to me 
 that he thought he probably would still be afraid to remain alone in a 
 
51 
 
 dark house. He showed no other obviously neurotic tendencies, but 
 admitted himself to be given to worry, and to being over-conscientious. 
 He confessed to a distinct vein of pessimism. He had, too, a strong 
 tendency to be unusually resentful when deceived or ill-treated. As 
 an example, he spoke of once being decoyed into buying some trash 
 at an auction sale. After discovering the worthlessness of the things 
 he thought and dreamed about the deceit that had been practiced on 
 him for some months. He felt very resentful at the auctioneer and 
 indulged in phantasies of revenge. Both his father and grandfather 
 had been soldiers of some eminence, and the ideals of military service 
 took a large place in his life. After being commissioned he had fre- 
 quent dreams of being in the army without having passed the necessary 
 examinations. In these dreams he felt that these examinations were 
 still to come, and that he was going to fail. On waking, this feeling 
 would persist for some time, with considerable depression. 
 
 On going to France he fought continuously for many months and 
 enjoyed it When first shelled he wanted to leave, but had no other 
 abnormal reactions. Occasionally he would feel a little timorous 
 when going into the front line trenches for observation of the effect of 
 his battery's work. This feeling was always qtiite brief, however, 
 and never incapacitated him. After eight months of fighting he was 
 one day very heavily shelled, after which he was "jumpy" and for 
 some weeks every sound he heard meant a shell. He recovered from 
 this spontaneously, however. 
 
 From May to November, 1916, he acted as liaison artillery oflScer 
 with the flying corps. He enjoyed this work extremely and felt so 
 full of life that, although it was not at all a part of his duties, he used 
 to go on bombing raids for the fun of it He did not enjoy being shot 
 at by the anti-aircraft guns, but was never sufficiently frightened to 
 develop any symptoms whatever. After five months of this work, 
 he felt that he was not doing all that he might, and so applied for a 
 position in the artillery again. He was sent home to raise and train a 
 new siege battery. His troubles then began. None of his officers or 
 men had ever been in France, so that he had to instruct all of them 
 in many essentials. An additional difficulty was that he was forced 
 by regulations to teach methods which he had not seen in use at the 
 front, and which he thought the men would only have to forget again. 
 At the end of this period he spent two weeks giving the battery 
 practice — firing which he thought ought to have been extended to 
 six months. He worried morbidly about the insufficiency of training 
 which his men were getting, and felt that he was up against a system 
 more powerful than himself. To add to his difficulties he had 
 innumerable administrative duties to attend to that he found very 
 irksome. 
 
 A week before going to France he had a bad throat. His physician 
 kept him in bed for two days, and said that his rest ought to be con- 
 tinued for a month as he was worn out and his heart was irregular in 
 
52 
 
 action. He left his bed, however, to go over to France, feeling quite 
 played out. He spent ten days tuning up his tractors, etc. , and then 
 to his intense disappointment his guns were taken from him, as they 
 were urgently needed for another sector of the line than that to which 
 he had been ordered. He and his men were sent to build gun posi- 
 tions for another offensive that was to take place months later. 
 Difficulties began once again. He had not, or felt that he had not, 
 enough men, material or transport facilities. Finally, the general 
 over-ruled his judgment as to where the emplacements should go. 
 The patient felt that a terrible mistake was being made, and it became 
 an obsession to him. On going to sleep at night it was in his mind, 
 and although he did not dream of it, he never slept more than four 
 hours and found himself thinking at once of the same subject when 
 he awoke. While continuing in his work, he saw a neighboring 
 battery knocked out with German shells, and began to live over in 
 prospect the experiences the batteries he was building would have in 
 the future. 
 
 Next, the Germans began to shell all the roads back of the British 
 lines, indiscriminately, which drove his men into a panic. He 
 managed to put some confidence in them again, but only with great 
 difficulty, and he himself was beginning to wish urgently that a shell 
 might hit him, so that he might get a wound which would remove 
 him from duty. It is interesting that he did not wish for death — the 
 only officer I examined who did not look for this form of release. It 
 was probably because he felt so outraged with the "system" that he 
 harbored the less honorable wish. On the other hand, when his 
 doctor recommended a ten days rest, the patient refused, being stub- 
 bornly determined to stick it out He was given thirty grains of 
 bromide a day which improved his condition, but only for a few days. 
 He had been working under these difficulties for six weeks when he 
 was given orders that he considered impossible of completion in the 
 time allowed. This made matters even worse and he got so that he 
 could not eat, nor concentrate his mind sufficiently even for the 
 purpose of reading orders. He was also trembling most of the time, 
 and starting nen^ously whenever shells came, although he felt no 
 fear of them, in fact they had a definite, conscious attraction for him. 
 Finally, he saw several men injured and one killed working on a gun 
 emplacement the location of which he had protested against. The 
 following day he was ordered to undo all his work and remove the 
 emplacement to another spot This was more than he could bear, so 
 he went to the doctor again and demanded relief from all responsibil- 
 ity. He was sent to a hospital, and had been in one hospital or 
 another for six weeks when I saw him. 
 
 He experienced great relief in leaving the line, but still had other 
 difficulties indicative of fatigue. He was "jumpy " and felt that he 
 was gripping hard on things in order to keep control of himself. He 
 spoke in a fixed tone and felt he was mentallj' incompetent Paralde- 
 
53 
 
 hyde gave him sleep for one night, but left him heavy for several days 
 following. When the sleeplessness passed, itlefthim feelingwell. He 
 was in bed for ten days altogether. Then he dreamed several nights 
 in succession of working on his gun emplacements. This upset him 
 once more, but only temporarily. His sleep finally became quite 
 normal, but he continued to suffer with headaches and difficulty in 
 concentration. His greatest difficulty when I saw him was depression 
 with a feeling of failure. He feared that having broken down in a 
 crisis, his future career as a soldier would be prejudiced. He con- 
 tinued to harbor resentment against the superiors from whom he had 
 suffered, but spontaneously developed more and more insight into 
 the fact that his own reaction had not been perfectly normal. 
 
 This case presents some interesting points for specula- 
 tion. The origin of his fatigue is plain enough, but we 
 have to account for so marked a degree of fatigue not 
 culminating in an anxiety condition. Two possibilities 
 must be considered. In the first place, he never desired 
 death as a release from his situation, which seems to be a 
 pretty constant forerunner of the anxiety state. Secondly, 
 his mental conflict remained quite conscious throughout. 
 It is possible that there was in his case less necessity for the 
 development of neurotic symptoms in that he had an open, 
 conscious antagonism to the military situation in which 
 he was placed. 
 
 Concussion : The role of concussion in the production of 
 anxiety states has been emphasized by the more organically 
 minded neurologists with probably too great an emphasis. 
 On the other hand, those who have been working psycho- 
 logically seem inclined to underestimate its importance, 
 and, so far as I know, neither school has attempted to 
 make any discrimination, in their reported cases, between 
 the symptoms which could be directly accounted for on this 
 physical basis, and those which were more probably purely 
 psychological in origin. In less than a fourth of the cases 
 I have. seen could concussion be determined as a prepon- 
 derating factor. Two-thirds had no suggestion whatever of 
 concussion in their history. That it is rarely, if ever, the 
 sole factor is suggested by the phenomena not infrequently 
 reported, that many men are often equally affected by the 
 same explosion, while only some of them develop symptoms. 
 
54 
 
 It has also been stated that cases have occurred where a 
 shell has dropped among a group of men who were resting. 
 One who was awake developed "shell shock." Those 
 who were asleep showed no bad effects. Perhaps the most 
 convincing argument of all is that the same man may be 
 repeatedly exposed to definite concussion at times when 
 his general condition is perfect, and develop only the 
 most temporary symptoms, whereas later in his career as a 
 soldier when fatigue or beginning neurotic symptoms are 
 present, a less violent concussion may precipitate a severe 
 neurosis. 
 
 By examining cases with definite history of severe con- 
 cussion one can discover the symptoms which are the direct 
 outcome of the physical injury. These are as follows : 
 
 There is first unconsciousness that may last for hours, even 
 days. Lumbar puncture at this time may, according to the 
 reports, show blood in the cerebro-spinal fluid. That there 
 are minute hemorrhages throughout the brain has been 
 determined definitely in some cases which have been killed 
 instantly by concussion, and is also suggested by the fact 
 that retinal hemorrhages may frequently be observed oph- 
 thalmoscopically. When consciousness is recovered it does 
 not remain immediately and permanently clear, as the 
 patient is apt to go through a period of hours or days in 
 which he is constantly drifting off into unconsciousness or 
 sleep. Sometimes consciousness may be retained for a 
 longer period, when the patient's attention is continuously 
 stimulated. Retention of urine or incontinence of both 
 urine and faeces is common in these stages. Many of the 
 patients, on becoming clear, are aphasic. A period of 
 delirium then is apt to ensue, during which the patient 
 imagines himself to be fighting again. This delirium is 
 distinctly of the occupational type, and so far as I could 
 learn, is not accompanied by fear unless neurotic symptoms 
 had been present before the concussion, or the patient has 
 an extremely abnormal make-up. The patient may gain 
 insight into the unreality of his hallucinations if his atten- 
 tion is forcibly directed to his environment. In fact, the 
 delirium is apt to disappear slowly as the patient gets 
 
55 
 
 to do this more and more for himself. He is then in a 
 condition of great fatigue and extremely poor mental 
 tension, the last being demonstrated by a difficulty in 
 collecting his thoughts, defective orientation, poor mem- 
 ory for the remote past, and practically no memory at all 
 for the immediate past. Generally there is retroactive am- 
 nesia for the concussion itself, and for a varying lapse of 
 time prior to the accident. All mental operations are per- 
 formed with great difficulty, and as a rule inaccurately, 
 which can easily be tested by demanding some simple cal- 
 culations. The voice is peculiar, being very often pitched 
 somewhat higher than is usual for the patient, monotonous, 
 and frequently slow, words being separated by a pause of 
 one or two seconds. The patient begins with greater or 
 less speed, according to the severity of his injury, to recover 
 his memory of the remote past, and also, strangely enough, 
 is frequently able to reconstruct a good deal of the period 
 which immediately preceded his injury, particularly if 
 some hints are given him. In the milder cases the patient 
 feels as well as he ever did, after a few weeks rest. 
 
 In the more severe cases, some symptoms are apt to per- 
 sist. For a long time the patient has poor mental tension, 
 and this is so frequently associated with carelessness and 
 with the brief appearance of fanciful ideas, that a suspicion 
 of paresis is often aroused. Occasionally the patient may 
 retain delusions for months that originated in his initial 
 delirium. 
 
 The importance of knowing these symptoms lies in the 
 fact that their presence in the clinical history (particularly 
 the dipping of consciousness and poor mental tension) are 
 tell-tale signs of genuine concussion. They are singularly 
 absent in the cases where mere burial, or some other such 
 precipitating cause, has suddenly produced symptoms. In 
 those individuals where definite fatigue or neurotic symp- 
 toms are already present, even in slight degree, the occur- 
 rence of concussion may cause a very sudden accentuation 
 in the anxiety picture. The following two cases illustrate 
 the effects of concussion on individuals previously normal 
 in their make-up and in good health when the accident 
 occurred: 
 
56 
 
 Case XTI. The patient is a Canadian from Toronto, aged 20. His 
 personal history shows an extremely normal make-up. In 1915 he 
 lost the phalanges and metatarsals of his left foot in a railway acci- 
 dent. This injury prevented his acceptance by the Canadian military 
 authorities for a long time, but finally he was commissioned in the 
 English Royal Flying Corps. He spent nine months in England in 
 training, which he enjoyed greatly, and at the end of that time he 
 was considered sufficiently competent to be sent to France. He made 
 several successful flights over the lines, but after only two weeks of 
 service he was shot down and crashed to the ground within his own 
 lines. He was removed at once to a British general hospital, where 
 twenty four hours later he was noted as being still unconscious, with 
 black eyes and bruises on his body, but no neurological signs. Four 
 days later he had apparently recovered consciousness, and had complete 
 control of his sphincters. A week later, it is stated that his memory 
 was much aided by questions, but that he was still hazy about recent 
 events. He could recognize that he was in the hospital, but was not 
 sure which one it was. A week after this again, he arrived in a Lon- 
 don hospital.* Here he refused to stay in bed and was found, by his 
 physician, lying half covered, with bright eyes, and speaking in a 
 very loud voice. Several questions were addressed to him, during 
 which time he made no response, merely staring at his examiner as he 
 moved around the bed. Finally, the patient shouted: " I want to get 
 up." He was told he could not do so immediately, and then when 
 questioned as to his orientation, he said that he was in Rosedale (a sub- 
 urb of Toronto). Asked where Rosedale was, he insisted it was a 
 part of London, that it was not far, that he wanted a taxicab to get 
 there. When his physician told him that he would have to cross the 
 ocean in order to get to Rosedale, he stared, but seemed content. His 
 physician discovered a wound on his right hip (it looked like a 
 superficial machine-gun wound) . He asked the patient about it, who 
 said he didn't knew, but thought it must be the mark of a hospital he 
 had been in in France. He expected the physician to know what it 
 was, that it was a secret mark meaning that he could return to the 
 line and fight whenever he wanted to. He also explained it as a mark 
 indicating that he could use the lavatory whenever he wanted to. 
 
 He gave no answers to several questions as to personal data, and 
 then suddenly exclaimed: ' ' I want to go to Rosedale, ' ' but was easily 
 quieted When asked if he dreamed, he looked up with a cunning 
 expression, and then said: "I down the Boche,"-"I ani a live 
 wire," - "he never lives," - "I kill him." He was asked "Every 
 time ? " to which he replied: ' ' I kill every time. ' ' During the utter- 
 ance of these few phrases he became very excited. 
 
 The next day he was tractable, but anxious to leave and still asking 
 about Rosedale. He wanted to leave at once. When asked where he 
 was, he laughed, and said the nurse told him he was a long way from 
 
 ♦ I am indebted to Captain Maurice Nicol, R. A. M. C, for the use of his notes 
 on the observations made in this hospital. 
 
57 
 
 Rosedale, and when qviestioned as to his belief in this, said: "I 
 guess I have to go in a train and in a ship," but seemed uncertain. 
 Further conversation showed that he had assimilated considerable 
 information gained from the nurses, and that he was much more thor- 
 oughly in touch with his environment. I saw him for a few minutes 
 and told him I would see him again the following day in another hos- 
 pital to which he was to be transferred. The next morning I found 
 him oriented for time and able to recognize me with difficulty. He 
 was much confused about the names of the hospitals, and his recent 
 movements. None of the necessary data seemed ever to be absent from 
 his mind, but to be present in rather a jumble. He showed a definite 
 mental tension defect. He was not aware of being slowed in his men- 
 tal processes, but admitted difficulty in recalling some data. In sub- 
 tracting seven from one hundred serially, he did it very slowly, and 
 made several bad mistakes, which he did not recognize. In giving an 
 account of the remote past, he had difficulty in getting his facts 
 straight, particularly in their right relations to one another. There 
 were a number of discrepancies into which he had only partial insight. 
 His carelessness concerning his intellectual defect was very striking, 
 reminding one of the similar reaction in a paretic. He could recall 
 no dreams at all, but remembered his life in France well enough to be 
 sure tliat he had no nervous symptoms. He could give no account of 
 any hypnagogic hallucinations. Although he was well enough ori- 
 ented concerning his situation in England, the idea of getting to 
 Canada was still in his mind, but he remarked a number of times that 
 he must speak to the head of the hospital about it. Physically he ad- 
 mitted some fatigability, and complained of his eyesight, that things 
 got foggy if he looked at them long. Nystagmus was present on look- 
 ing to the extreme left. His optic disks showed haziness and redness 
 with the margins obscured. The remains of one hemorrhage were 
 seen. 
 
 Two weeks later he complained of waking early in the morning, 
 but not of any other difficulties in sleeping. He said his memory was 
 much better. He could remember my name and the name of the hos- 
 pital where he had first seen me, and external events that had occurred 
 on the day of my previous visit. He also said that memory of his last 
 day of fighting was coming back. He could recall being chased by a 
 German aeroplane, and thinking that his observer had shot the Ger- 
 man down. He could also recall going through various manoeu- 
 vres in order to escape the German, and said that he suspected his 
 aeroplane had been hit by an anti aircraft gun. 
 
 He was still worried about going to Canada, this obsession now hav- 
 ing taken the form of fearing that a medical board would send him 
 directly back to France, that the board would not realize that he was 
 incompetent to fly again, whereas he knew that he could not, because 
 he had difficulty in telling "up" from "down," and was subject to 
 some dizziness. He also felt that there was something the matter with 
 
58 
 
 his vision as things did not look perfectly clear to him. When tested, 
 however, he seemed to haye no defect. The nystagmus on looking to 
 the left was still present and his left pupil was slightly larger than 
 the right. 
 
 As the foregoing account shows, the patient developed no 
 neurotic symptoms whatever, following this concussion, his 
 difficulties being strictly of the organic type. There was 
 first great confusion and disorientation, with some delirium- 
 like ideas; following this, considerable recovery, as evi- 
 denced by grosser intellectual tests, but a persisting defect 
 for grasping more subtle situations. 
 
 The next case gives an illustration of a less severe con- 
 cussion, also without any neurotic reaction. The dreams 
 he developed are of particular interest inasmuch as their 
 content and the accompanying affect was distinctly different 
 from that of the anxiety state: 
 
 Case Xlir. The patient is a major in the artillery, aged 39. He 
 fought during the South African war and had been in the regular army 
 all his adult life, There was no trace of abnormality to be discovered 
 in his make-up, in fact, he had an extremely open, pleasant personal- 
 ity. He fought until the end of May, 1917, without ever developing 
 real symptoms. He was wounded three times, though none of the 
 wounds were serious. Once after being wounded he had a few night- 
 mares, but could not recall the content of them. 
 
 At the beginning of March he was sent with his battery to the Mes- 
 sines region and was extremely busy preparing for and assisting in the 
 final bombardment. On Jiane 3, after having worked very hard, he 
 was tired and lay down in his dugout to rest. Although feeling weary, 
 he had developed no symptoms indicative of real fatigue and had had 
 no bad dreams or "jumpiness. " He remembers that the battery was 
 being bombarded and that he heard two 5.9 shells land near the bat- 
 tery. The last he remembers was reading some ilispatches and turning 
 them over to his captain. His next memory was of awakening in a cas- 
 ualty clearing station. A shell had come and pierced the roof of his 
 dugout, had killed three and wounded nine, and broken up the bed on 
 ■which he was lying. Some iron from the bedstead hit him in the ab- 
 domen. The shell fire was so heavy that those in the dugout could 
 not be rescued for some time. Then the patient was dragged out into 
 a field. He was partly conscious, but fainted in the field. When he 
 recovered from this he insisted on going to the battery and taking 
 charge of it. His junior officers saw that he was quite dazed and hope- 
 lessly incompetent, but were unable to get him to leave his post until 
 they told him that the brigadier had ordered him to headquarters. 
 He went to headquarters and there became confused again, so that he 
 
59 
 
 was removed to the casualty clearing station. His memories began 
 three or four days after the concussion. The first memory was of this 
 hospital being under shell fire, which did not frighten him. For 
 about a week he had intense pain in his abdomen, particularly on mic- 
 turition, but that soon left him entirely. His head ached and he had 
 a big bruise on the CKxiput, and he suffered from intense photophobia 
 and poor vision. There was considerable difficulty in talking as he 
 found it hard to get the right words. After a week in this hospital he 
 was transferred to London. There he was slightly confused and dis- 
 oriented and troubled by his dreams which recurred every night and 
 disturbed his sleep. I saw him a couple of days after tliis when his 
 confusion had cleared up, objectively at least. He spoke in a monot- 
 onous slow voice with pauses between the phrases as if it were an 
 effort to talk, and it seemed as if he had occasional difficulty in find- 
 ing the right word. The pitch of his voice was unnaturally high and 
 had a distinct monotony that was in marked contrast to his emotional 
 normality. In spite of the distress he was in, he talked fully and 
 pleasantly about his experiences. His chief complaints were of pain 
 in the head, weakness and "shakiness. " This last was not objec- 
 tively visible, but probably was his term to describe his fatigue. He 
 was unable to give any clear account of events prior to his coming to 
 London, although he could remember having been in Boulogne for, 
 perhaps, two days. He had become clear as to his immediate environ- 
 ment, but found difficulty in concentrating his mind on any topic. 
 He said he had had visions of the Messines Ridge on going to sleep, 
 and he was not quite sure whether he dreamed that he was there, or 
 that he felt that he was there before actually going to sleep. There 
 was absolutely no anxiety in these dreams, nor in the daytime, and no 
 "nervousness" at any time. There were no neurological signs, but 
 his eyes could not be examined on account of the intense photophobia 
 from which he suffered. 
 
 He told of a recurrent dream which he had had for a good many 
 nights, although it had not been present for the last two nights. The 
 dream was as follows: His guns were being fired by creatures having 
 the bodies of frogs and the heads of Baimsfather's caricatures. 
 (These are cartoons which are extremely popular both in England 
 and at the front ) These creatures did everything wrong and paid 
 no attention to his orders, and he felt much annoyed by his inability 
 to set things right. In the first dream they had the guns pointed 
 backward toward the British lines. In later dreams they were turn- 
 ing the treads from left to right instead of forward. Finally the 
 creatures had the guns pointed toward the enemy, but did not fire 
 them, simply stood there. The affect in all these dreams was the 
 same, namely, the annoyance at the inability to get his orders obeyed. 
 
 It seemed that the men either did not hear, or paid no attention. 
 
 A superficial analysis of this dream was easily made, showing that 
 the details were a jumble of ideas in his mind while on duty at Mes- 
 
60 
 
 sines. Near his battery there was a pool full of frogs. German shells 
 used to drop in this pond, after which frogs and slime would rain all 
 around them, which was very annoying. The Bairnsfather pictures 
 he was very fond of, and had the walls of his dugout covered with 
 them. The men not hearing them made him think of the frogs again. 
 They used to croak very frequently. One of the sergeants had the 
 name of "Brick," and there was a joke in the battery that one of the 
 frogs had called out "Brick, Brick," and the sergeant had answered. 
 An hour before the concussion, this sergeant, of whom the patient 
 was fond, was wounded in the ear. 
 
 This is a typical fatigue dream, in which the task of the day is 
 presented as something that is annoyingly impossible to complete, 
 wherein the distortions from the actual sitiiation are the result of other 
 annoyances being included, tending to make the confusion and the 
 impossibility of putting through the work all the greater. After 
 these recurrent dreams he had an isolated one that was again a distor- 
 tion of another difficulty at the front. For the last three weeks while 
 on duty he had had trouble in getting up his amunition and rations. 
 In the dream he discovered one of the nurses at the hospital in which 
 he was in London, trying to bring a box of tea into his room. She 
 was having a hard time of it and could not succeed. He wanted to 
 help her, but could not get to the door. He felt that the nurse was 
 trying to bring him rations. 
 
 Nine days later I saw him again, at which time he felt very much 
 better. His sight was still poor, particularly on the left, so he said. 
 It was difficult to believe that this was a neurotic difficulty for he 
 burned his fingers slightly in lighting a cigarette. There was little 
 ataxia in his movements. Speech had become quicker, but was still 
 high pitched. It was also possible to detect an occasional defect, as 
 when he said "t" for "th, " and sometimes "d" for "1." His eye- 
 grounds had been examined and found normal, but his visual fields 
 had not been tested on account of the photophobia. He had received 
 a letter from his captain giving the details of his accident and was 
 astounded to learn that at least three days were gone from his memory. 
 
 The attitude of this patient toward the war and fighting was in 
 marked contrast to that of the anxiety cases who are either consciously 
 aware of their resistance to returning to the front, or exhibit this re- 
 sistance in their dreams. The patient was anxious to return to duty 
 because he had been promised the command of a battery that was to 
 be sent to Italy. As he had never taken part in any mountain opera- 
 tions, this prospect was most attractive to him. His unconscious 
 desire to take up this work is illustrated in the following dream, where 
 difficulties are surmounted or made ridiculous. This dream occurred 
 about a week after the last one quoted, and in the interval he had 
 had none, or remembered none on waking. The dream is as follows: 
 He was training men for Italy at Aldershot, and decided to take his 
 men to a hilly country as that would be more like Italy. He therefore 
 
61 
 
 moved his battery to Devonshire and the men worked splendidly, so 
 that he was proud of them. He made them bivouac out Ihe first 
 night, however, and they all cai:ght cold in their left eyes (the 
 patient's vision was poorer in the left eye). He despised the men for 
 their softness, but then realized that it was partly his fault and felt a 
 little ashamed. Then the thought suddenly came to him that they 
 would no longer need to close their left eyes when they sighted the 
 guns, and he laughed aloud at the thought of it. He awoke laughing. 
 That the patient in this dream disposed of the only symptom he was 
 aware of which could prevent the assumption of his new duties, is too 
 obvious to require further comment. 
 
 The following case illustrates another concussion in a nor- 
 mal individual in whom there had been a short period of 
 fatigue prior to the accident, and possibly related to that, a 
 brief development of anxiety symptoms after the accident. 
 
 Case XIV. The patient is a ruggedly built officer about 30, who 
 took out his commission at the beginning of 1916 and went to France 
 at the first of 1917. Nothing indicating any abnormality could be 
 discovered in his mental make-up during a brief examination. In 
 his first exposure to shell fire he was frightened, but soon acquired 
 the ability of gauging the direction of the shells, after which he had 
 no fear whatever. The sight of bloodshed gave him no disabling 
 symptoms, but he knew very well what they were, as he said he had 
 seen many cases who had been incapacitated by horror. He fought 
 for several months without any particular incident, and enjoyed the 
 life. In May he was, with others, holding a salient for three days 
 under terrible fire. The trenches had just been taken, both flanks 
 were exposed and the enemy was making everj' effort to wipe out 
 this advance line. They had not had time to make any dugouts 
 and so there was practically no protection from shells. On the third 
 day only six out of twenty officers were left About 11 in the morn- 
 ing the patient was buried and unconscious for a short time. 
 
 On recovering consciousness he felt shaky and was "jumpy," but 
 carried on because there were so few officers left. His mind was hazy 
 and he wondered in a dazed sort of a way how long he would be able 
 to keep going, but was determined not to give up. He lost his abil- 
 ity to gauge the direction of the shells, and all the afternoon felt that 
 the Germans were aiming directly at him. This is of course a def- 
 inite symptom of the anxiety state, but not one from which recovery 
 could not have been made if he had been relieved from duty before 
 being exposed to further strain or accident 
 
 About 6 o'clock that evening he was buried again and awoke six or 
 seven hours later in a casualty clearing station, with a terrible head- 
 ache, and incoherent. For the next two or three weeks he was con- 
 scious and unconscious off and on, and could talk very little as the 
 
62 
 
 words seemed to stick in his throat. His head ached, and he felt con- 
 fused and was dizzy whenever he sat up in bed. From the fourth to 
 the twelfth day he had a fever that went as high as 10,5' and 104''. 
 "When this left him, his recovery began and went steadily forward. 
 When I saw him some six weeks after the concussion, he was able to 
 sit up and talk a little. His speech was slow, in isolated phrases, and 
 suggested a word-finding difficulty, with occasional wrong use of 
 words, such as when he said to me as I took my leave: "Much 
 obliged to meet you, ' ' a mistake of which he did not seem to be aware. 
 Headaches were still present, coming on as a rule about 8 at night 
 and keeping him awake half the night so that in the morning he would 
 feel very dull. Some nights, however, he had no headache at all. 
 Noises were very unpleasant to him and he started at every sudden 
 sound, but without any trace of fear. He confessed that his memory 
 was still treacheroiis, and was hazy, particularly for the period of time 
 he had spent in the hospital in France, and he still had some diffi- 
 culty in concentration. He said that at first he had slept very little, 
 and that when he did sleep his rest was disturbed by nightmares of 
 being under bombardment in which every shell was coming at him. 
 After a month the dreams became infrequent, and when he would 
 awake a realization of his surroundings always made him perfectly 
 comfortable, and he said that he had never had any fear whatever 
 during the day. 
 
 In this case we have a clinical picture which is almost 
 purely that of concussion, the only features of an anxiety 
 neurosis being the trouble a few hours prior to the second 
 concussion when he felt that the shells were coming directly 
 at him, and nightmares lasting for a month or six weeks, 
 with similar content. 
 
 Following the concussion, however, there were no diurnal 
 symptoms whatever that could not be traced directly to the 
 concussion. It was interesting that, unlike the neurotic 
 patient, he talked spontaneously not at all of himself, and 
 when personal questions were asked, replied to them briefly 
 and then passed to some external subject. 
 
 The following cases illustrate the aggravation of anxiety 
 symptoms by concussion in patients in whom the neurotic 
 manifestations were already well marked: 
 
 Case XV. The patient is a sergeant of the regular army, aged 30, 
 who denied having any definite nervous trouble prior to the war. He 
 was afraid of the dark as a child, however, and had night terrors at 
 this time. He has always had a fear of falling, and a slight feeling 
 of faintness on going down in an elevator into the underground rail- 
 
63 
 
 way, or would begin to feel faint when in an underground train for 
 any length of time, a symptom which he attributed to bad air. As a 
 small boy he was not particularly mischievous, but became more one 
 of the crowd after he had been a few years at school. He was also 
 as a boy very shy with girls, and recovered less from that difficulty 
 as he grew older than he did in respect to his sociability with inen. 
 He was engaged for three years, and married at 21, and there was 
 apparently no reason for this long engagement. He claimed, how- 
 ever, that his married life had been very happy. He was eight years 
 in the army before the war began, and acted as sergeant practically 
 all the time, a work which he enjoyed greatly and in which he was 
 quite efficient. He went to France with the first expeditionary force 
 and remained there for eleven months. For a couple of days he was 
 nervous about the shells, then got used to them and enjoyed the 
 fighting hugely. He was extremely expert with the bayonet, having 
 previously been an instructor in the use of that weapon, and derived 
 considerable satisfaction from his success with it. After fighting 
 nearly a year, he became rather tired and depressed and didn't care 
 what happened particularly, but slept well and had absolutely no fear. 
 Then suddenly he was wounded at the base of the spine and through 
 the right lung with machine-gun bullets. The former was not 
 particularly serious, but the latter was, for he lost a great deal of 
 blood and had a haemothorax for many months. He was invalided 
 home to England and was a long time in bed. During this period 
 he felt fatigued and had many dreams at night of fighting. These 
 were not dreams associated with fear, but more of the fatigue type, in 
 which he was ceaselessly fighting without relief, and would awake in 
 the morning tired from his efforts. 
 
 His convalescence was rather slow. For a long time he had diffi- 
 culty in talking on account of his weakness and shortness of breath. 
 After being in the hospital and on leave for five months he rejoined 
 the army, although he still felt far from well. He was put on light 
 duty, but this included drilling where he had to shout at his men, 
 and he discovered that these efforts resulted in his spitting up 
 blood. This not only alarmed him, but made him feel that he was 
 being unwisely and unfairly treated in being placed on duty before 
 he had completely recovered. This attitude was considerably accent- 
 uated by his being ordered a month later to return to France. He 
 was sent to the Ypres section where his trenches were five hundred 
 yards from the Germans, so that there was no possibility for any hand 
 to hand fighting. He felt there was little justice in the system 
 that could send an invalid into this terrible situation, and resentment 
 was strong within him. He settled down into the routine, however, 
 and ceased to think so much about this, although he became speedily 
 very fatigued and fearful of the shells. These symptoms increased 
 steadily and by the end of three months he had got to the point where 
 he had very little sleep and wished fervently that some shell would 
 
64 
 
 take him out of his misery. Then one night he was buried and was 
 under the earth for three-quarters of an hour. He came to some 
 days later with practically no memory at all; in fact, all he knew was 
 his own name. Consciousness apparently was coming and going for 
 some time, and he was very hazy as to his movements for nearly two 
 months. Although his memory steadily improved he had difficulty 
 in concentration for at least six months. At first he could not speak 
 at all; then for a month he would whisper, and when he recovered his 
 voice he stammered for several months. Among his first memories 
 were hallucinations of fighting, with great fear, which occurred during 
 the day, and of constant nightmares, many of them being bayoneted or 
 bombarded. The fear in these dreams was never of being wounded 
 but always of being killed. 
 
 For many months he got not much more than an hour's sleep on 
 any night, but after seven months of hospital treatment the dreams 
 became somewhat less frequent and his quota of sleep rose to four 
 hours a night. Headaches were most troublesome, being constant 
 for the first month or so, and after that a frequent result of nightmare, 
 as he would awake from one of his dreams in terror, and with 
 a frightful pain in his head which might last for hours. He talked 
 much in his sleep, and on awaking his head often felt very full, with 
 a swimming, giddy sensation. During many months he lay awake at 
 night for hours together, thinking of the war and imagining that he 
 was in action. 
 
 He also had other, not so usual, symptoms, such as a feeling of nau- 
 sea, difficulty in beginning to pass urine, and extreme constipation. 
 He was subject to marked trembling. His head for many months 
 shook almost constantly and he had also marked tremors of the legs. 
 After he had been in the hospital for two months, an attempt was made 
 to get him out of bed, but his legs trembled so violently and were so 
 weak that he could not stand, and any effort to make him walk re- 
 sulted merely in very exaggerated movements of his legs. When put 
 back in bed his legs would shake so violently that the bed trembled. 
 When put into a wheel-chair his calf muscles were in such constant 
 tremor that the whole chair shook. 
 
 After some months the patient exhibited few signs of recovery 
 under the ordinary treatment of rest, and it became evident that there 
 was a definite reason for this. He had an unusual depression. He 
 felt not only that he was not going to get well, but that he did not 
 wish to recover. Visits from his wife made no impression on him. 
 He had no desire to see any friends and did not care whether they 
 were alive or dead. In fact, this symptom was so strong that when 
 he heard of the death of his son, aged 4 years, he had difficulty in 
 realizing it, and was not greatly impressed. For several months he 
 did not care about either the success or failure of the war, although 
 that was the first interest to return. It developed that the basis of 
 this depression was his feeling of resentment at the government and 
 
65 
 
 the country that had sent him back to fight after he had already done 
 his dnty; he had suffered severely and was still an invalid, lie com- 
 plained frequently of the way in which a " British subject is treated, " 
 mentioning his own experiences and his having frequently seen men 
 shot for suspected cowardice. He thought that they, too, were not 
 treated as "British subjects" should be. He confessed to worrying 
 about these incidents constantly, and that these ideas were always in 
 his mind when he returned to France the second time. The mech- 
 anism of this depression apparently was that with this resentment 
 contact with his fellows was broken. He had no ambition to renew 
 it, and consequently was an isolated being for whom no one cared. 
 It is typical of the ready response to treatment which the war neu- 
 roses show that a little personal attention and explanation as to the 
 objects of examination, in which he was led to take some interest, 
 completely removed this depression, so that he became bright, cheer- 
 ful and anxious to get well. In the next few days, during which I 
 had an opportunity of seeing him, the recovery from many of these 
 symptoms was remarkable. For one thing, he got so that he could 
 walk fairly well, and he was perfectly confident that he would soon 
 be entirely recovered. 
 
 Case XVI. The patient is a man of 4.5, very happily married for 
 twenty years, who had been an efficient plumber with his own shop 
 for many years. His make-up seems to have been unusually normal. 
 At the beginning of the war he did not enlist because he was respon- 
 sible for the maintenance of his family. When the first Zeppelin 
 came over London, however, he felt that he could remain out of the 
 war no longer and joined up, although it involved closing his busi- 
 ness. He adapted himself well to the training, and then went to 
 France, where he acted as senior sapper for 130 days. He enjoyed 
 this work greatly, as he had a good gang of men under him and 
 was able to do most effective work. He felt sorry for the wounded 
 and the killed, but it did not upset him. Three weeks before the end 
 of his stay in France his working party was spotted, and most of the 
 men were killed with shells. Up to this time he said he had not felt 
 overworked, but after it the war got on his nen-es. The sight of the 
 dead horrified him. He felt as if all the shells were coming at him, 
 and was "jumpy" at every explosion. His sleep was poor and he 
 began to have bad dreams. He became quite hopeless of being able 
 to continue indefinitely, and wished that he might be killed. For 
 three days he had such a headache that he was not able to hold his 
 head up except when actively busy. Then a heavy high explosive 
 shell came and buried him. It exploded so close that his hair and 
 eyebrows were burned off. He remembered nothing of it, but was 
 told that he must have fought his way up through the loose earth 
 because his head and arms showed above ground. When the rescue 
 party dug him out and brought him to the hospital, it was found that 
 he had such a severe bruise on his buttocks that the doctor told him 
 
66 
 
 he would never walk again. This concussion took place on July 1, 
 1916. On July 7, he was taken to a hospital in London, and his 
 memories begin again from his stay in that hospital. He knows he 
 was conscious before reaching England but can recall nothing of the 
 time. He could not talk without great effort in getting a word "off 
 his chest," a difficulty which persisted for the better part of a year 
 when he was at all excited. He was at first very deaf, and still is 
 hard of hearing, although this has improved greatly. (Probably 
 middle ear trouble. ) He was so weak that he could not raise his 
 eyes, and was short of breath, a symptom which was still present 
 when I examined him in June, 1917. His legs were full of pain, and 
 it was some months before he could walk. The pain, although 
 greatly lessened in degree, persisted for a year. All these symptoms, 
 except the weakness in the legs, he ascribed to the exposure to the 
 noise and gases of the shells, which affected his eyes, his hearing and 
 his lungs. 
 
 At first, in London, he could not recognize his wife, and could 
 remember nothing about himself, but all his memory, except for the 
 accident, came slowly back. Some forgetfulness as to the past was a 
 persistent symptom. During the daytime he was constantly ' 'jumpy, ' ' 
 and trembling all over, although he felt no fear. In fact, the only 
 diurnal fears he had were when a Zeppelin raid occurred and bombs 
 fell in the immediate neighborhood of the hospital, or when thunder- 
 storms occurred. Also if he were left alone for a time, figures of 
 Germans would begin to appear on the wall and he would become 
 frightened. As he grew stronger and was able to move in a chair, 
 he would get out of the room and join others when any of these 
 visions occurred. He also suffered from hypnagogic hallucinations 
 of Germans, sometimes with, sometimes without fear. Bad dreams, 
 which were worse than any that he had at the front, began in the 
 hospital. These, during the following year, gradually decreased, but 
 were still occasionally present a year after the concussion. He could 
 tell when they were going to come by a thumping in his head before 
 going to sleep. The content of these was purely of fearful incidents 
 in France. But later he began to dream of bombardment without 
 fear. 
 
 He exhibited a splendid spirit. He blamed no one, and thought 
 he simply had had bad luck. When it was suggested that he ought 
 perhaps to have been given leave, he scoffed at the idea, because the 
 sappers were short-handed at the time. He was very anxious to get 
 well, and seemed to be improving rapidly in spite of having a high 
 blood- pressure. 
 
 Treatment: The treatment of the anxiety states, al- 
 though effective in an astonishingly large number of cases 
 when intelligently pursued, is nevertheless not such a simple 
 affair that the physician can be guided by any rule of 
 
67 
 
 thumb in his procedure. As has been stated, the symptoms 
 of the neurosis (no matter what fundamental physical fac- 
 tors there may have been) seem invariably to be determined 
 psychologically. Plainly then, the psychological effect of 
 every therapeutic measure must be considered. In this 
 report the etiological factors have been given prominence 
 because it seems that the treatment of the anxiety cases 
 must be individual, and must, in every instance, be aimed 
 at the removal of the effect of each cause. It can not be 
 too strongly urged that consistent plans of treatment should 
 be followed, as would readily be admitted by all who have 
 been interested in the treatment of neurotics during times of 
 peace. There is, therefore, nothing more inimical to the 
 interests of the patient (or of the army, in the long run) 
 than a frequent transfer of these patients from one hospital 
 to another, where different theories are held as to the cause 
 of the trouble, or where notes do not accompany the 
 patients, giving an outline of what has already been accom- 
 plished or attempted. 
 
 At the outset, every patient, once a diagnosis is made 
 (and it should be made speedily), ought to be removed as 
 quickly as possible to a quiet environment. It must be 
 borne in mind constantly that a highly important factor in 
 every case is the conscious or unconscious desire to get 
 away from the fighting. Not unnaturally then, symptoms 
 tend to be aggravated by mere removal from the line and 
 having the patient placed under the observation of a physi- 
 cian, because the worse impression the patient makes, the 
 longer is his absence from the trenches apt to be. Conse- 
 quently, we obtain the history of many patients of symp- 
 toms becoming very much greater as soon as they arrive in 
 a hospital. ( Merely coming under observation is not the 
 only reason for this exaggeration of symptoms.) Since 
 the soldier is incompetent to fight, he must be in a hospital, 
 but once there, he should be protected during this period 
 from every possible excitement that is liable to increase his 
 symptoms. The stay in any hospital which is under shell 
 fire, near parade grounds, or filled with wounded men, 
 should therefore be cut down to the minimum. On the 
 
68 
 
 other hand, if the patient be taken too far from the firing 
 line, if he be sent over seas, for instance, he is likely to 
 develop an idea of permanent absence from his duties that 
 may stand in the way of a complete recovery. Ideally, 
 therefore, we should seek to place these men in a hospital 
 quietly situated in the same country where the fighting is 
 in progress. 
 
 The treatment at first should be purely symptomatic. 
 Every patient suffers more or less from fatigue, and it 
 is ridiculous to attempt psychological treatment in one who 
 is suffering from such a definitely physical disability as 
 fatigue. The first treatment should be to give the patient 
 absolute rest in bed and produce sleep in as normal a way 
 as possible. The Weir Mitchell type of treatment is of 
 value with some cases, but if the patient is subject to fear 
 when left alone, isolation can by no possibility lead to any 
 improvement in his condition. Some idea of the individual 
 difficulties must therefore be gained at once. The question 
 of producing sleep is also one concerning which no general 
 rule can be laid down. Although there is nothing worse 
 for these patients than the indiscriminate and constant use 
 of sedatives, they may nevertheless be of great value if prop- 
 erly administered. A good method is to give sufficient 
 dosage of whatever drug seems to be indicated to produce 
 sleep the first night when treatment is begun. The patient 
 should be kept as quiet as possible during the following 
 day, and an effort be made to produce sleep the next night 
 in a more normal manner, that is, by the use of baths, 
 packs, etc. Mild suggestion may be of considerable value 
 at this stage. In practical experience the most potent 
 influence in suggestion seems to be the general morale and 
 attitude of a hospital as a whole. It is a striking fact that 
 in those hospitals where reliance is placed chiefly on drugs 
 there is a constant difficulty met with in combating insom- 
 nia, whereas the difficulties are much less in those institu- 
 tions where drugs are largely taboo. If, on the second 
 night, no sleep is obtained by hydrotherapeutic methods or 
 suggestion, a milder dosage of a hypnotic may be effective, 
 and for this a placebo may be later substituted. 
 
69 
 
 The above statements refer to the acute stage where gen- 
 uine fatigue is undoubtedly present. It must be borne in 
 mind that fatigue, as such, is a condition which is readily 
 and rather speedily recovered from simply through rest. 
 Consequently the period during which the patient is kept 
 isolated and no demands are made for him to exert himself 
 in the slightest degree, should be kept as brief as possible. 
 If this is not done, a condition of invalidism is fostered. 
 Just how long this period should be is a matter which must 
 be settled individually, but as a general rule one might 
 say that the patient should not be left without any demands 
 being made for cooperation on his part in the treatment for 
 longer than one or two weeks. This is, however, rather a 
 guess, inasmuch as I have not had an opportunity of see- 
 ing many of these cases immediately after they have been 
 in the trenches. It is of course obvious that when concus- 
 sion of any severity has occurred, a very much longer 
 period of rest is indicated, as we know even from civilian 
 experience that nothing is more inimical to the welfare of 
 one suffering from physical injury to the brain than fatigue. 
 Complete and prolonged rest for these cases is therefore 
 obligatory. At present we have no drugs that combat 
 fatigue of the central nervous system directly. If further 
 study of these cases reveals the chemical nature of this 
 disease, we might hope to find some antidote for it that 
 would materially reduce the period of rest required. Fur- 
 ther than that, we might even hope that the same remedy 
 would prevent the steady increase of the accumulative 
 effects of the fatigue that we see in the trenches, and thus 
 prevent many neuroses from developing beyond the initial 
 stages, where fatigue dominates the clinical picture. 
 
 Proceeding along the lines of symptomatic treatment, the 
 next stage should be to combat the patient's most obvious 
 subjective difficulties, namely, the fear of war and the 
 obsessions with thought of its horrors. These can best be 
 met acutely by distraction in one form or another. The 
 patient should be given a common sense talk and assured 
 of two things: The first is that he is going to get well, 
 since he has been removed temporarily from the influences 
 
70 
 
 which caused his breakdown, and that this recovery will 
 be greatly facilitated by his active cooperation. The 
 second is that he is now under medical control and that he 
 need have no fear of being ordered to do anything that 
 will not be to the advantage of his health, that there is no 
 possibility of his being sent back to the line until he is 
 completely well, but that, on the other hand, because his 
 disease is curable, he will, of course, have to return eventu- 
 ally. In other words, an effort must be made to produce a 
 state of mind wherein he is willing to forget the war, for the 
 time being, without fostering the idea that he is out of it 
 for good. It is not enough for the patient merely to be 
 willing to forget. Active efforts must be made to distract 
 his mind. His environment should therefore be made as 
 nearly that of civilian life as is possible and practicable. 
 This does not mean that uniforms should be abandoned. 
 The men are still in the army, and should not be given such 
 a suggestion as to leaving the service. Rigorous military 
 discipline, however, should be relaxed, and the artificial 
 social distinctions between different ranks reduced to a 
 minimum. A medical man, for instance, who can not 
 forget that he has the rank of major, is bound to make a 
 pitiful failure in his efforts to treat a subaltern. 
 
 Occupation of some kind should invariably be given, but 
 never according to any hard and fast rules. A game of cards 
 may be all the man can stand at first, perhaps it will be 
 only a very small amount of light reading. He can progress 
 from this to the less violent out-of-door games, and as his 
 strength increases, be given something more productive. 
 For this reason, well equipped workshops are invaluable, 
 particularly for privates and non-commissioned officers. A 
 course of study is sometimes of considerable value for an 
 officer whose interests are naturally in an intellectual field. 
 The objects of these occupations are two-fold, being first, 
 to distract the man's mind from the worries that had so 
 much to do in the establishment of his neurosis, and secondly, 
 to give him that confidence in himself which is often pain- 
 fully lacking, and which can be re-established only by the 
 patient's actually achieving something. The prescribing 
 
71 
 
 of occupations should alwa\'s be directly under the control 
 of the physician in charge of the case, whose duty it is to 
 note the exact effect which the occupation has on the 
 patient, and to var\' its nature or aim accordingly. Much 
 harm is frequently done by advising some exertion which 
 fatigues him unduh', and convinces him that he has some 
 terrible weakness. The consequent discouragement may be 
 extreme, and for a long time stand in the way of any 
 improvement. Every patient should therefore be examined 
 with great frequency, particularly at the beginning of any 
 occupation treatment. The granting of leave from the 
 hospital for a few hours, or for a week-end, if judiciously 
 used, may help a patient considerably. He is thrown on 
 his own resources to a greater extent than when in the 
 hospital environment, and consequently he has a much 
 greater feeling of achievement and greater pleasure from 
 this than from any intramural entertainment. As practi- 
 cally all those who suffer from anxiety neuroses are impotent, 
 at least in the acuter stages, sexual indiscretions do not 
 need to be borne in mind, when leave is granted, so con- 
 stantly as tiiey do when the patients are suffering from other 
 forms of disabilit\'. In fact, feminine companionship is an 
 excellent form of distraction to the soldier who has been for 
 many months in a purely military environment. 
 
 The treatment so far outlined is essentially environmental, 
 and aims at combating the symptoms in a superficial way. 
 In most cases it will be successful in removing all or most 
 of the obvious symptoms. There remains, however, the 
 fundamental difficulty which has so much to do with the 
 development of the neurosis, namely, the antagonism to the 
 duties forced on the soldier, and often to war in general. 
 These can be eradicated oyily by the patient gaining some 
 psychological understanding of the origin and nature of his 
 symptoms. Occasionalh" one meets with an officer who is 
 sufficiently intelligent to understand the situation without 
 any outside help, and who is capable of taking himself in 
 hand and combating these tendencies alone. This, how- 
 ever, is rare. 
 
 On the other hand, those who have experienced the great 
 
72 
 
 difficulties to be met with in civilian practice, in getting 
 patients to understand themselves, will be delighted with 
 the ease with which the sufferers from war neuroses are 
 capable of grasping the psychology of their disease and 
 making use of their knowledge. This is, of course, not 
 unnatural, considering that we deal here with men who are, 
 relatively speaking, quite normal, and with situations that 
 are essentially simple. In a few talks a patient can be led 
 to see how the war sublimation, which has been outlined, 
 has broken down, and how it was that he therefore developed 
 the tendency to think of himself rather than of the needs of 
 the army and of the country, and so became a prey to fear 
 and horror. 
 
 When once the patient sees that his disinclination to 
 return to the front is essentially a selfish desire to avoid his 
 responsibility as a citizen, he is in a position to decide quite 
 consciously whether he wishes to be a slacker or to assume 
 his share of the country's burden. If he has the right stuff 
 in him, he becomes ashamed of his symptoms and begins to 
 control them quite speedily. He is soon eager to take some 
 part in the struggle, and if he is given light duty which 
 does not make too great a demand on his capacity, this 
 capacity grows, and with it a desire to return to the field of 
 active operations appears. Probably nothing is gained by 
 an attempt to send a man back to the firing line who does 
 not spontaneously wish to be there. Each patient has 
 learned that the development of certain symptoms will cause 
 his removal from the trenches, and if he consciously desires 
 to be out of them he will make little effort to combat their 
 redevelopment. 
 
 Even when this type of analysis is attempted, reliance 
 should not be placed on it alone. It can not be too con- 
 stantly borne in mind that one of the greatest difficulties 
 from which these neurotics suffer is a lack of complete 
 rapport with their fellows. Many of them feel (with some 
 justice) that they have been ill-treated, and a feeling of 
 responsibility toward the State is difficult to foster in an 
 individual who feels that the State has no regard for him. 
 For this reason a demonstration of personal interest in the 
 
patient maybe of g^eat value (Case XV is an example of 
 this). The physician must therefore learn to have a keen 
 sympathy for the patient as an individual, but never to 
 have any sympathy whatever for the patient's symptoms as 
 such. This is not an easy attitude to acquire, and is 
 probably the reason why few physicians who are not trained 
 psychiatrists are successful in treating- the war neuroses. 
 
 As has been said before, there is a tendency present, 
 particularly among- those having- had a definite neurotic 
 history before the war, of developing neurotic troubles of 
 the civilian type when convalescence from an anxiety state 
 is achieved. It is not within the provinces of this report to 
 enter into the treatment of these complicating neuroses, 
 inasmuch as they are essentially peace disturbances. In so 
 far, however, as they are determined by unconscious resist- 
 ance to active service, they are amenable to treatment in a 
 greater degree than are similar neuroses of civilian life, for 
 this is, psychologically speaking, a simpler situation than 
 that which, as a rule, precipitates a neurosis in a civilian. 
 
 Conversion Hysterias. 
 
 The conversion hysterias do not require so protracted a 
 discussion as it has seemed wise to devote to the anxiety 
 cases. Although in absolute numbers they are more frequent 
 in occurrence than pure anxiety states, yet they are so 
 much simpler in mechanism that it is less di"f£cultto under- 
 stand them and to treat them. Moreover, much of what has 
 already been said as to fatigue and dissatisfaction with active 
 service may be applied directly in discussing the conversion 
 hysterias, provided one remembers that, although these fac- 
 tors operate in the two conditions alike, their development 
 is much less extensive in the cases of conversion hysteria. 
 
 These may be defined as neuroses in which there is an 
 alteration or dissociation of consciousness regarding some 
 physical function . The term * ' Conversion Hysteria' ' is used, 
 because an idea is transferred over into a physical symptom. 
 The cases are confined almost entirely to privates and non- 
 commissioned officers, the reason for which will be discussed 
 
74 
 
 later. The purely hysterical manifestations are apt to be 
 accompanied by mild anxiet3^ symptoms; occasionally the 
 latter are severe. 
 
 The symptomatology is extremely varied, although there 
 have been no s3'raptoms described in the war cases, so far 
 as I know, which have not been well known in times of 
 peace. Even a brief study convinces one that the more 
 important and frequent s3'mptoms are those which obviously 
 provide the patient with a relief from active service. Mut- 
 ism is the commonest, apparently. Aphonia as a prelimi- 
 nary symptom is rarer, but it often develops as a stage of 
 recovery from mutism, as does stammering. Deafness is 
 fairly frequent. After the speech group, motor disturbances 
 are the most important. These include monoplegias and 
 paraplegias or pareses; tics, spasms and contractures are not 
 unusual. Tremors are usually a complication of an anx- 
 iet3^ state, and it is quite frequent to find gait disturbances 
 such as have been described in connection with the anx- 
 ieties. It is quite frequent to find an initial and not very 
 severe anxiety state in a private develop into a gait disturb- 
 ance that is unaccompanied by any emotional trouble. 
 Spasticity of the legs is also a rare symptom, except as a 
 complication or result of an anxiety state. Hyperesthesias 
 may occur alone. Parsesthesia and anaesthesia usually 
 accompany hysterical sj^mptoms. Blindness and amblyopia 
 are not very common. Disorders of smell and taste are still 
 rarer. 
 
 Clinical Course: What has been said as to the make-up 
 in connection with the anxiety states applies also to the 
 hysterical group, but with the latter complete normality 
 seems to be more frequent. The adaptation to training may 
 or may not be good; naturally those who adapt themselves 
 well are less likely to develop symptoms. Fatigue is, as a 
 rule, the first s^^mptom that can be discovered, butitis almost 
 never so severe as in the anxiety cases. Its sj-mptoms are 
 therefore not so well marked. There is little sleeplessness, 
 and rarely nightmares, in the purely hysterical case. More 
 frequently one gets a history of purely diurnal dissatisfaction. 
 As a rule, there is fear, with much less "jumpiness" than 
 
75 
 
 is met with among- officers. There is almost always some 
 weariness and a distinct antagonism to the fighting. The 
 patient is rarely subjected to the mental conflicts that are so 
 distinctive of the prodromal anxiety state in officers, because 
 the men who develop hysterical symptoms are privates whose 
 ideals are not so high, and who do not have to make de- 
 cisions for themselves. Their responsibilities begin and end 
 with obedience to orders. And it is the duty of the officers 
 to put courage into them, not for them to develop and main- 
 tain it themselves. Not unnaturally then, we find these 
 men seeking to gain release from the situation they dislike 
 in a way which is incompatible with the higher standards 
 of the officers. They look for some valid excuse from the 
 firing line, and so, almost universally, hope to be wounded 
 in some way that will incapacitate them from active serv- 
 ice. I have found either this wish for a " blighty one," or 
 else thoughts of some physical disease in the history of 
 every hysterical case, except one, that I had an opportunity 
 of examining. The exceptional patient did not seem suffi- 
 ciently intelligent to give an accurate histor3^ Occasionally 
 the antagonism to fighting is the direct outcome of physical 
 accident or disease which removes the soldier from the 
 trenches. The wish that develops is then that he may not 
 have to return. 
 
 This attitude of antagonism with some idea of release 
 constitutes the background of the hysteria. Then some- 
 thing happens which is the occasion for the development of 
 definite symptoms. A frequent cause is concussion which 
 may or may not be severe. Case XV, the sergeant who was 
 exhausted and had been worried about his inability to shout 
 without spitting up blood, and therefore had his attention 
 directed to his voice, is an example in point. After his con- 
 cussion and return to consciousness he was mute, following 
 that, aphonic, and then stammered. A not infrequent 
 symptom is auEesthesia at the area of some slight injury 
 which is received at the time of concussion. Not unnat- 
 urally burial without concussion is a highly frequent 
 precipitating factor. It is not improbable that the over- 
 strung soldier imagines that he is about to be killed when 
 
76 
 
 the shell explodes close to him, and this emotional shock 
 upsets his mind sufficiently to cause that disturbance of con- 
 sciousness which we term h^^steria. As with the anxiety 
 cases, the infliction of an actual wound does not at the time 
 precipitate hj^sterical symptoms, but these very often develop 
 later when the private who does not wish to fight is conva- 
 lescing ph5'sically from his wound. The subjective symp- 
 toms are apt to be continued indefinitely in a h3"sterical way, 
 that is, the pain or disability may not be recovered from, 
 although there may be complete healing- at the sight of in- 
 jur3'. Monoplegias or spasticities are common symptoms 
 with this etiology. Torticollis may also occur in this way. 
 It is not difficult to reconstruct the original histor^^ of these 
 cases. There is, while a soldier is still in the trenches, the 
 usual wish to be awa}'' from the distasteful employment. 
 This wish reaches its fulfilment when a disabling wound is 
 received, a situation which is quite satisfactory so long as 
 the injury continues to be disabling. Once recovery sets in, 
 however, the prospect of returning to the trenches is plainly 
 before the eyes of the soldier. Under these circumstances, 
 while he is both consciously and unconsciousl}^ loth to leave 
 the comfortable position in which he finds himself, he nat- 
 urally pays considerable attention to the pain or disability 
 that is a direct outcome of his wound. This attention, 
 backed by his wish for the symptoms to be permanent, con- 
 vinces him that there is no improvement in any respect that 
 is to him subjectively obvious. Consequently his conscious- 
 ness gradually adapts itself to the disability until it is 
 incapable of conceiving the idea of true recovery. The 
 patient, therefore, whose head has been bandaged over to 
 one side with a wound in the neck, continues to hold his 
 head in that position in spite of the fact that there is no real 
 contracture of scar tissue. Similarly the man whose arm 
 may have been put up in a sling finds when the sling is re- 
 moved that all power is gone from the arm, or the limb which 
 has been held in a certain position to avoid pain on move- 
 ment is retained spastically in that position. Apart from 
 the presence of these objective symptoms, he may be in a 
 normal mental state. He is usually untroubled by any anx- 
 
77 
 
 iety, is not easily fatigued, and his behavior is that of any 
 wounded man, that is to say it is quite normal. 
 
 As long as war is in progress and return to the front is 
 imminent the patient prefers (unconsciously at least) to 
 retain his disability rather than to face the perils and 
 discomforts of trench life. Consequently these symptoms, 
 when not treated persist as a rule indefinitely. Occasionally 
 through some accident the patient discovers that the 
 function, which he thought he had lost, is still present. 
 This usually occurs under the stimulus of some sudden 
 emotion. It is, of course, one thing for an outsider to 
 observe a man using a paralyzed arm and another thing for 
 the patient himself to be aware of it. This is only to be 
 expected when we consider that one of the most fundamen- 
 tal characteristics of an hysterical symptom is that con- 
 sciousness, and therefore awareness, as to the function in 
 question is lost. The patients who recover spontaneously, 
 therefore, by making such observations themselves are rare. 
 On the other hand, owing probably to the simplicity of the 
 mental mechanisms involved, treatment is as a rule a very 
 simple matter and frequently successful in a dramatic and 
 permanent way. Once the disability has been recovered 
 from, the patient is in a much more normal state than is a 
 man suffering from anxiety whose obvious symptoms have 
 disappeared. 
 
 The diagnosis of these conversion hysterias is not so simple 
 a matter as that of the anxiety states. Any competent 
 neurologist should of course be able by the usual methods 
 to make speedy and accurate discrimination between 
 organic and functional loss. When the two are combined, 
 however, the problem becomes somewhat more difficult. 
 Hysterical anaesthesia, for instance, may occur with, but 
 have a wider distribution than, that of a pure nerve injury. 
 The latter may be overlapped by the former and lead the 
 physician to believe that he is dealing with a purely hysteri- 
 cal condition. A final diagnosis may therefore be made, 
 only after treatment instituted on purely functional lines 
 has been successful, and has reduced the disability to its 
 legitimately organic distribution. Quite the most difficult 
 
78 
 
 problem, however, is to differentiate a conversion hysteria 
 from malingering. As I have had little opportunity to see 
 cases of malingering as they are presented at the front, I 
 am unable to say much on this topic that is not second- 
 hand. Some workers rely largely on the suggestibility of 
 the hysterical patient as a diagnostic criterion. Occasion- 
 ally one meets with a physician who goes so far as to state 
 that no patient who is not hypnotizable has a true hysteria, 
 and therefore must be malingering. As the individual 
 capacity to hypnotize varies greatly from man to man this 
 is probably a rather unsafe rule. Again, if one relies on 
 the impression which the personality of the patient makes 
 on the physician error is apt to be frequent. The true 
 malingerer is frequently, if not always, a psychopath. 
 Again it may require a rather exhaustive study to determine 
 whether the symptoms are produced on the basis of a con- 
 scious or an unconscious wish, which is essentially the 
 difference in etiology between malingering and hysteria. 
 Probably the safer guide is the history of onset. One 
 should inquire, therefore, as to the mental attitude of the 
 patient before the onset of the symptoms. In a true hysteri- 
 cal case an admission is apt to be made as to the breaking 
 down of adaptation to warfare and the consequent wish to 
 be rid of it all, particularly the wish for an incapacitating 
 wound. The malingerer is not apt to reveal the history 
 because the symptom represents this wish to him quite con- 
 sciously. The hysteric, on the other hand, because there 
 has been an unconscious motivation, does not see the con- 
 nection between his previous desire to be incapacitated and 
 the symptom his malady presents. He is, therefore, more 
 apt to be frank in the matter. In another respect the his- 
 tory may be of importance, I imagine. In all the cases, 
 which I have had an opportunity of examining, whose 
 symptoms arose while in the trenches, there was a history 
 either of concussion or of a definite precipitating cause, the 
 immediate result of which was some disturbance of con- 
 sciousness, no matter how slight. Frequently it amounted 
 to no more than the patient being dazed for a few minutes 
 and finding himself with the hysterical symptom, when he 
 
79' 
 
 became quite clear again. As the opinion of the physician 
 on this matter when delivered to a court martial may mean 
 life or death for the soldier I would prefer to leave this last 
 diagnostic criterion as a suggestion until such time as 
 further experience may show whether the phenomenon in 
 question is universal or not. 
 
 The prognosis in these cases depends on a number of 
 factors. An important one is naturally the mental make- 
 up of the patient. An individual who has a definite psy- 
 choneurotic make up is prone to develop symptoms, to cling 
 to them more tenaciously, and to develop new ones if his 
 original cause for removal from the firing line is done away 
 with. The more normal soldiers, as has been stated, are 
 apt to keep their symptoms indefinitely until appropriate 
 treatment is instituted. Once cured, they are delighted 
 with the result and rarely suffer a relapse. Inappropriate 
 treatment, however, is so ineffective that the opinion has 
 grown up that it is useless to try to get these men back to 
 the trenches. The experience gained in the better hospitals 
 which are devoted to the care of the neuroses speaks dis- 
 tinctly against this, as they have sent a large proportion of 
 their patients back to France, only a few of whom have 
 relapsed. 
 
 Various types of treatment are in common use. The one 
 which appeals most to the physician, who has a military 
 mind, is discipline; and this is logical enough if the assump- 
 tion be made that the symptoms are really under conscious 
 control. If fear of punishment is greater than fear of the 
 life in active service, the symptoms will naturally tend to 
 disappear. On the other hand, the well-disciplined soldier 
 has the habit of obeying developed to such an extent that 
 he is highly suggestible to commands from those of super- 
 ior rank. These two factors apparently account for the 
 cures which result from this method of treatment. They 
 are, however, few in number and not apt to be permanent. 
 This can be easily explained psychologically if one bears 
 in mind what has previously been reiterated as to the 
 adaptation of the soldier. An all-essential factor in this 
 adaptation is the feeling of unity with his group which 
 
80 
 
 the individual develops. Undue coercion — in fact any 
 treatment which the patient may regard as unfair — is apt 
 to weaken the bonds between the soldier and the army 
 rather than to strengthen them; consequently although the 
 symptoms may temporarily disappear, the wish for escape 
 from military life is apt to be even stronger than it was be- 
 fore, so that a still firmer foundation for neurotic symptoms 
 is built up. The application of electricity in various forms 
 and of massage is highly popular and more often success- 
 ful than disciplinary treatment. Its results, however, are 
 dependent purely upon suggestion, and therefore open to 
 the criticisms which shall immediately be made of this 
 method. 
 
 Naturally enough conversion hysterias arise on a back- 
 ground of extreme suggestibility. It is not surprising, 
 therefore, that any form of suggestion — particularly hypno- 
 tism — is extraordinarily effective in the removal of the 
 immediate symptoms. Moreover it does not serve to alien- 
 ate the soldier from the causes for which he has been 
 fighting. On the other hand it has a grave defect psycho- 
 logically in that it is aimed at the removal of symptoms 
 rather than causes. To the uneducated soldier the sj^mptom 
 has come from nowhere and, if it is removed by the sug- 
 gestion of electricity or the more direct suggestion of 
 hypnosis, it leaves him through the agency of a miracle — 
 consequently his mind is strongly imbued with the idea that 
 such things can happen, with the not unnatural result that 
 they do happen again. What should be aimed at is much 
 more the training of the patient to control the workings of 
 his mind, steadily combating the idea that there is anything 
 miraculous or lawless about the functions of his body which 
 have gone wrong. What is essentially re-education is, 
 therefore, without any question the best method of treatment 
 for the conversion hysterias. Those who are most success- 
 ful in gaining permanent results begin as a rule with an 
 introductory talk, when they explain to the patient the 
 nature of the disease from which he suffers. They impress 
 upon his mind the fact that his legs, for instance, are not 
 really paralyzed but that he has simply forgotten how to 
 
81 
 
 use them and that he must learn to do so over again. An 
 effort is made to make the soldier understand that this 
 process is perfectly natural and that it will be quickly suc- 
 cessful provided he makes the necessary effort. The next 
 stage is to demonstrate that the function which is lost or 
 disturbed is really not vitally affected. At this point sug- 
 gestion or hypnotism may be of great value, provided that 
 the patient be given immediately and convincingly the ex- 
 planation that he has done these things rather than that the 
 physician has accomplished them. Many of those whose 
 treatment is most successful prefer to rely on some sort of 
 trick in demonstrating the presence of the capacity which 
 seems to be gone. It would be impossible to enumerate all 
 these — in fact it is probably best to leave the choice of 
 method to the natural ingenuity of the one who is responsi- 
 ble for the treatment. A few examples, however, may be 
 given. One has already been cited in Case II, in which the 
 patient who was deaf and dumb, was made to see in a 
 mirror that he jumped when a sudden sound occurred 
 behind his back. Patients who are mute or aphonic may 
 be shown that all the movements of the lips, tongue and 
 glottis which are necessary to produce speech have not been 
 lost. The patient, for instance, may be able to whistle, to 
 put his tongue in required positions, or to cough. In order 
 to make the patient breathe evenly Captain McDowell has 
 introduced the method of inducing the patient to inhale a 
 cigarette, the smoke from which, if forcibly or irregularly 
 expelled, is apt to be irritating and may produce a cough. 
 Coughing of course involves the use of the vocal chords and 
 produces a voiced sound. Any patient who can cough can 
 also say " ah " and the training may begin from this point. 
 That power is not lost from limbs may be demonstrated by 
 the presence of reflexes, or of contractions elicited by elec- 
 trical stimulation or by sudden movements that are made to 
 prevent falling, etc. A means which is frequently effective 
 is to induce passive movements while the operator actually 
 does less and less in the way of movement until after a few 
 trials the patient makes the motions without any aid from 
 the operator at all. Where a swimming tank is available a 
 
82 
 
 demonstration of the ability to use the legs perfectly can be 
 readily made in those patients who suffer from difficulties in 
 walking. Apparently no matter how severe any gait dis- 
 turbance may be there seems to be no interference with the 
 function of the legs in swimming. Once it has been dem- 
 onstrated that any function is not totally absent, it is the 
 responsibility of the physician to see that constant practice 
 is made and to insist on a steady increase in the extent and 
 number of movements that are executed. When this treat- 
 ment is patiently carried out improvement is apt to be rapid 
 and the results permanent. The reason for the latter is 
 that the patient has learned two things : first, that his symp- 
 tom originated mainly in a lack of control, and secondly, 
 that he has found a method of controlling symptoms when 
 they do arise or tend to develop. 
 
 Many of these patients, of course, have personal diffi- 
 culties which operate in connection with the simple motiva- 
 tion, that has been discussed, in the production of, or 
 maintenance of, symptoms. Many soldiers realize vaguely 
 that their symptoms, although obvious in a physical way, 
 are really mental in origin. The result of this is to produce 
 in the uneducated man a belief that he is going insane. 
 This is naturally a fear which he is apt to keep to himself, 
 and one which is bound to increase his worry and therefore 
 make his symptoms worse or more permanent unless he can 
 have the situation carefully explained to him and this redic- 
 ulous fancy dispelled. It is therefore of first importance 
 for the physician to establish friendly relationship with the 
 patient and to encourage him to bring his troubles to the 
 consulting room for discussion and advice. Improvement 
 when some quite simple personal problem has been cleared 
 up is sometimes so rapid as to be startling. In connection 
 with this individual treatment one factor must not be lost 
 sight of : the majority of the men who are now fighting 
 in all the armies in Europe are essentially civilians. For 
 the greater part of their lives therefore they have been 
 accustomed to natural and friendly social contacts. In the 
 army the demands of discipline necessitate much more 
 artificiality, particularly in the relationship between officers 
 
83 
 
 and men. As a result the private soldier is very apt to feel 
 a need for friendly advice such as he was able to receive in 
 times of peace from his physician, employer or clergyman. 
 Not unnaturally a feeling of isolation may grow up during 
 his military life which operates to increase his dissatisfac- 
 tion with the employment that is forced upon him. The 
 private soldier is therefore extraordinarily affected for the 
 better when any sympathy is shown him by a superior 
 officer such as his physician is. Any hospital in which a 
 minimum of stress is laid on military artificialities is incom- 
 parably more successful in the treatment of these cases than 
 is one where military discipline is rigidly enforced, and, it 
 may be added, a wise laxity in this regard tends to increase 
 the respect which the private soldier feels for his superiors 
 rather than to diminish it. 
 
 Any physician who has a reasonable fund of common 
 sense and a natural interest in his patients is bound to be 
 successful in the treatment of many of these cases. On 
 the other hand, as has been said before, great care must be 
 taken not to confuse sympathy for the patient with that 
 sympathy for the patient's suffering which fosters a hypo- 
 chondriacal tendency. For this reason the man who can 
 best treat the war neuroses is he who has had years of 
 experience in handling neurotic patients and has learned to 
 be sympathetic with the sufferer as an individual and yet to 
 be impatient with the symptoms as such. 
 
 After these general statements as to the causation, symp- 
 tomatology and treatment of the conversion hysterias it may 
 be well to quote a few illustrative cases. 
 
 Case XVII. The patient is a lieutenant in the Royal Flying Corps, 
 aged 23. His clinical history gives an excellent example of final 
 symptoms representing a regression to a previous disability, which 
 had occasioned him some worry. In make-up he was apparently an 
 unusually normal individual who had at no time shown any neurotic 
 tendencies and had a frank and open personality. He had supported 
 himself from the age of 14, at which time his father died, had 
 been successful in business, and had in addition found time to 
 develop into quite an athlete, as well as to become socially popular 
 with both sexes. He entered the army in the first year of the war, 
 took well to his training and enjoyed the fighting keenly. For over 
 a year he was in the infantry. About a year before the onset of his 
 
84 
 
 symptoms he was caught suddenly in a gas attack from which he 
 suffered severely. He was in bed for some days and then, although 
 he recovered rather quickly in other respects, had a severe tracheitis 
 and laryngitis that persisted for weeks. Not unnaturally he was able 
 to do no more than whisper for some time. As it happened, this 
 disability was a considerable blow to the patient because he had 
 always taken a considerable interest in his voice. He had been a good 
 singer and was very proud of his ability to make his voice carry on 
 the parade ground for a much greater distance than could his brother 
 officers. When his voice returned he was much worried to find that 
 any effort to shout caused it to become worse, after which his voice 
 would be quite weak for some hours or days. On the first occasion 
 when he was granted leave he went to London and consulted a 
 laryngologist, who unfortunately told him that he would never be 
 able to sing again. This was a distinct blow and he worried about it 
 considerably, although this worry never was severe enough to 
 incapacitate him as a soldier in the slightest degree. He continued 
 to enjoy the life extremely. 
 
 As he was obviously fitted for that type of work he was transferred 
 from the infantry' to the Royal Flying Corps and soon became an 
 expert airman. In the Spring of 1917 he one day went over the 
 enemies' lines and made the necessary observations so quickly as to 
 avoid attack. While returning he was shot at by the anti-aircraft 
 guns. The shrapnel, so far as he was aware, although bursting 
 thickly around him, did not hit him or his machine, but he considered 
 it advisable to return to his own lines. As a matter of fact one of the 
 wings of his machine had been hit and consequently weakened. The 
 sudden strain thrown on this wing when he was landing caused it to 
 break, so that he crashed to the ground. Careful inquiry failed to 
 reveal any history of his feeling at all upset or nervous prior to the 
 instant of this accident. As a matter of fact he was elated over his 
 success. After striking the ground he was unconscious for three 
 hours. When he came to. he saw his servant in the distance and 
 tried to attract his attention. Whether he attempted to shout and 
 found his voice too weak or not he was unable to remember, as his 
 memory was never entirely clear for the first few minutes after 
 recovering consciousness. At any rate, it was some time before the 
 servant came to him and when he did he found the patient unable to 
 speak. It seems reasonable to suppose that with the concussion he 
 received and the consequent mental confusion his mind harked back 
 to the only physical trouble which he had ever known, namely, the 
 disturbance of his voice that had worried him so much. He may 
 have lived over in this brief period of confusion the previous accident 
 when he was gassed. At any rate, he seems to have automatically 
 begun to protect his voice as he had trained himself to do for the 
 last year. This time, however, the effort of protection was so 
 extreme as to be pathological and resulted in total disuse of his voice. 
 
85 
 
 The concussion from which he suffered seems to have been mild in 
 degree, for after a couple of days' rest he felt quite well physically. 
 For two weeks he was in a hospital in France and then, as there was 
 no improvement in his mutism, he was sent to England, where I saw 
 him three weeks after the accident. In this hospital efforts were at 
 once made to make him talk, and these speedily were successful 
 in so far as he learned to whisper a few words. He was soon able to 
 whisper anything that he wished to say, although it seemed always 
 to require a greater mental than physical effort. By maldng him 
 cough and then say "ah" he gained the use of the voiced sounds. 
 Another symptom then developed, namely, that of stammering. It 
 seemed as if he could bring himself to say not more than one or two 
 words with one breath. By training him to say two, three, four and 
 then five letters of the alphabet in one expiration he was able to 
 make considerable improvement in this. Finally, under mild 
 hypnosis that was practically nothing more than distraction, normal 
 speech was attained that produced an even, uninterrupted repetition 
 of the alphabet. He was forced to apply this smoothness in utterance 
 to his ordinary conversation at once, and did not relapse. The next 
 stage in his treatment was to get him to sing, and after a few weeks' 
 practice he discovered that his singing voice was practically as good 
 as it ever had been. The total treatment lasted about six weeks, but 
 would not have required so much time had the physician who was 
 taking charge of it been able to see the patient every day. 
 
 The next case also illustrates a probable regression to a 
 previous laryngitis with the production of mutism. 
 
 Case XVI II. The patient is a private, aged 26, who had a normal 
 make-up apparently but was not sufficiently intelligent to answer all 
 the questions concerning the minuter details of his mental life. It 
 was impossible to induce him to give any data as to his subjective 
 experience — in fact he seemed to be one of those individuals who 
 are totally incapable of any introspection. Before his symptoms 
 developed he had been fifteen months in France and had not received 
 a scratch. At first he had been in the Ypres section, and there had 
 been sickened by the sight of wounds, did not like the idea of 
 having to kill the Germans, and was frightened by the shells. He 
 got used to all these things, however, and then rather liked the 
 warfare. He was particularly proud of the work of the bombing 
 squad of which he was a member. He was able to give no history 
 of exhaustion nervousness or bad dreams before his final accident. 
 While at Ypres he was gassed and laid up for a week. He had little 
 recollection of what symptoms he showed at that time or of any 
 resemblance they might have to the ones he developed later. In 
 July, 1916, he was blown up by a shell which he could remember 
 seeing as it burst at his side. His companions told him that he was 
 
86 
 
 blown into the air. He received a wound in the back and the right 
 arm and lost a great deal of blood. He was operated on and came to 
 only after several days. He then fonnd himself with a bad headache, 
 dizzy, and with consciousness coming and going for several days. 
 The first time he was conscious it lasted for only a few seconds. 
 The next time a nurse was there who spoke to him. He could not 
 understand what she said and tried to speak. He found he could 
 not. This was possibly due either to weakness or to aphasia which 
 so many patients suffering from concussion show for a short time. 
 The patient was also deaf for some days and it is possible that not 
 being able to hear any sounds which he did make he developed the 
 idea that he was really dumb. For some time he was so numb all 
 over that he could not feel his wounds. This was possibly also an 
 hysterical symptom that was essentially a protective matter. At any 
 rate, he was mute from then on. He had difficulty in thinking for 
 several weeks. His memory for these first weeks was extremely 
 vague and he may have been subjected to some shocks during this 
 period which he later forgot. He was at this time in a hospital that 
 was subject to bombardment. And he remembers that he was 
 "jumpy " there, and fearful when anyone approached him. Night- 
 mares began which continued for a year with gradual improvement. 
 The setting of these dreams was always in France with a constant 
 content of being wounded and having a fear of death, the latter fear 
 predominating over any anxiety about wounds. He said that in 
 these first weeks he thought of the fighting all the time and that 
 when the acuity of his consciousness would lapse he would see the 
 trenches and the enemy, but did not have any hallucination of 
 hearing. 
 
 The patient was treated in general hospitals for ten months and 
 showed no improvement whatever except in that his dreams became 
 somewhat less insistent. He was then transferred to a special 
 hospital where improvement began at once and had continued 
 steadily throughout the month that had elapsed before I examined 
 him. He was then able to speak and make all the necessary voiced 
 sounds, but suffered considerably from stammering and a distortion 
 due to over-action of the lips and tongue. He could sing, however, 
 with only an occasional stumbling. 
 
 As has been said, the patient was not able to give a fully 
 intelligent account of his symptoms or mental state at 
 different times. Any explanation as to psychological 
 mechanisms of his mutism must therefore remain purely 
 speculations. There can be no doubt that he suffered from 
 a severe concussion and that the symptoms he showed on 
 recovering consciousness — weakness, deafness and con- 
 fusion — could be attributed directly to the physical effects 
 
87 
 
 of the concussion. Whether the dumbness was due to the 
 weakness, the deafness, or was a direct product of a tempo- 
 rary aphasia it is impossible to say. Myers has suggested 
 that mutism may be psychologically an outcome of stupor. 
 Stupor is, he says, essentially a shutting out of the en- 
 vironment and, as speech is the chief means of communi- 
 cation which an individual has with his environment, it is 
 not unnatural that mutism should survive and represent 
 symbolically the lack of contact with his surroundings. As 
 I have not had an opportunity of examining these cases at 
 this stage I am not competent to criticise this view with any 
 assurance. This would certainly be a natural type of mech- 
 anism and fits in well with what we know of stupors and 
 hysterias in times of peace, but this applies to stupors that 
 are functional and not organic in origin. In the case just 
 quoted, for instance, the symptoms of an organic type are 
 suflBciently evident to justify the belief that the unconscious- 
 ness from which he suffered was not at all functional but 
 depended upon the concussion directly. 
 
 Case XIX. The patient is a corporal who was apparently normal 
 in mental make-up except for so:ne shyness with the opposite sex. 
 He went to France in May, 1915, after some months of training to 
 which he adapted himself well. He was at once exposed to eighteen 
 days of almost continuous bombardment. He was frightened at first, 
 but got used to it, and settled down to his work quite satisfactorily. 
 In September, 1915, the weather had been very bad and he got tired 
 of the situation. He began to have bad dreams. Most of these were 
 of the peace type of falling into a deep hole, but he also had night- 
 mares of being shelled. His account of this period was rather indefinite. 
 He admitted, however, that he was so tired of the situation he 
 thought of committing suicide. He also wished that a shell would 
 come and give him an incapacitating wound or else kill him. He be- 
 gan to have pains in his head, arms and legs, and was feeling distinctly 
 "groggy" when a gas attack came. He thinks he may have gotten 
 a whiff of the gas; at any rate he felt giddy, but was able to pull off 
 his mask for an instant and take a swallow of water. This made him 
 feel a bit better and the gas having passed he came out of the dugout 
 into the open air. He felt somewhat fatigued after this experience, 
 however, and was much relieved when his company was ordered 
 back that night. Once back to the lines, however, he got very shaky 
 and finally collapsed, falling in a heap on a pile of straw. At the 
 time of this collapse he did not lose consciousness at all. From his 
 own account and from notes made at the hospital to which he was im- 
 
88 
 
 mediately taken, it seems likely that he had an attack of acute articular 
 rheumatism. He had a sore throat and a pain in his head which would 
 shoot down to his left shoulder and to his finger tips, and also shot 
 through his legs. The pain was particularly agonizing in the right 
 leg whenever his knee joint was moved. This pain persisted for a 
 month after being in the hospital. He said his leg was like a log from 
 the time of this collapse on the straw. This was an hysterical symptom 
 of some duration, for when the pains left him after a month in the 
 hospital his right leg was paralyzed, with an anaesthesia of the skin 
 of the whole leg. He was got up out of bed but he had a gait typical 
 of hysterical monoplegia, and had to walk with a crutch. The use of 
 this led to a crutch palsy, and after a month or so he had paralysis of 
 the right arm, purely hysterical, and also accompanied with a super- 
 ficial anesthesia. These symptoms persisted for eight months before 
 I examined him, at which time the power of both arm and leg were 
 steadily improving with methods of re-education. 
 
 The mechanism for this conversion hysteria seems fairly 
 plain. The patient was tired of the situation in which he 
 found himself and was anxious to receive some sort of an 
 injury which would incapacitate him for active service. 
 Then he had what was apparently an attack of acute arthri- 
 tis in the ri^ht knee which caused him great pain whenever 
 his leg moved. The paralysis, which then developed, can be 
 easily explained as a protective reaction, since it immobil- 
 ized the knee joint. The explanation for its persistence and 
 for the development of the paralysis of the arm is equally 
 simple. These disabilities provided ample occasion for his 
 continued absence from the front. It may be added that 
 these paralyses were accompanied by the typical, hysterical, 
 mental altitude, for the patient was unable to imagine him- 
 self using his leg at all. 
 
 But this patient also showed other symptoms. It has been 
 mentioned that he wished for death and that he had had 
 some nightmares of fighting. He therefore was in the men- 
 tal state prior to his rheumatism of a man who develops an 
 anxiety condition, and had also begun to show some symp- 
 toms of it. When he was removed to the hospital he began 
 to have more severe nightmares, although he never had any 
 anxiety symptoms during the day that were at all severe or 
 noticeable. Complicating the conversion hysteria, there- 
 fore, he had a mild anxiety state. This was always in the 
 background, for the dreams became infrequent and less 
 
89 
 
 severe long^ before there was any improvement at all in 
 his paralysis. 
 
 The following three cases represent the development of 
 hysterical phenomena as a continuance of disabilities that 
 are more or less organic. 
 
 Casc XX. The patient is a private in the heavy artillery who en- 
 listed in December, 1914, but did not reach France until March, 1916. 
 His history showed that he had some mild neurotic tendencies inas- 
 much as he was afraid of high places, uncomfortable in thunder-storms, 
 and did not like to go into tunnels. In other respects he was quite 
 normal and seemed to have an open personality and to be quite sociable. 
 He was happily married. 
 
 He enjoyed his work at the front tremendously and the severe strain 
 of long continued duration produced no symptoms, not even subjec- 
 tive fatigue. On August 2, 1916, when he had been fighting for four 
 months, he was buried by the earth thrown up from the explosion of 
 a heavy shell, and suffered severe concussion. Consciousness, that he 
 could remember, returned only after three weeks, and following that 
 for about ten days he suffered from lapses of consciousness whenever 
 he exerted himself in the slightest degree. For months he continued 
 to be extremely weak. Soon after recovering consciousness for the 
 first time he found that he was easily startled by sudden noises, but 
 had only occasional nightmares of fighting, and absolutely no con- 
 tinuous anxiety during the day. He was, as is often the case after 
 severe concussion, subject to almost constant tremors that were inde- 
 pendent of any conscious anxiety. This "shakiness," as he termed 
 it, continued whenever he made any exertion for some months, and 
 he found that the only way that he could control it was to cross his 
 legs and hold them slifHy in this position. At first, of course, he 
 was too weak to stand. Later, when his strength had returned, he found 
 that whenever he would attempt to get out of bed his legs would go 
 immediately into an adductor spasm and shake violently. He was 
 treated with no improvement whatever in general hospitals for some 
 eleven months, and was then transferred to a special hospital where I 
 saw him only for four days after he had been admitted there. The 
 treatment given was to stretch forcibly the adductors of the thighs by 
 pulling his feet apart This was continued until the adductor nuiscles 
 were exhausted and incapable of further contraction. He was then put 
 on his feet and, being supported, was encouraged to walk. For the 
 first time he was able to get one leg past the other. During the four 
 days that had elapsed he had lost the spasm in his left thigh almost com- 
 pletely and was able with an effort to control that in his right. The 
 tremors too had almost entirely disappeared. He felt himself that he 
 would be quite well in a few days. This case is a dramatic example 
 of how simple a matter it is to cure these hysterical symptoms, in 
 spite of long duration, when once rational treatment is employed. 
 
90 
 
 In connection with this gait disturbance it might be well 
 to recall Case IX. This patient it will be remembered de- 
 veloped a similar condition of spasticity when he attempted 
 to walk on leaving his bed for the first time. With him, 
 too, the spasm developed as an effort to control the violent 
 tremors of his legs, but these tremors were probably much 
 more functional in origin than those present in the patient 
 whose history has just been quoted. 
 
 Case XXI. The patient is a private, aged 25, whose only neurotic 
 tendencies had been a fear of lightning and of snow. He had, how- 
 ever, rather a poor personalit3% enjo3-ing distinctly low ideas and 
 being rather given to lying, although not at all in a malicious way. 
 He enlisted in the regular armj' in 1911, but deserted before long and 
 became a professional foot-ball player. When the war broke out he 
 reenlisted and went to France in September, 1914. 
 
 He fought for six months and claimed to have enjoyed this first 
 period of fighting. It was terminated, however, by an accident when 
 he fell into a deep dugout, fracturing both his ankles, and suffering 
 frost-bite before he could be taken back to the hospital. This ex- 
 perience seems to have given him a distaste for the war. He was 
 back in England for three or four months, and then did not wish to 
 return to France so soon. Even on the way back he began to be 
 frightened at the prospect. He was kept for two months in barracks 
 aud then went up the line. He approached the trenches feeling 
 quite anxious and, on arrival, got immediately into a panic but was 
 saved from further difficulties bj- being wounded through the thigh 
 almost at once. This was a minor injury but it necessitated his 
 remaining in a hospital for a couple of weeks. This hospital was 
 exposed to occasional shell fire and the patient found that he was 
 constantly starting at the noises and now and again had nightmares 
 of fighting, although he would sleep through many nights without 
 any disturbance whatever. He was then sent back to his base for 
 some time, where he had no more nightmares at all, but was still 
 
 jump)- ' ' when any particularl}- loud noise would occur. A fear of 
 going back to the line had b}' this time become a settled part of his char- 
 acter. He was returned for three weeks to the trenches during which 
 time he was constantl)- in fear but developed no sj^mptoms whatever. 
 This brief period of fighting was again terminated when he received 
 some superficial woimds from fragments of a shell, and this time he 
 was fortunate enough to be sent back to England for five months. 
 He returned again in May, 1916, and fought till September. During 
 this time one gathers that he tried hard to work up the sjTuptoms of 
 appendicitis and trench fever but was never able to convince the 
 medical officer that there was an3-thing serious the matter with him. 
 He was frightened, of course, but alwa3^s slept well and had no night- 
 
91 
 
 mares. In the middle of September he saw one of his own men run 
 over and crushed by a tank and, for the first time, he felt horror. 
 From then on any sight of blood affected him. Two or three hours 
 after this unpleasant experience he was shot in the right forearm 
 (another flesh wound) which caused his removal to a dressing station 
 and then to a rest camp. He was in the latter for two weeks, during 
 which time he felt constantly afraid of returning to the trenches and 
 was very loth to get better. From the rest camp he was sent to the 
 base to join another battalion and was then thrown into the line 
 again. He was there for three days, during which time he suffered 
 considerably from his horror of bloodshed and from his constant fear. 
 He was therefore much relieved when after only three days' fighting 
 he fractured his left collar-bone and left wrist. He was sent back to 
 a casualty clearing station, and was only too glad to give a pint and a 
 half of his blood for transfusion as he was rewarded for this by being 
 shipped home to England. After a few weeks his left arm came out 
 of the splint, when he discovered (probably not without satisfaction) 
 that his arm was paralyzed. He remained without the use of this 
 limb for five months during which time all kinds of treatment were 
 attempted. He was then sent to a special hospital where simple 
 methods of reeducation resulted quite quickly in the steady return of 
 strength to his arm. It is interesting to note that once his hysteri- 
 cal paralysis began to improve he developed some nightmares. This, 
 presumably, indicates the strong resistance he felt to the idea of 
 returning to the front. 
 
 The following case could perhaps be described as an 
 atypical anxiety state but is probably better grouped with 
 the hysterias inasmuch as tremors and weakness and diges- 
 tive disturbances were more prominent than the signs of 
 pure anxiety. The case is also important as it shows how 
 poor a soldier the individual makes who up to the time of 
 enlistment has been a highly neurotic individual. It is not 
 imp)robable that his symptoms were typical because he was 
 suffering as much from a peace as from a war neurosis. 
 
 Case XXir is a private, aged 23. He had always been nervous. 
 As a child he would scream if left alone either day or night. He had 
 such fear of falling that he could not approach a window. It required 
 the greatest effort for him to enter a subway. He was afraid of 
 lightning. He hated to see anybody fighting, and accidents made 
 him sick. He would pant with anxiety if he heard fire-engine bells. 
 He also had suffered from occasional bilious attacks. Frequently he 
 dreamed that the house was on fire. When the Zeppelin raids began 
 over London he was terrified by them. He was so seclusive that he 
 had never made any friends with either sex, and had such poor stuff 
 in him that his brothers called him a girl and not a boy. 
 
92 
 
 This individual, so poorly adapted to civilian life, enlisted in 
 October, 1915, and went to France four months later. The training 
 in an artillery company did him good physically, taut it led to 
 further difficulties mentally and nervously. He could not make any 
 friends and was constantly afraid of doing things wrong. Fear of 
 the fighting, that was to come, increased steadily as the time grew 
 near when he would have to go to the front. On reaching France he 
 was at first back of the front line of trenches, and consequently he 
 saw very little fighting for some time. Some enemy aeroplanes 
 appeared, however, which scared him horribly, and for some nights 
 he could not get to sleep thinking of them. For the first month he 
 was busy carrying rations and munitions from the rear up to the 
 communication trenches; then he began to work with his battery. 
 For the first three weeks the battery remained immune from attack; 
 then it was shelled. The patient was frightened horribly and could 
 not help crying out "What a terrible one that was!" whenever a 
 shell came. He was promptly told to keep quiet but was unable to 
 do so. In subsequent bombardments he would listen attentively to 
 the successive reports from the guns, and convince himself that the 
 enemy guns were coming closer. The first sight of the wounded 
 affected him so extremely that he almost cried, although somehow or 
 other he managed to get used to this suificiently for him to continue 
 at work. From the time when he first approached the line, however, 
 he began to dream of the enemy coming after him with bayonets. 
 These nightmares of course disturbed his sleep, and he also had great 
 difficulty in getting to sleep at all when he lay down to rest. 
 Although he got gradually worse he somehow or other managed to 
 continue in his ineffective way for some nine months. His battery 
 was finally relieved and sent to a rest camp where he at once felt a 
 little better. Then a false report came that the battalion was to re- 
 turn to the front. The patient at once collapsed. He could not stand, 
 was shaking all the time, crying and vomiting. The nightmares 
 became so severe that he could not sleep at all for four nights after 
 his admission to a hospital. For some days also he was able to keep 
 nothing whatever on his stomach, and during the six months that 
 had elapsed since that time when I saw him he had not eaten a single 
 full meal. He was sent back to England and treated in various hos- 
 pitals. He improved twice, being able once to walk from one bed to 
 another, although he often fell with giddiness, after which he would 
 shake terribly and sweat profusely. This improvement lasted for a 
 week. There was then some talk of his being sent to a convalescent 
 hospital. The patient began to fear that, if he recovered, he would 
 be sent back to France, and although this was more a passing idea 
 than a constant worry, it may explain the fact that he fell down again 
 when this transfer was imminent and was not able to get up again. 
 He was sent to the convalescent home, however, where he improved 
 again, this time with electrical treatment. He got so that he could 
 
93 
 
 walk but then pains developed in his back and across his hips which 
 soon put a stop to his walking. He had been told that he would not 
 be sent from the convalescent home to a special hospital i:nless he 
 became worse again, and probably this is what caused the develop- 
 ment of the pains. When I saw him he had been in this special hos- 
 pital for ten days during which time he had become much less shaky 
 although he was still unable to walk. He had a rigidity of the muscles 
 along his spine and some diminishing signs of hyperthyroidism. 
 His dreams had become much belter — that is his nightmares of being 
 bayoneted were tending to disappear, biit he was troubled with other 
 nightmares of the peace type; for instance he would dream that the 
 hospital was on fire, or that Zeppelins were going to come. Once 
 while sleeping on a balcony he dreamed that it collapsed but that he 
 hung on to the edge with his fingers. He awoke screaming to the 
 nurse to come and rescue him. 
 
 The following case shows how an anxiety state in an 
 officer can be inhibited from further development when other 
 symptoms develop — in this case symptoms of a gastric 
 neurosis. 
 
 Case XXIII. The patient is a lieutenant, aged 24. He had never 
 had any illness in his life, but had always been of a high-strung 
 nervous temperament. He was afraid of the dark as a child and had 
 night terrors. These were mainly of falling into a huge funnel and 
 being jammed in the bottom. He had had no fear of thunder-storms 
 or of tunnels, but would become rather excited and could not trust 
 himself if he were in a high place. He was shy with girls and saw 
 nothing of them until he left school at 18, but thought that he had 
 improved somewhat in this respect as he grew older — in fact he has 
 recently become engaged. His social relationships with those of his 
 own sex were apparently quite normal. It is important to note that 
 he had always been sensitive to pain and more than normally sympa- 
 thetic. Once when he was a boy a companion took him into a 
 butcher's yard to see a pig killed. This upset him greatly and he 
 felt excited for some time after. 
 
 He enlisted as a private in September, 1914, and reacted well to his 
 training except that he was troubled with a little fear of being a 
 coward in France. He conquered this, however, to the point of being 
 able to look forward to the trial, and when he went there in March, 
 1915, he was pleased to find that his nerve was as good as that of the 
 rest. He got used to being shelled quite quickly but found in the 
 nine months of fighting, during which he served, that, so long as he 
 was in perfect physical condition, he had the feeling that nothing 
 could hurt him, but that whenever he became tired this conviction 
 would disappear. After seven months of fighting he was exposed to 
 a monotonous bombardment with howitzers for three days. He and 
 
94 
 
 his comrades were in an advanced " bay " and it was only a question 
 of time before every man would be killed in all probability. Nothing 
 happened to him, however, before he was relieved. He was calm 
 mentally but could not stop shaking for three hours after leaving the 
 trenches. Following this experience he was "jumpy " and felt dis- 
 appointed in himself. He did not lose sleep, however, or have any 
 nightmares, but found it gradually more difficult to control himself 
 whenever a methodical bombardment was in progress. In December, 
 1915, he was sent back to England to receive training as an offi::er, 
 which lasted for six months. He was glad of the rest but disappointed 
 to find that it did not do him so much good as he had hoped. He 
 went to work to have as good a time as possible because he expected 
 that he would be killed when he went back to France. He was much 
 more worried at the thought of going to pieces nervously than by any 
 fear of death itself. He went back as lieutenant in June, 1916, and 
 found that it cost more effort than before to control his fear. The 
 strain of constantly encouraging his men told on him. He did not 
 actually lose sleep, but always felt heavy when he awoke in the morn- 
 ing. Trench mortars were very active in his section of the line and 
 the frightful explosions from them constantly upset him. His whole 
 spirit grew weary of the war. So far his history is qtiite typical of 
 the prodromal period of an anxiety state. 
 
 The sight of blood had not bothered him at any time, although 
 seeing a man blown to bits or losing a comrade always upset him. He 
 felt distinctly encouraged when he saw dead Germans. After being 
 nearly four months in France as an officer a shell blew up a group of 
 men right beside him. One of them remained sitting down with his 
 back against the wall of a trench and the patient thought that he was 
 alive. He went up to him and touched him on the helmet. Im- 
 mediately the whole back of the man's head rolled off and exposed 
 the back of his eyes and his nose and teeth. This sight gave the 
 patient a terrible "turn." He went into the dugout and trembled for 
 several hours. He did not feel any nausea but when the time next 
 came to eat he discovered that he had absolutely no appetite, and 
 from that time on it required a great effort to put any food in his 
 mouth. In describing this incident the patient emphasized the fact 
 that he was merely a calm observer of the tragedy. He felt that if 
 the shell had knocked him over it would have given him some degree 
 of relief. From then on he began to feel horror of all bloodshed and 
 was quite incapable of developing any excitement no matter how 
 active the fighting might be. He felt that all individuality in the 
 struggle was lost and that it was a pure matter of siege warfare. He 
 could gain no satisfaction in killing one or many of the enemy. His 
 sleep, however, was not interfered with and he had no nightmares. 
 
 While in this condition (October, 1916) he was transferred to Salo- 
 nika. There was no active fighting there, but sufficient exertion was 
 demanded to cause fatigue, particularly since he was eating little or 
 nothing. In making a landing on the coast from the transport he 
 
95 
 
 got wet and had not an opportunity of changing his clothes for several 
 days. Shortly after this a neuralgic pain appeared in his mouth. 
 Previously, however, he had begun to suffer from flatulence. The 
 next symptom to develop was constipation, the faecal matter being 
 foul, and he began to have nausea whenever his bowels did move. 
 Possibly as a result of the restricted diet, which was mainly canned 
 beef and biscuits, pyorrhea began to develop. Although he was 
 thoroughly miserable his symptoms remained in the physical sphere, 
 except once when an enemy airplane flew over the lines. They fared 
 at it with anti-aircraft guns, and this incident excited the patient so 
 much that he knew his nerve was no better. After suffering for three 
 weeks with neuralgia he asked to be sent to the hospital, which re- 
 quest was granted. He was there for three weeks, and then was sent 
 to the base depot. The food was worse than any supplied previously 
 and after three days he began to vomit and was sent back to the hos- 
 pital where he was put on a milk diet. As all tests were negative it 
 was concluded that he was suffering from a gastric neurosis, and he 
 was shipped to IMalta where he was kept for three or four months and 
 then sent home to England. While in Malta there was no improve- 
 ment in his condition and he settled down to the belief that he was 
 a confirmed invalid. In England he was put in a special hospital 
 where he had improved slightly at the time that I saw him. His 
 neuralgia had almost entirely left him and the vomiting had disap- 
 peared. He still had no appetite, however, and frequently suffered 
 from nausea either before or after eating. Constipation was alter- 
 nating with diarrhea. Mentally he complained of a lack of interest 
 and spontaneity. He said he had forgotten his education — that his 
 youth and his eagerness were all gone. In explaining his poor 
 adaptation to fighting he said that he thought that the strain told on 
 him because of his imagination. It was impossible for him to keep 
 the belief from his mind that every shell was meant for him. 
 
 In this case, therefore, we have a patient who had always 
 had some neurotic tendencies although they had never 
 incapacitated him during- civilian life. One of these was 
 an undue sensitiveness to cruelty or bloodshed. After some 
 months of fighting the strain began to tell on him, his 
 condition growing steadily worse, and it seems as if the 
 normal development of his difficulties would have led to a 
 typical anxiety state. Up to this time, however, he had 
 always remained more or less immune to the horrors of war. 
 Then suddenly a particularly fearful experience branded 
 horror on his mind and symptoms of another kind developed 
 at once. From then on the pathological tendencies seemed 
 to flow in the direction of a gastric neurosis rather than in 
 the ordinary channel of an anxiety state. 
 
96 
 
 Heart Neuroses. 
 
 In times of peace certain symptoms related to the function 
 of the heart are frequent concomitants of anxiety conditions 
 — in fact fear of death may be directly associated with fear 
 that heart failure is imminent. Except for some rapidity 
 of the pulse of which the patient is often not aware the 
 typical war anxiety neurosis shows nothing of this tendency. 
 There is, however, rather a large group of men who are 
 invalided from the trenches with heart symptoms but who 
 show no signs of valvular trouble. These cases have been 
 termed "soldier's heart" or "disordered action of the 
 heart." The cardinal symptoms of this cardiac trouble are 
 weakness, shortness of breath, palpitation and dizziness. 
 Not infrequently there is an area of hyperalgesia over or 
 near the heart. Owing to the obvious analogy between 
 these symptoms and those presented by the cardiac difficul- 
 ties of civilians suffering from anxiety it has been suggested 
 that the " disordered action of the heart" is really a form 
 of the war anxiety neurosis. Some internists who have 
 been engaged in treating these cases make the statement 
 that 50 per cent are really neurotics. The word neurotic 
 is one, of course, that is used in widely varying senses. 
 By some it is an adjective to describe any physical symptom 
 that has not an obvious physical cause, being therefore 
 equivalent to functional disturbance. The narrower sense 
 of the term implies a mental condition which shows itself 
 in certain types of reaction and produces or tends to produce, 
 somehow or other, physical symptoms. Those who use the 
 term in the narrower sense find, for instance, that prior to 
 the appearance of active symptoms the patient gives a 
 history of being subjected to some mental conflict or having 
 suffered from some mental shock. Neurologists or psychi- 
 atrists who have this view would not call disturbances of 
 the ductless glands, e. g., hyperthyroidism, neuroses. 
 
 Work which has been done by Frazer and Wilson at the 
 Hampstead Hospital (for heart cases) in London seems to 
 indicate that a large number of these cases are suffering 
 from some irregularity of function in the endocrinic or 
 vegetative nervous systems. The administration of very 
 
97 
 
 small quantities of adrenalin, for instance, they find to 
 produce excessive excitement, great pallor, discomfort and 
 real collapse, although there is no change in the pulse rate. 
 On the other hand, small doses of apocodein result in 
 flushing even to the point of erythema accompanied by 
 extreme tachycardia. Atropin on the other hand even in 
 full doses produces no effects whatever. A few patients, 
 who were treated experimentally with small doses of pineal 
 extracts, showed vomiting and collapse. These results 
 would certainly seem to indicate that these patients were 
 suffering from some definite disturbances of the mechanism 
 which regulates the action of the heart and are therefore 
 definitely organic, although not suffering from valvular 
 diseases. This view is sustained by the histories which 
 show as a rule that these individuals have never been 
 capable of a normal amount of exertion — for instance, they 
 have been unable to play any games that demanded 
 endurance, although capable of taking part in such milder 
 sports as golf. It has been found that this lack of vitality 
 of the heart can be quickly determined by an "exercise 
 test." The patient's pulse is counted and he is then made 
 to go briskly up a flight of thirty steps. His pulse is taken 
 immediately and then again after he has rested for two 
 minutes. The normal individual will show a rise of 40 or 
 perhaps 45 in the pulse rate after this exertion, but this 
 falls after two minutes' rest back to the original rate or to 
 within 10 or at most 15 of it. Patients who suffer from 
 " disordered action of the heart," however, may show an 
 increase of rate of 60 or more and the pulse does not slow 
 down again after two minutes' rest, or at least will slow 
 only in slight measure. 
 
 In order to see whether from a psychiatric standpoint 
 they were really "neurotic" I examined some ten cases 
 with a view to determining what their mental and emotional 
 history had been. These cases were very kindly picked 
 out for me by Dr. Wilson as ones most likely to be 
 purely neurotic. I was able to make diagnosis of a true 
 neurosis in only two of these cases, and in all of them a 
 prediction as to the result of the exercise test was found to 
 
98 
 
 be accurate when reference was made to the notes on the 
 patient. Although this is of course too small a number to 
 make an}^ deductions in the form of percentages, the results 
 are nevertheless suflBciently striking to justify one in 
 assuming that the majority of the patients who suffer from 
 'disordered action of the heart" are not neurotics in the 
 narrow sense of the word. A few illustrative cases may be 
 quoted. The first gives an example of the purely organic 
 and non-neurotic type of disease. 
 
 Case XXIV. The patient is a private, aged 29, who enlisted in 
 February, 1917, in a labor battalion and did clerical work in a casualty 
 clearing station in France. He had never been able to keep up any 
 severe exertion and for this reason had to restrict his activities in 
 athletics. All his life he was subject to palpitations of the heart and 
 would frequently wake up with a choking feeling at night, although 
 he had not had any bad dreams that he could recall. When his sleep 
 was thus disturbed he would have a terrible sensation, with difficulty 
 in getting himself fully awake. On the other hand he seems to have 
 been emotionally a normal individual. He suffered from no night 
 terrors as a child and had none of the ordinary neurotic fears or 
 sensibilities except a slight giddiness in high places, which is a 
 symptom that affects almost everyone whether he be otherwise 
 neurotic or not. He was never given to worry. He had been a 
 normal mischievous boy, had never had any shyness with either sex, 
 and at the time when I examined him had been married for five years 
 and professed himself happier since his marriage than he had ever 
 been before. 
 
 In his work in the casualty clearing station he was of course 
 exposed to shell fire at times. This bothered him only temporarily. 
 The sight of the wounds also affected him with horror for a short time 
 only, after which he became fully accustomed to both forms of strain. 
 He had no nightmares. On the other hand the physical exertion 
 that was necessary told on him gradually more and more and his 
 previous symptoms of palpitation and nocturnal choking got so bad 
 that he could not continue working and he was sent to a hospital. 
 All during this time he had no anxiety whatever and was bitterly 
 disappointed to find that he had to stop ' 'doing his bit. ' ' The exercise 
 test showed that he had an initial pulse of 120 which rose to 168 after 
 exertion and fell only to 144 after two minutes' rest. 
 
 The following two cases exhibited the more neurotic 
 reaction. 
 
 Case XXV. The patient is a private, aged 20. As a child he had 
 night terrors and was subject to sleep walking until 8 years of age. 
 He was always anxious during thunder-storms and giddy in high 
 
99 
 
 places, although he admitted no uncomfortableness in tunnels. He 
 made some boy friends but was very shy with girls and not at all 
 mischievous. lie had never had any serious disease although he had 
 a slight attack of tonsilitis at the age of 6 from which he recovered 
 without any subsequent complications. He was able to play games 
 as a boy and was particularly fond of foot-ball, but gave it up when 
 he was 14 because he found that he was getting short of breath. 
 Considering that he was incapable of exertion prior to this time, it is 
 not impossible that this dyspnoea coming on at the time of puberty 
 was a neurotic symptom, since so many neuroses begin at this time. 
 
 The training did him good as he made more friends than he ever 
 had before. At first he found himself considerably fatigued with the 
 efforts demanded of the recruits, but he improved in this as the 
 training went on. When he reached the front he was frightened only 
 temporarily by the shells but never could accustom himself to all the 
 horrors of war. He fought for seven months, when he was invalided 
 home for six months with "septic poisoning." On his return to the 
 front in July, 1916, he felt nervous again at first but got used to it 
 once more. In September, he began getting pains in his side, for 
 which he was sent to the hospital. There he had no fever and the pains 
 quickly disappeared and remained absent while he was convalescent 
 for a month. As soon as he returned to the trenches, however, they 
 reappeared. His condition grew severe enough to justify hospital 
 treatment in December, 1916, at which time he was away from the 
 trenches for three months. On his return to them again he lasted 
 only three weeks, and for the next three months, at the end of which 
 time I saw him, he had been traveling from hospitals to convalescent 
 camps and back again. 
 
 Evidence of there being definitely neurotic prodromata is furnished 
 by the following information which he gave: Before any heart symp- 
 toms developed he had become "nervous." He was "jumpy " during 
 the day and frequently awoke at night with a start. He also had diffi- 
 culty in getting to sleep. He was thoroughly dissatisfied with his 
 situation and had reached the point where he hoped that he might re- 
 ceive some incapacitating wound. This situation is therefore identical 
 with that which one usually meets in the history of the typical con- 
 version hysteria, and it is also like that rather than resembling the anx- 
 iety state in that he had no desire for death and no thoughts of suicide. 
 The symptoms began after he had been in this state of mind for some 
 time, and consisted at first merely of a pain in the region of his heart. 
 The subsequent difficulties with palpitation, shortness of breath and 
 weakness developed later on. There is, therefore, nothing in this 
 case that points definitely to any organic condition, and, on the other 
 hand, the evidence does seem to indicate that the heart symptoms 
 were essentially hysterical in nature. This is confirmed by the exer- 
 cise test which showed him to have a pulse of 75 before exertion, 108 
 immediately after running up the thirty steps, and only 84 when he 
 had rested two minutes. 
 
100 
 
 Case XXVI. The patient is a gunner, aged 35, an Australian. He 
 seems to have had a distinctly neurotic make-up. As a child he had 
 night terrors with dreams of falling. He was always horrified at the 
 sight of blood and was afraid of thunder-storms, high places, tunnels 
 and horses. He does not seem to have been a normal mischievous 
 boy, and when he grew older was shy with both sexes. He had had 
 only one love affair, which he broke off in 1911 for no apparent 
 reason. His training was of benefit physically but not mentally or 
 nervously and he showed no increased sociability during it. His 
 first service was in Egypt. On the way there he developed a fear of 
 shipwreck which was not shared by his companions. He was in Egypt 
 for some months, and although there was no fighting, he fouad the 
 weather hot and uncomfortable and he suffered from occasional 
 palpitations and "sinking feelings " which he ascribed to the heat. 
 
 He was then transferred to the French Front in May, 1916. In his 
 initial experience of being shelled he became first terrified and then 
 dull and depressed. He was horrified by the sight of blood and would 
 think about it whenever he was not busy. He never was able to reach 
 the point of enjoying any of the fighting. He soon began having 
 peculiar sensations when going off to sleep as if he were sinking, or 
 that his soul was leaving his body, and he would have to sit up in bed 
 two or three times to get rid of this queer feeling. He also would 
 awaken with sudden starts, although not having any memory of a bad 
 dream. Things got gradually worse and then he began to have night- 
 mares of "things" (mainly shells) falling on him. He would try to 
 get away from them, but could not. His sleep consequently began to 
 be much worse, and he worried for fear he would not be able to stick 
 it out. He wished that death might come, but never had a hope of 
 receiving an incapacitating wound. He frequently thought of suicide. 
 At the beginning of May, 1917, he was blown off his feet by a shell. 
 This did not injure him physically apparently but disturbed him men- 
 tally a great deal. From that time on he felt that the shells were being 
 aimed at him, and four days after this experience he developed a pain 
 in his side, trembling and difficulty in breathing. He said his throat 
 swelled up and he felt as if he were going to choke. He attributed 
 this to being gassed, although he had not been exposed to this any 
 more than had his companions, who showed no symptoms of it. As 
 he had been wishing for death it is not unnatural that he should have 
 looked on this choking sensation as a forerunner of death and he 
 quickly concentrated most of his fear on this symptom which nat- 
 urally made it much worse. He claims that it once was so bad that 
 he "went black in the face " and he got so short of breath and trem- 
 ulous that the bombardier sent him back to a hospital. Once in the 
 hospital he grew weaker and weaker and was so terrified by his dreams 
 that he would scream aloud on awakening from them. After six 
 weeks in a special heart hospital all the symptoms directly related to 
 the heart cleared up although he was still troubled occasionally with 
 
101 
 
 suffocating- feelings during the night which continued to frighten him, 
 the fear being always of instant dissolution. Nightmares with a war 
 content had entirely disappeared, although he still had occasional 
 dreams of falling. There was no evidence of any organic trouble 
 which could have caused the feeling of suffocation. The exercise test 
 showed an initial pulse of 96 running up to 168 after exercise but 
 falling to 84 after two minutes' rest. 
 
 The history of the following patient is interesting as it 
 seetns to demonstrate the existence of both organic and 
 neurotic factors. It appears that he had the prodromal 
 symptoms of a neurosis the further development of which 
 was essentially organic. As has been said before, a large 
 part of the motivation of any neurosis comes from a desire 
 to be rid of trench life. When any real occasion for absence 
 from the firing line appears there is therefore little reason 
 left for the development or continuance of the true neurosis. 
 
 Case XXVII. The patient is a private, aged 19, who enlisted in 
 the territorials in January, 1914, but did not reach France until Septem- 
 ber, 1916. As a child he had had night terrors and some fear of the 
 dark which persisted up to the time when he enlisted at the age of 16. 
 He had no fear of thunder-storms but was giddy in high places and 
 would break out into a cold sweat and tremble whenever he had to go 
 through a tunnel. He suffered from enuresis until 10 years of age 
 and from puberty onward had considerable worry about emissions. 
 He does not seem to have been particularly seclusive so far as his 
 social adaptations are concerned. He was good at games but always 
 had a tendency to shortness of wind. When he began training he 
 was, of course, only 16 years of age and had considerable difficulty in 
 carrying his pack at first. Then he got used to it and felt distinctly 
 stronger. When he reached France he found the life in the trenches 
 distasteful. He could not accustom himself to the horrors around him 
 and worried over them constantly. He was never able to make him- 
 self perfectly indifferent to bombardment. He began quite soon to 
 wish that he might be killed or, at any rate, be removed from the 
 trenches for some cause or other. He had no nightmares, however, 
 and did not lose any sleep. Then pains developed under his heart, 
 accompanied by shortness of breath, palpitation, dizziness, and a feel- 
 ing of faintness. He connected these heart symptoms with the 
 previous "weakness of his bladder" from which he had suffered 
 (enuresis) but did not worry about them more than he did about the 
 shells.* 
 
 * Although not a final diagnostic point by any means, this emotional attitude 
 of indifference toward the heart symptoms is suggestive of an organic rather 
 than a functional condition. The ideas of heart disease and death are closely 
 allied; so we find as a rule that a fear of death is frequently associated with 
 neurotic heart symptoms — in fact, as in the last case, the neurotic "cause of 
 death " is apt to occasion more fear than a real cause. 
 
102 
 
 The medical officer sent him off duty several times for treatment of 
 his heart trouble. After three months in the trenches and having^ 
 been sent to the hospital for short periods several times he developed 
 "trench feet" and was sent back to England. His heart condition 
 then attracted attention and he was transferred to a special hospital 
 where I saw him. On admission the pulse test was positive — that is, 
 the rate did not diminish as it normally does after two minutes' rest. 
 After being treated for several months with graduated exercises he 
 was capable of going through the heaviest routine and the pulse test 
 had become negative. It is therefore likely that the cardiac mech- 
 anism had recovered very largely in a purely organic sense. The 
 patient still insisted, however, that his heart trouble was not getting 
 any better. One might therefore be justified in suspecting that this 
 patient was rather consciously hoping for a persistence of his 
 symptoms. 
 
 Although the heart cases examined for the purpose of this 
 report were too few in number to justify any finality in the 
 discussion of the mental mechanisms involved, it may be 
 suggested that there are perhaps two types that correspond 
 roughly to the anxiety and the conversion hysteria groups. 
 Some heart cases like Case XXVI seem to have a very strong 
 coloring of anxiety, and this is associated with a desire for 
 death as a form of relief before the actual appearance of the 
 symptoms. In the other group as represented by Case XXV 
 a wish for an incapacitating wound rather than for death is 
 present in a prodromal state and when the heart symptoms 
 develop they are looked on more objectively as a disease and 
 are not accompanied by the same anxiety. This feeble 
 emotional reaction to the symptoms is therefore closely par- 
 allel to, if not identical with, the phenomena of the conversion 
 hysteria. There are of course no statistics available as to 
 the number of purely neurotic heart conditions that develop at 
 the front. It is safe to say, however, that they form an insig- 
 nificant group numerically when compared to the anxiety 
 states and common conversion hysterias. The reason for this 
 is probably to be found in the fact that there is nothing that is 
 much more painful both mentally and physically than symp- 
 toms of heart trouble which are so commonly associated with 
 idea of death. The neurotic, therefore, who is unconsciously 
 on the search for some relief is much more apt to wish for 
 death by a shell or a bayonet than for the more protracted 
 and painful struggle that precedes death by heart failure- 
 
103 
 
 General Psychologicai, Considerations. 
 
 It maybe well to summarize what has been said earlier in 
 this report by a few generalizations as to the psychological 
 mechanisms at work in the production of the war neuroses. 
 The most fundamental factor is of course the resistance of 
 the officer or soldier to the warfare in which he is forced to 
 engage. A striking feature of these conditions is that this 
 resistance can be present in the patient's mind consciously 
 and still operate unconsciously in the production of symp- 
 toms, which is a phenomenon rarely if ever met with in 
 civilian practice. It is probably more accurate to say that the 
 general antagonism to the situation remains conscious, while 
 some specific wish for relief begins to operate unconsciously 
 and reaches expression when a situation develops that 
 facilitates its transformation into a symptom. 
 
 That these transformations should differ so widely in their 
 nature as do simple hysterical symptoms and the mental 
 torture of an anxiety state demands some brief discussion. 
 The first clue to be followed in solving this mystery is the 
 striking fact that the vast majority of those suffering from 
 the pure anxiety state are officers, while the conversion hys- 
 terias are almost entirely confined to the privates and non- 
 commissioned officers. The most obvious difference between 
 these two groups of men lies in their intelligence, and here 
 we find an analogy with the experience of civilian practice. 
 The common conversion hysterias are met with in times of 
 peace very largely among the lower and more poorly edu- 
 cated classes, while more intelligent people are apt to be free 
 from them. One explanation of this may be that the mod- 
 ern educated man knows enough of neurology to realize, 
 even if it be in a vague way, that paralysis comes from 
 injury to a nerve or the central nervous system at some 
 distance from the site of the paralysis. The intelligent lay- 
 man, for example, knows that if he breaks his wrist the 
 forearm and hand are apt to be painful and consequently 
 there may be some weakness in the forearm and hand, but 
 he does not expect that all the muscles involved in wrist 
 movements will be paralyzed. He would expect this 
 to occur more probably after a paralytic stroke, injury to 
 
104 
 
 the spinal cord or an accident to a nerve in the upper arm. 
 The ignorant dispensary or hospital patient, on the other 
 hand, has a definite association in his mind between local 
 symptoms and local functions and he has little if any concep- 
 tion of nervous control from a distance. An example of this 
 failure to localize function correctly is the popular use of 
 the term " a strong wrist" when a strong forearm is really 
 meant. 
 
 But the difference between officers and men does not be- 
 gin and end with intelligence and education. That one is 
 a leader and another a follower is equally the result of a 
 difference in ideals and emotional attitude. The private's 
 ambition is not to think for himself but to follow orders im- 
 plicitly and to sink his own personality so far as that may 
 be possible. If a dangerous project is on foot the private 
 is not in a situation to decide whether he will join in with it 
 or use some caution — he is merely faced with the alterna- 
 tives of obeying orders or being court-martialed. The 
 officer on the other hand has to a larger measure the respon- 
 sibility of individual decision. He has to make up his mind 
 whether he is or is not going to give a certain order — 
 whether he will or will not expose himself to danger. More- 
 over, it is his duty not only to be courageous himself and to 
 prevent the thoughts of his personal danger from disturbing 
 his judgment, but he must also act before his men as to in- 
 spire them and give an example of indifference to all the 
 hazards of war. This implies that the officer must be en- 
 dowed with higher ideals than the private soldier. It is to 
 this more than to any other factor probably that we may as- 
 cribe the difference between their clinical histories, when 
 war neuroses develop. The officer who feels his responsi- 
 bility in the great struggle which the war represents is 
 prepared to do all he can for the country, even to the point 
 of facing death itself, but before that final release may come 
 his mind stops at no other excuse. When fatigue and the 
 horrors of war grow on him, therefore, he does not let his 
 fancy play with any failure to meet his full responsibilities 
 but looks forward rather to making the supreme sacrifice, 
 namely, that of dying for his country. The private, on the 
 
105 
 
 other hand, is willing- to accept an order to leave the trenches 
 with the same or even greater willingness than he will obey 
 an order to advance against the enemy. The most obvious 
 occasion for an order to go back of the line is, of course, a 
 wound which will incapacitate him from further active serv- 
 ice audit istherefore "a Blighty one" for which he yearns. 
 The transformation of these wishes into symptoms is the 
 next point to be considered. The fate of the private is a sim- 
 ple matter. He wishes for some physical disability and 
 when the appropriate physical or mental accident occurs 
 some physical disability appears, that is to say, a conversion 
 hysteria develops which is, so far as he can see, purely a 
 physical disability, and his mental attitude toward the 
 symptom is very much like that which any man exhibits to- 
 ward a wound or some somatic disease. The determination 
 of the particular symptom can usually be traced to some pre- 
 vious illness, when the function in question was organically 
 disturbed. The conversion of the wish for death into the 
 anxiety symptom is, however, not so obvious a matter. In 
 general one may say that nightmares, which are the most 
 distinctive feature of the anxiety state, do not seem to de- 
 velop until the wish for death has appeared. It is possible, 
 therefore, that the unconscious mind seizes on that in the 
 environment which is most likely to occasion death and 
 makes the patient dream of this danger. The "wish-ful- 
 filment," therefore, in the dream of being shelled or bay- 
 oneted may be ascribed to the wish for death which may 
 previously have been rather diffuse and now becomes speci- 
 fically allied with one particular form of mortal danger. 
 To account for the presence of anxiety in these dreams, 
 when there has been previously a calm desire for death, is 
 a more difl&cult matter. The only explanation seems to be 
 that emotional reactions in dreams seem to represent the 
 natural reactions of the individual, as an individual, rather 
 than of the socialized being who is burdened with a feeling 
 of moral responsibility. It is of course a commonplace 
 that we constantly dream of performing acts which we 
 would never indulge in when we are awake, out of con- 
 sideration for the feelings of others, or out of respect for 
 
106 
 
 laws or conventions. In a somewhat similar way our 
 emotional reaction in dreams is determined bj'' our more 
 sel&sh attitude toward the situation presented in the dream. 
 It is of course a perfectly normal thing for any man to be 
 afraid of a high explosive shell or of a baj^onet; the 
 instinct of self preser\^ation bids him be afraid. This too 
 is his initial reaction when first exposed to such dangers, 
 but he soon learns to inhibit this fear during the daj'time 
 because he knows that it is his dut}'' to be indifferent to 
 these dangers. This inhibition is lifted during sleep, 
 however, and consequently his emotional reaction during 
 the dream is that which anj^ civilian would have when 
 placed in such an extremity. Another factor maN' possi- 
 bly also enter in. Fear, as has been said, is a protective 
 reaction. Now the individual has to protect himself 
 from real dangers not onlj" from without but from the un- 
 conscious cravings which are at variance with his social 
 standards. All the protective emotions of dreams are there- 
 fore probabh" operating in part to keep the unconscious 
 tendencies in subjection — in other words, to keep them un- 
 conscious. It is for this reason that any man is often most 
 fearful of that which he unconsciously most desires. 
 
 The unconscious wish for death b^^ some definite agency 
 operates in many cases at first during sleep but soon it 
 begins to show itself in the daytime. Unconsciously desir- 
 ous of being hit by a shell, the patient's attention is more 
 attracted to bombardment than it previously was, conse- 
 quently his thoughts become focussed willy nilly upon it. 
 It is then that the instinctive protective reaction of fear 
 develops, perhaps in order to make the individual shun this 
 danger. The patient loses the ability to gauge the direction 
 of shells b3^ their sounds, which gives a beautiful example 
 of how the unconscious works at cross purposes from the 
 conscious mind. The patient has consciously no fixed and 
 constant desire to be hit by a shell. Unconsciously he has, 
 however; so in the fatigued condition from which he suffers, 
 the unconscious warps his judgment, making every shell 
 the fulfilment of the unconscious wish. 
 
 The foregoing speculations as to the psychological stages 
 
107 
 
 in the formation of anxiety symptoms refer to those cases 
 where nightmares precede diurnal fear. This does not 
 always happen; in fact, it is probably of rarer occurrence 
 than the reverse. There is no reason to suppose that there 
 is any essential difference in mechanism between the two 
 types of cases. The smaller group is chosen as a paradigm 
 merely because unconscious motivation and individualistic 
 reactions are always more easily observed in dreams than in 
 the reactions of walcing life. 
 
 It is now more or less of an axiom that unconscious factors 
 retain their power very largely because of their remaining 
 unconscious, and so beyond the sphere of influence of the 
 individual's judgment. This is a factor of no small impor- 
 tance in the production of the anxiety states. The fear 
 which the patient feels must be repressed. He is ashamed 
 of showing any evidence of cowardice before either his 
 men or his brother officers. He is therefore the subject of a 
 conflict which he must fight out alone. He knows that he 
 has at least a tendency to be afraid, but he also knows that 
 he can maintain the respect of his men and officer friends 
 so long as he keeps that fear to himself. He is constantly 
 repressing this most natural reaction and there is accumu- 
 lated, naturally enough, a stronger and stronger tendency 
 for active exhibitions of fear. It is this which probably 
 accounts for two phenomena. The first is that when the 
 patient is sent back from the trenches to the hospital and 
 the occasion for this repression removed there is almost in- 
 variably a sudden increase in the severity of the symptoms. 
 The second is that an opportunity for the frank discussion 
 of a man's fear with his physician is often the occasion for 
 his " getting a good deal oflF his chest " and leads to marked 
 improvement in his condition. 
 
 A few remarks on the psychological role of concussion 
 may not be out of place. In many patients in whom there 
 have been gradually accumulating difficulties not sufficent to 
 incapacitate the patient there is a sudden increase of symp- 
 toms following even a mild concussion. This is of course 
 quite obviously the result of organic injury to the brain, 
 but how this affects mental mechanisms should be con- 
 
108 
 
 sidered. As has just been said, the unconscious seems to 
 be a prominent factor in the actual production of symptoms. 
 Normally, the unconscious is kept under such severe 
 repression that no ideas are allowed to come into conscious- 
 ness which are not fully adapted to the situation at hand, 
 so that the reactions of the individual are in keeping^ with 
 his natural standards of behavior. This repression, how- 
 ever, is closely related to the higher mental functions, and 
 for its perfect operation demands the fullest degree of both 
 intellectual and moral judgment. Any injury to the brain 
 naturally affects its more specialized functions first and 
 more severely than it does those functions which we term 
 "habitual" or instinctive. Consequently in the low state 
 of mental tension consequent on cerebral injury the higher 
 functions are in abeyance and the unconscious and instinc- 
 tive tendencies can readily gain the upper hand. The 
 situation with concussion is therefore — only in a psycho- 
 logical sense, of course — analogous to that of a mental shock. 
 A purely psychic trauma so confuses the patient's ordinary 
 mental processes that his critical judgment is for the time 
 being impaired, and the unconscious has an opportunity for 
 fuller expression than it previously enjoyed. Both concus- 
 sion and mental shocks are by their nature sudden. We 
 see also many cases in which there is a gradual increase in 
 the severity of symptoms. It is not at all impossible that 
 modern warfare produces conditions of such extreme neuro- 
 psychic fatigue that mental tension may be lowered thereby 
 to that same level of inefficiency that occurs acutely with 
 concussion or psychic trauma. The process is necessarily 
 more gradual with the unconscious developing symptoms 
 in inverse proportion to the weakening strength of the 
 critical factors. 
 
 Throughout this report there has been considerable stress 
 laid on the psychological aspects of the war neuroses. In- 
 asmuch as it seems certain that purely physical factors play 
 a larger role than they commonly do in times of peace in 
 the production of functional nervous disturbances, this 
 constant emphasis of the mental aspects of the neuroses 
 demands some apology. The reason for it is a purely prac- 
 tical one. The treatment of these conditions, in so far as 
 
109 
 
 it demands the attention of specialists, must be almost 
 purely psychological, or, to put the matter in a somewhat 
 more accurate form, it may be said, perhaps, that every 
 method of treatment instituted must be carefully considered 
 in the light of its probably psychological effect. The 
 physical factors, although of the utmost importance, are 
 beyond our present capacity to change specifically. The 
 best we can do, failing knowledge as to what they really 
 are, is to meet them symptomatically with such simple 
 measures as rest, diet, catharsis or sedation. It is only the 
 physician who constantly maintains the psychological 
 standpoint, however, who will be consistently successful in 
 treating the war neuroses. 
 
 Prophylaxis. 
 
 In conclusion it may be well to speak briefly of means 
 that may be taken to prevent in future such terrible strains 
 being made on the efficiency of fighting forces as the 
 neuroses have produced in all the armies at present at 
 war. The first method which naturally comes to mind is 
 the removal at the time of enlistment of all men who are 
 not adapted to fighting. This is, of course, a simple 
 recommendation but one that demands keen judgment and 
 wide outlook on the part of those who would put it into 
 operation. One difficulty is inseparable from the problems 
 of war itself. It must be obvious to every reader that the 
 vast majority of cases quoted in this report show men who 
 are well adapted to civil life but capable only to a limited 
 degree of enduring the strain of modern warfare. The sad 
 fact is also plain that the very qualities which may be the 
 greatest assets to the civilian, and to the country in which 
 he lives, may be just those characteristics which are most 
 apt to jeopardize complete adaptation to trench warfare. I 
 need only mention independence of judgment and a strong 
 feeling of sympathy for those in pain, to make it clear that 
 the ideal soldier must be more or less of a natural butcher, 
 a man who can easily submit to the domination of intel- 
 lectual inferiors. Whether men who are more valuable to 
 the State as civilians than they are as soldiers, should be 
 drafted into an army or not, is, fortunately, not a question 
 
110 
 
 for a physician examining recruits to decide. It is his 
 duty, rather, to make up his mind, after an examination of 
 any given applicant, whether the chances of that man's 
 competency in the firing line will be sufficiently good to 
 justifj^ the money which the government will spend in 
 feeding, clothing and training him. It goes without saying 
 that all men should be eliminated who show marked 
 psychopathic tendencies or who are obviously psychoneu- 
 rotic at the time of examination. I have been much 
 impressed with the large number of cases (many of which 
 are not reported here) that I have had an opportunity of 
 examining who gave a history of previous breakdowns or 
 of having had tendencies toward psychoneurotic reactions in 
 their past life, but who nevertheless adapted themselves well 
 to training and fought well for many months, some of them 
 indefinitely. I am therefore forced to the belief that there 
 is in military discipline a powerful therapeutic agency and 
 that not only the country as a whole, but many individuals, 
 would lose a great deal if they were denied service in the 
 army simply because they could show a history of some 
 psychoneurotic disturbances in the past. 
 
 The problem therefore would reduce itself to a matter of 
 gauging the probable persistence and severity of such 
 tendencies, which is obviously a difficult matter. No one 
 of course who is ill-adapted to civilian life at the time of 
 enlistment should be considered. Those patients who have 
 given a history of such tendencies as night terrors, fear of 
 the dark, fear of the underground or fear of thunder-storms, 
 and who present no evidence of having outgrown these 
 tendencies, who are still in considerable measure incapaci- 
 tated by them — all such persons are probably poor risks 
 from the army standpoint. Again it is practically certain 
 that any individual who is in times of peace temporarily 
 incapacitated by sights of cruelty, bloodshed, accidents, 
 etc., is very unlikelj^ to have any but the briefest resistance 
 to the constant strain imposed by the inevitable horrors of 
 war. Such symptoms as giddiness in high places are so 
 universal as to have practically no significance when 
 occurring alone. If it were practicable much more finality 
 in the physician's judgment could be given if he had an 
 
lit 
 
 opportunity of examining recruits twice. In his first 
 examination he could pick out doubtful cases and then 
 reexamine them after some months of training in order to 
 discover whether the military life had had a salutary or a 
 deteriorating effect on them. If they had improved they 
 would probably be good risks. If they had not improved, 
 however, it would be highly improbable that their experience 
 at the front would be anything but temporary. Although 
 I have seen many cases showing neurotic tendencies who 
 improved under training and became excellent soldiers, I 
 have not seen one who failed to improve under training 
 whose condition became better when he was actually in the 
 firing line. 
 
 The next problem in connection with prophylaxis has to 
 do with lightening so far as possible the strain that is inevi- 
 table in trench warfare. It is of course an easy matter for 
 the physician to say that the soldier must have frequent 
 relief from duty and be given all possible distractions, and 
 equally easy for the staff oflScers to reply that such coddling 
 of the men is incompatible with the conduct of a campaign. 
 Obviously this problem is at once both a military and a 
 medical one. At the present time the line officers of the 
 British Army are as acutely aware of the necessity for rest and 
 distraction as are the physicians, and the reason for this is 
 that they have discovered that no matter how much men 
 may be forced and no matter how willing they may be to 
 continue in the trenches they nevertheless become inefficient 
 when subjected to more than a certain amount of fatigue. 
 If at all feasible, a system of relief should be worked out in 
 conference between psychiatrists and the staff. If also 
 practicable, a certain laxity in the arrangements should be 
 left whereby psychiatrists might be allowed the privilege of 
 removing certain men from the trenches earlier than they 
 would their fellows. If possible, this would be of great 
 military advantage, as the history of many patients show 
 that when they have an opportunity to rest they quickly 
 recover from the premonitory symptoms of a war neurosis 
 and return to fight again quite competently. Once the 
 disease has progressed beyond a certain point, however, 
 there seems to be no return except after a long period of 
 
112 
 
 treatment. The best criterion I have been able to discover 
 
 for permanence of symptoms is the presence of repeated 
 nightmares of actual fighting. I was not able to find a 
 single patient who had once shown these symptoms and 
 subsequently improved without regular and protracted 
 treatment. These remarks refer of course more particularly 
 to the anxiety states than to the conversion hysterias. If 
 all the private soldiers who complain of the milder degree 
 of resistance to the trenches, which so many of these men 
 show before the actual hysteria begins — if all these men 
 were allowed to go back into rest camps there would prob- 
 ably be very little army left. On the other hand, the 
 officers who break down with anxiety conditions, if they 
 are good officers and of value to the army, are men who would 
 be loth to leave their duty unless ordered to do so. It goes 
 without saying that all forms of comfort and distraction, 
 particularly the presence of palatable food and drink, are of 
 importance from a medical standpoint in the present war as 
 they never have been before. Where every factor seems to 
 operate in making it hard for the soldier to maintain his 
 adaptation — his pleasure in the service — it is essential that 
 his difficulties should be reduced to a minimum, and that, 
 on the other hand, he should be furnished with every pos- 
 sible means for giving him that pleasure which would 
 distract his mind from all that is unpleasant and horrible 
 around him. 
 
 Finally, when men are sent back to rest camps in order 
 to recover from their fatigue it would be highly desirable 
 that they should receive an examination before they return 
 to active duty again. As has been shown in a number of 
 cases in this report, the prospect of returning to duty, when 
 recovery has not been complete is frequently the occasion 
 for utter discouragement and consequent collapse. In a 
 war that may last for years an extra week or even an extra 
 month of absence from the trenches is less loss to the army 
 than is that which is occasioned by the protracted conva- 
 lescence which follows only a week, perhaps, of efficient 
 service. Here again then the problem is reduced to a 
 question of adapting individual treatment to the military 
 necessities that consider all men alike. 
 
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