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_ PSYCHOSOMATIC MEDICINE MONOGRAPH II-III _

THE TRAUMATIC NEUROSES OF WAR |}

BY

ABRAM KARDINER, M.D.

FORMERLY ATTENDING SPECIALIST U. S. VETERANS HOSPITAL NUMBER 81

FORMERLY INSTRUCTOR IN PSYCHIATRY CORNELL UNIVERSITY AND

ASSOCIATE IN PSYCHIATRY COLUMBIA UNIVERSITY

- 1941 +

PUBLISHED WITH THE SPONSORSHIP OF THE COMMITTEE ON PROBLEMS OF NEUROTIC BEHAVIOR DIVISION OF ANTHROPOLOGY AND PSYCHOLOGY NATIONAL RESEARCH COUNCIL, WASHINGTON, D.C.

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‘

THE TRAUMATIC NEUROSES OF WAR

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PSYCHOSOMATIC MEDICINE MONOGRAPH II - III

THE TRAUMATIC NEUROSES OF WAR

BY

ABRAM KARDINER, M.D.

FORMERLY ATTENDING SPECIALIST U. S. VETERANS HOSPITAL NUMBER 81

FORMERLY INSTRUCTOR IN PSYCHIATRY CORNELL UNIVERSITY

AND

ASSOCIATE IN PSYCHIATRY COLUMBIA UNIVERSITY

EQAI.*

PUBLISHED WITH THE SPONSORSHIP OF THE COMMITTEE ON PROBLEMS OF NEUROTIC BEHAVIOR DIVISION OF ANTHROPOLOGY AND PSYCHOLOGY NATIONAL RESEARCH COUNCIL, WASHINGTON, D.C.

BDITORIAL BOARD

MANAGING EDITOR: FLANDERS DUNBAR

FRANZ ALEXANDER

Psychoanalysis

DANA W. ATCHLEY

Internal Medicine

STANLEY COBB

Neurology

HALLOWELL DAVIS

Physiology

EDITORS

FLANDERS DUNBAR

Psychiatry

CLAR

K L. HULL

Psychology

HOWARD S$. LIDDELL

Comparative Physiology

GROVER F. POWERS

Pediatrics

ADVISORY BOARD

PHILIP BARD

CARL BINGER HERRMAN BLUMGART E. V. L. BROWN WALTER B. CANNON BRONSON CROTHERS FELIX DEUTSCH OSKAR DIETHELM GEORGE DRAPER EARL T. ENGLE LOUIS Z. FISHMAN JOHN F. FULTON

W. HORSLEY GANTT ROY R. GRINKER

WALTER W. HAMBURGER

LUDVIG HEKTOEN M. RALPH KAUFMAN WILLIAM J. KERR LAWRENCE S$. KUBIE DAVID M. LEVY

NOLAN D. C. LEWIS KARL A. MENNINGER ADOLF MEYER WALTER L. PALMER TRACY J. PUTNAM

STEPHEN WALTER RANSON

SAUL ROSENZWEIG LEON J. SAUL ELMER L. SEVRINGHAUS

EPHRAIM SHORR DAVID SLIGHT

JOHN H. STOKES JOSEPH STOKES, JR. MARION B. SULZBERGER ALFRED H. WASHBURN EDWARD WEISS

JOHN C. WITHEHORN HAROLD G. WOLFF ROLLIN T. WOODYATT EDWIN G. ZABRISKIE

PRINTED BY THE GEORGE BANTA PUBLISHING COMPANY, MENASHA, WISCONSIN, U.S.A.

PSYCHOSOMATIC MEDICINE MONOGRAPH II-III

FOREWORD

THE TRAUMATIC NEuROsIs has long been a troublesome medical and forensic problem. The medical aspects are fundamental because it is the resolution of these problems upon which all other social issues depend. Until the war of 1914-1918 this neurosis received but little attention. The main problem in connection with it was whether to account for the symptoms on the basis of organic or “functional” hypotheses. Moreover, the neurosis usually carried the name of the provoking agent, like lightning neurosis, railroad spine, shell shock, etc.

The neuroses incidental to the great war made the world neurosis- minded. They were studied with more care than at any time pre- viously, and the literature is encyclopedic. Explanations of this neurosis on a functional basis came largely from the influence of psychoanalysis. The work of W. H. R. Rivers and William Mc- Dougall was highly significant, as well as that of Ferenczi, Abraham, Simmel and Jones. Freud never discussed this neurosis systematically, but made some extremely important observations about it in 1921.

Between this work and the present time lie the experiences with the chronic neuroses of the last war. This taught us much about psychopathology, treatment, and the complicated forensic issues con- nected with it. Nevertheless the conclusions of this work did not get much attention, and hardly influenced the conception of the peace- time traumatic neurosis, which is the same in structure as those pre- cipitated in war.

The current war has again brought to the foreground the problem of the neuroses incidental to it. This time, however, the problem is much more urgent because, owing to the widespread aerial bom- bardment of urban centers, the traumatic neurosis is now no longer likely to be confined to combatants. In fact the traumatic neurosis bids well to be one of the commonest neurotic disturbances in the world. It is difficult to predict the nature and scope of the medical |

vi THE TRAUMATIC NEUROSES OF WAR

and social problems that this new aspect will create, but there can be no doubt that these problems, both psychiatric and social, will be of prime importance. If we are not to repeat the errors made during the last war, with its accompanying waste, important problems in organi- zation and study lie ahead. In our preparatory efforts the experi- ences of the last war and those in the current war should be our chief guide.

This book purports to be a guide to the study, treatment and postwar care of those neurotic disturbances which are incidental to war. [he greatest stress in this work falls on the discussion of those principles of psychopathology necessary to make these neuroses in- telligible and to furnish a rational basis for therapy. This was re- garded as the prime objective, for without this knowledge no intelligent program for treatment, prophylaxis, and postwar care can be formulated. In addition, an attempt is made to discuss the forensic aspects of the traumatic neuroses, since so many of them be- come government charges for a long postwar period. Treatment 1s discussed at length only in connection with several chronic cases which terminated successfully. This is in no way to be construed as indicat- ing that therapy in these chronic cases is universally successful.

Most of the clinical material included in this book was gathered while I was Attending Specialist in the Outpatient Department of U. S. Veterans Hospital Number 81 during 1922 to 1925. All but a few of the cases were studied there. Some of them were repeatedly demonstrated to classes in psychiatry from 1923 to 1928. The case which is the basis for the discussion on therapy was demonstrated in person before the New York Society for Clinical Psychiatry in Feb- ruary, 1924.

Although the purpose of the book is purely practical, the oppor- tunity was used to discuss all the accessory data necessary to a more complete understanding of this type of neurosis, and also to discuss some pertinent issues in psychopathology. The reader not interested in any but the clinical and practical aspects of these neuroses can safely delete Chapters IV and V.

The material of this book was the subject of a paper originally published in the Psychoanalytic Quarterly (Vol. 1, nos. 3-4), under

FOREWORD Vil

the title, “The Bioanalysis of the Epileptic Reaction.” In that paper the emphasis was largely theoretical. The chief interest there was to reconstruct the nature of the epileptic reaction. Some of the cases there used are reproduced here. The clinical material in the present book is much more extensive, however. As regards the psychopathol- ogy, the conception of the traumatic neurosis is essentially the same. However, the theoretical reconstruction has been considerably altered and much simplified, this simplification being due to a change in the operational concepts employed. The chief operational concept in the first version was that of “‘instinct,”? and in order to describe the dy- namics a good many obscure concepts had to be devised which were not very helpful. These have all been deleted. I am indebted to the publishers of the Psychoanalytic Quarterly for permission to repro- duce some of the material published in the earlier work.

The short bibliography is no indication of the extent of my in- debtedness to other writers on this subject. I have included in this bibliography only those references of which I have been able to make positive use.

For the consummation of this work I am indebted to: Dr. Walter Treadway, through whom I received the opportunity to study these neuroses; to the late Dr. George H. Kirby; to Dr. Adolph Meyer, for discussions while the material was organized; to Dr. Sandor Rado, for continual encouragement; and Dr. Otto Fenichel for a very stimulating criticism of the above mentioned paper (Jwz. Zeitschr. f. Psychoan., 1934).

I owe a great debt of thanks to the editors of Psychosomatic Medt- cine, especially to Drs. H. Flanders Dunbar, H. S. Liddell and Franz Alexander, for their editorial criticism and assistance in the preparation of the book. I am also indebted to Dr. Harold Kelman for studying the theoretical parts of the book, for some suggestions on organization for treatment, and on problems for future research. His experience with civilian and war traumatic neuroses was useful to me as a check on my observations, and discussions with him were useful in formulating my opinions on many matters.

New York A.K. November 3, 19 40

PSYCHOSOMATIC MEDICINE MONOGRAPH II-III

CONTENTS

FOREWORD

PART Iz CLINICAL I. INTRODUCTION

Il. SYMPTOMATOLOGY OF THE TRAUMATIC NEU- ROSES Pathoneuroses—Hypochondriasis Schizophrenia ‘Transference Neurosis Defensive Ceremonials and ‘Tics Autonomic Disturbances Sensory-motor Disorders The Epileptic Symptom Complex Summary

III. ANALYSIS OF THE SYMPTOMATOLOGY

War and the Traumatic Situation What is a Trauma? The Alteration of Adaptation in . . Repetitive tics and ceremonials 2 ee, phenomena . 3. Sympathetic-parasympathetic shiaastetes 4. Syncopal phenomena The Organization of the Neurosis Constant Features of ‘Traumatic Neurosis, fac aihig I. Fixation on the traumatic event 2. Dream life 3. Contraction of general level of fanctontne 4. Irritability 5. Tendency to aggression aiid diletice 6. Inhibitory phenomena Regression or Disorganization ‘Traumatic Neurosis and Epilepsy Conclusion

x THE TRAUMATIC NEUROSES OF WAR

PART II: THEORETICAL IV. THE DEVELOPMENT OF THE EFFECTIVE EGO

135 Introduction: Methodology : 135 What is Adaptation? . 14! Development of Adaptive Patierts 142 The Development of Maxtery—Antoriatlzation of Fu unctions 146 The Internal Environment and Its Réle in Activity 157 The Effective Ego and Failure Reactions _.. 160 Summary and Conclusions : : ; 169 V. PSYCHODYNAMICS . . 17% Structure and Relations of the Action Syndrome _. 177 The Consequences of the Inhibition. 182 Nosological Considerations—The a 193 Summary and Conclusions , 198

PART I: PRACTIGAL

VI. COURSE, PROGNOSIS, DIFFERENTIAL DIAGNOSIS | 209 Course ; : 209 Prognosis. 211 Differential eee : ' ; ; 252 VII. TREATMENT : . 216 Acute Cases . : ; 279 Treatment of Acute Conditions | . | j 217 Chronic Cases . ; 221 Further Points in Techetios . : 227 Hospital Organization for Treatment . ; 228 Prophylaxis and Civilian Morale : 230 Summary : . : ; 232 VIII. FORENSIC ISSUES | ; 233 IX. OPEN QUESTIONS AND FUTURE PROBLEMS _. 240 Questionnaire on Traumatic Status. : 242 BIBLIOGRAPHY . ; ' 247

INDEX : ’ ; : 253

PSYCHOSOMATIC MEDICINE MONOGRAPH II-III

PART I: CLINICAL

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PSYCHOSOMATIC MEDICINE MONOGRAPH II-III

I. INTRODUCTION

THE TRAUMATIC NEUROSIS is the commonest neurotic disturbance of war. This does not mean that the traumatic neuroses of war differ in any way from the traumatic neuroses of peacetime or from those following upon natural catastrophes like great fires and earthquakes. Nor is the traumatic neurosis the only reaction to the war situation. These latter may include every known neurotic and psychotic dis- turbance occurring in peacetime, the only difference being that their course is in no small measure altered both in tempo and intensity from those that occur in peacetime. In addition to these, every pos- sible variation of concussion syndrome with or without actual somatic damage, and every conceivable emotional reaction to these injuries may result from the war situation.

This book does not purport to treat of all the psychic disturbances of war. It seeks merely to explore a highly specific syndrome which can be called the traumatic neurosis. Its purpose is to establish the symptomatology, criteria for differential HABBO, and to establish a rationale for therapy.

The importance of this neurosis is due, not only to the severe in- capacities which result from it, but also to the many and complicated forensic problems which it brings in its wake. The chief of these is the problem of compensation and the management of the veteran with such a neurosis. A second type of problem presents itself in the traumatic neurosis which refers purely to psychopathology, and in this the significance of the traumatic neurosis becomes very great indeed. These problems in psychopathology concern ‘first those of method: namely, what criteria to use in establishing the sympto- matology of this disease; what operational concepts are to be used to establish the nature of the symptoms; the essential psychological processes; and finally, what therapeutic indications follow upon the conception of the illness derived from these sources.

During the last war several conceptions of these neuroses pre-

4 THE TRAUMATIC NEUROSES OF WAR

vailed. Those who were accustomed to the organic point of view naturally regarded all the phenomena of this neurosis as due to the direct effect of a widely disseminated organic lesion. The support for this idea came from the vast number of neuroses associated with severe concussion syndromes, with indubitable evidence of the ex- istence of actual organic lesions. For practical purposes this concep- tion of the traumatic neurosis did very little harm, for it encouraged a regime of supportive treatment; and even if many of these cases did not recover, the residuals were still attributed to the organic in- jury. This point of view was, however, seriously brought into ques- tion when large numbers of neuroses were found with no evidence of concussion but still with symptoms in many ways like those in which the evidence for organic injury was unquestionable. This jus- tifies the conclusion that the symptoms resulting from the concussion were not direct evidence of organic lesions but that they were the indirect effect of these lesions upon the tota] adaptation possibilities of the individual and that the interference in adaptation could occur with or without organic injury.

A second point of view exploited in connection with this symptom complex was that the traumatic neurosis was “psychogenic” in char- acter. Whereas this point of view was very plausible, one again needed definite criteria. One group of authors elected to describe the illness as due to specific conflicts occasioned by the war situation as against the peacetime situation; that is, the peacetime ego was con- trasted with the wartime ego, and the conflicts were entirely in terms of the issue of self-preservation as against ideals of heroism, patriot- ism, and the like. Whereas it is plausible that such conflicts do exist and undoubtedly contribute much to the ultimate picture of the neurosis, it must again be pointed out that these neuroses are ex- tremely common in peacetime when the issue of peacetime versus wartime ego does not exist. Furthermore, such conflicts do not in any way explain the symptomatology of the disease. In other words, many factors may contribute to the formation of the traumatic syn- drome, organic lesions, self-preservative interests, and conflicting ideals. The essential problem of psychopathology is to explain the manner in which the symptoms are constructed.

— Ss ee oe

INTRODUCTION 5

From the point of view of interpretation of the symptoms, that is, their origin and meaning, psychoanalysis made some interesting sug- gestions. Psychoanalysis offered its particular conception of the neu- rotic process as it was known up to that time (1918). The neurotic process was conceived as an interference with certain instinctual drives, and the symptom could be accounted for on the basis of re- gressive substitute formation. In this regard the traumatic neurosis did not fall easily into the category of the previously well-studied transference neuroses, hysteria and compulsion neurosis. Efforts were made to create new classifications. Traumatic neuroses were consid- ered “actual neuroses,” organ neuroses, pathoneuroses, pregenital conversion hysterias, narcissistic neuroses, and so forth. These classifi- cations, in extremely confusing terms, offered little basis for psycho- therapy. In fact, the therapeutic measures used successfully in treat- ing these neuroses had very little to do with the conception of the psychopathology.

From the point of view of psychopathology the orientation in terms of instinct was very misleading. The pathology of the transfer- ence neuroses was worked out on a series of illnesses in which the sexual instinct was supposed to be directly involved. In the case of the traumatic neuroses, the psychopathology had to be accounted for indirectly as due to the operation of the castration complex. It as- sumed that one could track down the pathology of an interference with self-preservation with the same criteria used in establishing the interference with the sexual instinct, notwithstanding the fact that up to 1918 there was no success in describing the pathology of the so-called ego instincts, and that “self-preservation” was the name of a result and not of an instinct.

The point of view of this volume is somewhat different. Let us make the general assumption that elementary drives do exist. But we cannot today any longer assume that the phenomena we observe in psychopathology are in any way to be construed as direct evidence of the operation of this, that, or the other instinct. The reason is that the object of study is always a personality as a whole. We observe functional and functioning units and not drives. These units are either effectual or ineffectual as regards their ultimate purposes for

6 THE TRAUMATIC NEUROSES OF WAR

the personality as a whole, and the question as to whether or not they furnish direct evidence of “instincts” is irrelevant. What we observe in the traumatic neurosis is a characteristic interference with certain effectual units, the ultimate purpose of which may be self-preserva- tion or preferably, a certain kind of effectual adaptation. This is quite a different thing from saying that we observe an interference with the instinct of self-preservation. With this shift in point of view, the emphasis in the psychopathological data falls in a new direction. The concern with the question about the content of the manifestations (that is; is it narcissistic, pregenital, and so on) yields to the question as to which executive function is interfered with and why. In other words, emphasis is shifted from content to form. The failure due to describing the neurosis in terms of content was the fact that it did not take in the main factors in the psychopathology. If one describes a neurosis as narcissistic, one has yet to describe the difference between narcissism as it occurs in manic depressive psychosis, epilepsy, schizo- phrenia, or the traumatic neuroses.

In short, it is the purpose in this book to describe these neuroses from the point of view of the field, or action syndrome, rather than that of instinct. This must not be construed as a denial of drives; it merely questions the assumption that imstinct or drive is an ade- quate operational concept that can do justice to the clinical facts and offer a basis for therapy.

The traumatic neuroses can be studied in the acute or stabilized forms. For the purposes of this book the stabilized forms offer the best opportunities. Recent literature on the current war demonstrates that the symptomatology of this syndrome is no different today than it was during the last war (64). It further demonstrates that in the acute stages no definite opportunity exists for the study of this neurosis.

The plan of the book is first to describe the clinical forms of the traumatic neuroses; then to determine, from the analysis of the symptomatology, what aspects of the personality are involved; to arrive at some working definition of trauma, thence to a discussion of the psychopathology, and finally to a discussion of therapy and the forensic problems involved.

PSYCHOSOMATIC MEDICINE MONOGRAPH II-III

Il. SYMPTOMATOLOGY OF THE TRAUMATIC NEUROSES

THE syMPTomMs of the traumatic neuroses vary according to how soon they are observed after the trauma. This is particularly the case with the neuroses of war. The symptoms can be described as acute, transt- tional, and stabilized forms. The time interval between the acute and stabilized forms is generally two or three weeks. There are excep- tions to this, as will be seen from a number of the cases below, some of which take as long as six months to become stabilized. The cases which stabilize most rapidly are the sensory motor disturbances; those which take longest, the ones terminating in epileptiform phenomena. The cases which, in the stabilized form, have purely autonomic (sym- pathetic and parasympathetic) phenomena have the most varied symptomatology and generally represent residuals of a long series of changing symptoms. The acute symptoms may be: . Symptoms of shock, with typical manifestations of terror. . Comatose conditions. . Maniacal reactions, excitements, and fugues. . Delirious reactions. . Paralyses and sensory disturbances, without other manifesta- tions.

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For purposes of study the stabilized forms of the neurosis are the most important. For the greater part, once this stabilized form is reached, it can remain stationary for as long as ten years—the longest period I have had the opportunity to observe them.

PaTHONEUROSES—H YPOCHONDRIASIS

Case 1. The patient, a soldier twenty-five years old, fell with an airplane from a height of one thousand feet. He struck the ground with great violence but was not killed. He could remember nothing after the moment of striking.

8 THE TRAUMATIC NEUROSES OF WAR

During his convalescence he was told that, immediately after the injury, he acted as if he were not unconscious; in fact, he had helped himself into the ambulance and had spoken to the woman who as- sisted in his rescue. But for all these circumstances he had a complete amnesia. He was in a state of “unconsciousness” for five days, Dur- ing that time he remembered a dream in which he had an enemy helmet on his head and was engaged in tearing it off. After he re- gained consciousness he was told that during his sleep he had torn a plaster of Paris cast from his head.

During the past six years the patient had had falling dreams two or three times, and he remarked that this was about the frequence with which he used to have falling dreams before the accident. He had had a certain amount of fear of high places, fear of driving, but hardly to a degree of being distinctly neurotic.

His chief preoccupation was with a facial deformity which had resulted from this fall. He now carried about in his coat pocket a picture of himself as he was before the accident and, gazing at it fre- quently, continually bemoaned this disfigurement. As a matter of fact, no one would have realized that the young man had suffered a deformity of the face, unless he had previously known the patient. There was nothing but a slight asymmetry and a flattening of the nasal bridge. In this case the effects of the trauma were completely dissipated in the preoccupation with the deformity it had caused.

Here it is important to note the rapid disappearance of the typical dream life and the absence of irritability, aggressiveness, and inhibi- tions. But in their place was a severe hypochondriasis. This type of outcome is extremely rare. The hypochondriasis is not nearly so prominent in cases where the injury is inflicted on a part less im- portant, from the narcissistic point of view, than the nose. The reac- tion to the traumatic situation consists of a preoccupation with his appearance. The general formula for his obsessive thinking is, “I have lost the claim to social recognition and love, and I do not love myself any more.” Such a syndrome was described by Ferenczi under the name of pathoneurosis. This type is one of those responsible for the conclusion that those who are injured do not develop a traumatic neurosis.

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES- 9

SCHIZOPHRENIA

Case 2. The patient, twenty years old, was intellectually below average and was always engaged in unskilled labor. While in service he was “buried by a shell.”? He was taken to a hospital but did not remember any of his immediate symptoms. He did, however, remem- ber that most of the symptoms of which he now complained began after his trauma. Symptoms included persistent insomnia, typical nightmares of things being on fire, people being killed, he himself being annihilated. He had distinct delusions of reference, of people talking about him, and an irresistible impulse to strike people on the street. He thought other people on the street offended him. He was also constantly hallucinating the voice of his dead mother, who was always reassuring him not to be afraid. Extremely superstitious, he was afraid of seeing ghosts, afraid of crossing the street. He had delu- sions about a foul odor’s emanating from his person. He thought he “smelled like a dead rat.” He could not adjust himself to his father, with whom he always quarrelled. So difficult had relations between them become, that his father once put him out of the house. The rea- sons for these quarrels were usually some trifling matter, but the patient was evidently responsible for all these disturbances. At the time of his treatment he was better than he had been at any time during the preceding five years.

A simple paranoid schizophrenia, this case is of special interest because, besides the outspoken schizophrenic features, some of the features are distinctly characteristic of a traumatic neurosis. A great deal of resemblance lies between the persecutory fantasies of a para- noiac and the dreams of a traumatic neurotic. In paranoia the patient is persecuted by the individual by whom, unconsciously, he expects to be loved. In the traumatic neurosis he is persecuted, in a similar way, by the environment, which has for the time being withdrawn its protective character. The fantasy of world destruction in schizo- phrenia is apparently a manner of perceiving in the outer world what is really happening within himself. The paranoid delusion, in the above case, cannot be considered in any way a transference symptom of the reaction to trauma because, as a rule, the secondary defenses

10 THE TRAUMATIC NEUROSES OF WAR

of the traumatic neurosis have a psychological elaboration which usually has no resemblance to the paranoid delusion. I have, how- ever, seen several cases in which the quality of the symptom was pre- eminently that of the traumatic neurosis, but in which persecutory ideas were present occasionally and intermittently. Possibly the trauma, in this and in similar cases, serves rather as the occasion for touching off a deep-seated latent schizophrenia, but it seems also to impart to the resulting clinical picture something of the characteristics found in all traumatic neuroses.

It is worth noting that transient schizophrenias, many of which terminated in complete recovery, were common during the war. The trauma can only be considered a precipitating factor, hardly a causa- tive agent that provoked the illness. In the light of what we know about the characteristics of traumatic neuroses, a schizophrenic reac- tion is, conceivably, one of the effects to be expected; the trauma gives the already enfeebled adaptive resources an additional setback.

‘TRANSFERENCE NEvuROSIS

Case 3. The patient was twenty-eight years old. Since fourteen, he worked at various trades and finally became a pipe fitter. Prior to service he got into some difficulties with the law because of his participation in street brawls. He was evidently a very pugnacious individual.

The life of a soldier apparently agreed with him. He enlisted for service on the border but was recalled to serve in France. Never wounded, he had only one traumatic experience in the form of mild gassing, in August, 1918. Neither during his convalescence nor im- mediately thereafter did he have any symptoms, but his breakdown occurred after returning to his country. The occurrence of the first symptoms after the return to a peaceful environment is usually more apparent than real. As a matter of fact, there usually is a continua- tion of the same symptoms that were present in the danger zone, but they are not noticed there. They are usually felt when the external turmoil has ceased. ¥

His symptoms were irritability, depression, tremors, sensitiveness to noise—so much so that he could not resume any form of work

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 11

involving constant noise. He had spells of aggressiveness and un- reasonable temper; vertigo was a pronounced symptom, often keep- ing him in the house. In addition to these, he had several well-defined phobias; fear of riding in the subway and fear of insanity. During the day he was obsessed with recollections of the scenes of war, and at night he used to have typical nightmares.

The capacity for displacement, in this case, is quite pronounced. His fears displaced themselves on a great many situations and had the character of true symbolic displacements and not of superficial resemblances to his war experiences, as is so frequently found in traumatic cases. He had constant fears, for example, that someone was entering his house, fears that his child was going to die, fears that something would happen to his wife or to other members of the family.

The chief interest in this case lies in the fact that the anxiety of this type of patient is very readily recognized as such. The escape from the repressed ideas takes place in much the same way as it does in the ordinary transference neurosis. The patient accordingly showed himself, to a large degree, accessible to psychoanalytical therapy. The neurotic picture had two different aspects, one of them belonging to a psychosexual conflict, the other to a traumatic neurosis, and the two communicated freely with each other. His accessibility to treat- ment brought good results. The remarkable feature is the fact that his displacement phobias were much more readily removed than his secondary symptoms resulting from the traumatic neurosis—his sen- sitivity to noise, his irascibility, etc.

The patient married after his return from abroad “in order to cure himself.” The transference symptoms were very largely super- imposed upon and independent of his irascibility. However, in the course of treatment, the patient was able to utilize his marriage as he originally designed. His newly-born child came to be the focus of his entire interest and attention.

Case 4. The patient was thirty years old. From his past history he gave a typical psychoneurotic picture. He was never in love with any woman; he was unmarried; his sex life was far from normal. His

12 THE TRAUMATIC NEUROSES OF WAR

symptoms were a general and a constant apprehensiveness, fatigabil- ity, and insomnia. He had grown away from all his social connections, was quite seclusive, and according to his own description, very unlike his former self. Since the war, his sexuality had been more repressed than ever. He had the typical dreams of the traumatic neurotic—of war scenes, particularly those in which he was being buried by shells; of being in close spaces; of being in the trenches.

He had one very pronounced phobia, the fear of riding in the sub- way; while in the subway he had characteristic anxiety crises—a feel- ing of discomfort, a choking sensation, an uncontrollable anxiety. He would heave a sigh of relief when the train reached the surface.

During the war he was exposed to many petty traumata, but the most distressing experience he could recall was that of “going over the top.” He was on several occasions buried in the trench, where he saw several of his companions killed. Symptoms began shortly after he was taken away from active duty.

The predominance of displacements in this case is quite obvious. To all intents this patient had an ordinary claustrophobia. The pre- disposition to neurosis was present prior to service, and one can readily see that the fear of the subway serves to carry off anxiety from both his egoistic and his sexual conflicts. This is typical transference neu- rosis. The traumatic experience aggravated a previous neurotic char- acter disturbance.

Case 5. The patient, thirty-six years old, was married prior to service. Domestic life was very unhappy, and service was undertaken, in part, as a release from his difficulties at home. When he first pre- sented himself, his chief concern was with the anxiety which was occasioned by riding in a train. This symptom, he said, made tt impos- sible for him to go to work and thus interfered with his economic independence. The symptom, he also stated, arose while he was 1n service. His dreams were of the usual distressing character, most often concerned with being in a vehicle which was colliding with another. His dreams, however, as well as his daytime fantasies, usually contained a good deal besides this. He saw himself wounded as a result of the collision and mourned over by his wife and children.

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 13

He described other symptoms—intensive vertigo, some gastroin- testinal disorders, tremors, irritability. He was also very quarrelsome.

An investigation of his phobia showed that it was connected with a special feature of train-riding, that he was never uncomfortable while the train was in motion, and that it showed itself only after the brakes were applied. He then grew very tense and feared a col- lision. Consciously he never associated his anxiety with any experience he had had. However, the patient had actually been in a collision. He was riding a motorcycle, without lights, on a dark night, and while making a turn in the road, he ran into a stone wall. Unconscious for some time, he regained consciousness in a hospital. Shortly after- wards he began to have distressing dreams usually involving some collision. After a while these dreams were elaborated into fantasies which indicated that the traumatic experience was serving the func- tion of a displaced conflict. The following is a typical dream: “I was riding in the automobile when we collided with another car head-on. I was taken out of the car, all mangled, and my wife and children were standing over me, weeping.”

We are now in a position to understand the phobia. The anxiety occurs when the brakes are applied; it is, to all intents, a defense mechanism which protects him from a recurrence of his traumatic experience. However, the dreams of collision have a definite relation to his sex life. After his trauma, the patient became completely im- potent. He had a very ambivalent attitude toward his wife and, as we noted before, went into service with the unconscious motive of becoming incapacitated. His symptoms now kept him from going to work, and we find that the patient’s interests were now overtly con- fined almost entirely to himself. His children and his wife hardly ever occurred in his associations.

The mechanism of defense in his phobia, as far as it was related to the actual trauma, was readily accepted; but when any step was made in the direction of analyzing the effects of the trauma in rela- tion to his family conflict, I encountered the greatest resistance. He was able to ride in trains without anxiety, but his impotence, his irascibility, etc., persisted unabated. Moreover, he began to shift his interest entirely upon a hypochondriacal symptom which, prior to

14 THE TRAUMATIC NEUROSES OF WAR

this time, was latent. The vertigo now became his most distressing complaint. He was a building contractor; his vertigo was most pro- nounced in high places, thus constituting a perfect defense against his work. He then became much preoccupied with some gastroin- testinal symptoms which grew more intense as time went on. He insisted on X-rays, numerous gastrointestinal examinations, pro- toscopies, and operations. He also insisted that he was subject to fre- quent hemorrhages from the bowels.

Although it is premature at this point to discuss dynamics of the disease, to make clear some of the transference reactions of these patients, I must anticipate. The physician, in these compensated cases, stands for the government, which stands for mother (breast). Any attempt to deal with this dependency constellation is resisted. De- pending on the previous historical development of the subject, he will flee from one symptom to another indefinitely, and if one gets anywhere near this oral dependency, he will not infrequently resort to flight from treatment. If the dependency is taken by force—by a reduction of compensation or the like—this precipitates the most violent aggression against physician (mother). The flight into other symptoms with cessation of treatment is the rule in these cases.

We see, therefore, that the traumatic neurosis, per se, occupied a relatively unimportant place in the clinical picture of the last case cited. The defense mechanism which directly referred to the trau- matic experience was very readily removed. However, that part of his neurosis which signalized the trauma as a symbolic “castration” formed indeed the largest bulk of the clinical picture. The case 1s, to all intents, a transferance neurosis released by the trauma.

These cases are of great importance; they make up the largest volume of those cases which in peacetime are considered “traumatic hysterias.” They differ in no essential respect from the transference and narcissistic neuroses. Inquiry into their personal histories usually reveals infantile anxieties and subsequent psychosexual difficulties of gross character which, prior to the trauma, showed themselves in the

--form of inhibitions. In Case 3 the claustrophobia gets its special char- ——. acter from the experience in the trenches. These cases, in which transference mechanisms abound, in which the dreams and the sec-

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 15

ondary defenses show gross evidence of psychosexual conflicts, have no claim to the name of traumatic neuroses. How much a given clinical picture belongs to one or to the other is not very difficult to decide. It often suffices to hear merely the narrative of the type of dream which the patient has. In this regard the true traumatic neu- rosis is very easy to distinguish from the transference neurosis. The stereotype of the dream life of the traumatic neurotic is pathogno- monic, as are likewise the secondary defenses and inhibitions.

DEFENSIVE CEREMONIALS AND Tics

A large group of cases possess symptoms which are chiefly uncon- scious defense reactions against the original trauma. This may persist in the form of a tic which, when analyzed, shows itself to be a defen- sive reaction actually engaged in during the original traumatic event. The defensive reaction remains, as it were, petrified, and the clinical picture looks like the photograph of a person engaged in running or like a pointer fixed in the posture in which he locates his prey. It may be a more complete elaboration of a defensive reaction which was not carried out on the original traumatic occasion. Of the first type we may mention a very simple case. A sailor was on board a battleship, when, without his being warned, a turret situated above and to the right of him discharged a volley. He was thrown to the ground, and since that time he has had a persistent tic of the head to the left. Consciously, the patient has no knowledge of the purpose of this tic, and he has long since forgotten the connection between the action and the purpose it served. Another common reaction type of this variety is shown by the defensive attitude of patients constantly on the alert for something to happen. Thus a soldier received a severe shock on the battlefield when a dud landed in front of him. Whenever he sees something that is “almost going to happen”—such as a child crossing the street and being “almost killed”’—he is thrown into a panic of expectancy.

In the second group the defense ceremonials have the nature of compulsory acts which the patient carries out without knowing ex- actly why, but which relieve him of anxiety. The case described below is of this character. In this case a group of ceremonials, impulsive

16 THE TRAUMATIC NEUROSES OF WAR

postures, and attitudes are, so to speak, correctives. These activities are usually carried out with no more control of the will than is the ordinary compulsive ritual.

A third, though very uncommon, type is that in which a series of tics involves practically every part of the body. This is, so to speak, a fragmented, interrupted, and piecemeal convulsion. One such case was observed over a prolonged period. No part of the body was im- mune from these tic-like actions. In these generalized tics is a lack of the codrdination and purposiveness encountered in the simple forms mentioned above.

The single and multiple tics are active most of the time during the day, but the patient is quiet after he retires. In this regard these tics differ in no way from ordinary tics of peacetime. They are aggra- vated by any effort or by sudden stimuli. Usually patients having these tics do not show the characteristic dream life. This symptom is evidently a sufficient outlet.

I have stated that the symptoms of compulsion neurosis are rarely found in traumatic cases. But here I recall one case in a soldier who was blown up by a shell. He had the usual nightmares and a few spells of unconsciousness. But these symptoms disappeared to give way to a series of tics involving every part of his body and giving to his intentional muscular movements an athetoid character. This pa- tient had a compulsion to touch certain objects he would see, but he felt compelled to touch no specific object, and never the same object twice. I could not succeed in allocating any mechanisms in this case. He is the only case in which I have ever seen symptoms of a true compulsion. Unfortunately, opportunity did not present itself to study him more thoroughly.

Case 6. This patient was twenty-four years old. There was no his- tory of neurotic traits. He had never suffered from any form of syncope, fainting spells, or convulsions. His sex life, as far as could be ascertained according to the usual criteria, was quite normal. He was a sociable fellow and enjoyed the pursuits fitted to his sex and age. Hardly out of high school, he enlisted in the army for purely patriotic motives. No history of friction or maladaptation at home

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 17

existed to serve as an unconscious motive for his departure. On ex- cellent terms with his father, he also had, as far as could be elicited, quite a normal attitude toward women.

During his service in the army he suffered but one injury and that not a serious one; he was mildly gassed on one occasion. As a result of this, he had a mild chronic bronchitis. He was thus disqualified from doing certain forms of work, especially that connected with irritating fumes. Since his discharge from the army, he found that his efficiency was much impaired, He worked as a post-office clerk, then tried business for himself but was not very successful. His neu- rotic illness interfered with his efficiency to such a degree that he applied for and received vocational training. Between the time he left the service and the time he came under treatment, he had married and now had one child.

His physical examination was negative except for a few sibilant rales in the chest. Neurological status was negative. On mental ex- amination I found only the evidence of an anxiety hysteria. During the daytime he suffered merely from a vague apprehensiveness.

The salient feature of his neurosis was a typical hysterical trance which overtook him just at the point of falling asleep and in the brief interval between sleeping and waking. Other features of the trance included his becoming stiff all over, an intense anxiety, and violent palpitation of the heart. “I feel as though I were passing out of the world, as if I were trying to fight death.” These spells came about two or three times a week, sometimes as often as six times in one night. Naturally he feared going to sleep.

The neurosis began several days after he had been removed to the hospital, following his gassing (1917) and was initiated by anxiety dreams of the horrible scenes he had witnessed in the trenches. Sev- eral days later he had the first of these twilight terrors which per- sisted for five years thereafter. During this interval of five years he dreamed frequently of war scenes, always with anxiety.

After the attacks had troubled him for many months, he spon- taneously devised a method for preventing their occurrence. What he did cannot be regarded as anything short of a compulsive ritual. It consisted of lying, face down, on his pillow, burying his nose in the

18 THE TRAUMATIC NEUROSES OF WAR

pillow and putting his hands alongside his face. In this prone position he had a feeling of security, and though he could not stop one of his spells by assuming this position, he was quite sure that, if he took this position on going to bed, he would not have a spell. He remem- bered often being awakened by one of these twilight states to find himself in the supine position.

When asked to explain what relation his ceremonial would pos- sibly have to do with warding off one of his spells, he was completely at a loss. Evidently the meaning of it was entirely unknown to him, and ordinary introspection would be of no use in unraveling its mys- tery. The patient was asked to tell quite freely what occurred to him when he thought about this posture. His associations to the ceremonial were as follows: 1) swimming, 2) coitus, 3) “taking cover.” Swimming is quite naturally a birth symbol, and here the patient, like many others, associates the trauma with birth. In con- nection with coitus was a long series of associations, all of which dealt with the subject of more children. He had but one child, his economic situation being so uncertain that he could not take the chance of hav- ing more. This led to a very complicated series of attitudes and reac- tions based on the issue of compensation, all to the effect that he needed compensation and could not get on without it, that his illness had robbed him of every bit of self-confidence he had ever had, and so on.

The association of “taking cover” led him back to the original in- jury, the only one he had received while in service. He then told how he happened to be gassed. On guard duty with five other men, he was awakened one morning by the sound of exploding shells, and in this semiconscious state he saw a large shell explode about twenty feet in front of him. On seeing the red flare, he immediately began putting on his gas mask. He remembered trying to hold his breath in order not to catch any of the gas before the mask was ad- justed. And he then remembered that holding his breath was one of the features of his anxiety attacks and also one feature of the ceremonial. In the few seconds between seeing the flare and putting on his mask, his neighbor accidentally brushed it off just as he had it fitted and thus dislocated it. This resulted in his breathing the gas,

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 19

as he could no longer hold his breath. Then he lay there, face down, overcome, for a period of about half an hour, when he was removed to a yard station. He was much more frightened then seriously gassed.”

Little doubt remains after this description, of what the neurosis consisted and what scene the patient was re-enacting in the trance and the associated ceremonial. The facts that the trance was accompanied by anxiety, palpitation and holding his breath and was relieved by his taking a position which he associated with “taking cover” and that this was accompanied by movements very like the motions of a man trying to fasten a gas mask to his face, indicated the typical phenom- enon of traumatic neurosis, the repetition phenomenon. Here, again, is a symptom and a few secondary elaborations based on a traumatic experience which jeopardizes the individual’s life; the ideational con- tent is completely lost (repressed); the emotional reactions which originally accompanied it are split off and recur with monotonous regularity on the same occasion, namely the interval between sleep- ing and waking. Being on guard duty, he was not completely asleep at the time the shell exploded; his hysterical symptom guarantees an excessive amount of anxiety and preparedness which was absent on the original occasion. On each successive occasion he holds his breath, puts on his mask, and, thus prepared for a gas attack, he can go to sleep peacefully.

Several other features of the case must be included in this descrip- tion. The issue of government dependency was intimately bound up with his neurosis, although it did not call forth the symptoms of the trance. The patient, as mentioned above, was in vocational training and was, in the meanwhile, being supported by the government. His training officer, owing to some misunderstanding, threatened to put him out of training for insufficient codperation. For a short time he was without pay. During the interval the patient went into a pro- found depression and developed a new set of symptoms, fear of poverty and fear of insanity. With the adjustment of his difficulties in training, these symptoms disappeared. Interesting to note is that

* This case was presented in person before the New York Society of Clinical Psy- chiatry, February, 1924.

20 THE TRAUMATIC NEUROSES OF WAR

the old traumatic neurosis did not disappear under these conditions; he developed, on this occasion, new symptoms which he never had before. There is reason to believe that the symptoms which arose in connection with compensation link up very closely with psychosexual conflict but that the traumatic neurosis enjoys almost complete autonomy.

In this case, we note, the patient did not realize that the hysterical trance was directly connected with the traumatic experience. In other cases the patient seems to know that a certain given phenomenon is connected with a traumatic experience. On close examination it proves, however, that he is not much wiser than the one who is en- tirely ignorant of this fact.

This type of case is theoretically of great importance. We see here a repetition mechanism of high degree of organization; it is purpose- ful in making a correction over a situation which threatened the patient with annihilation. Capable also of symbolization and carrying a deep-seated psychosexual conflict, this type is the most highly or- ganized form found in the various reactions to trauma, excepting, of course, the pure transference type. This patient’s anxiety states have something of the quality of twilight states, which we shall subse- quently encounter in the epileptic type.

This last case is important for many other reasons. It demonstrates the spontaneous cure of the neurosis. This condition is very like that of the ordinary compulsion neurosis; a ceremonial is devised, the purpose of which is to ward off anxiety. Here the resemblance stops, because in our case the ceremonial has a real basis and not, as it does in the compulsion neurosis, a symbolic one. The ceremonial which the patient unconsciously devises takes form some years after the original traumatic event. Moreover, it is not completely efficacious; the anxiety persists unabated. This ceremonial, therefore, has the mechanism of a compulsory act; its purpose is unknown to the patient, but it is used to ward off anxiety. Moreover, when the ceremonial is analyzed, the anxiety appears to be displaceable, much like that in the transference neurosis. This part of his neurosis is undoubtedly the result of an old character disturbance.

We note, however, that the control of the patient over his body-

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 21

ego remains intact. The unconscious memories of the traumatic event are capable of engendering anxiety, which is a much more highly organized reaction to danger than the death faint or any other form of complete lapse of consciousness. The conscious representability of anxiety, when it is capable of being perceived as such, evidences, therefore, a high degree of organization. As we shall subsequently see, this anxiety does not entirely preclude the possibility of epilep- toid reaction types but renders it much more unlikely. Sometimes the barrier of anxiety is insufficient to stem the tide of the reaction, and it proceeds to complete loss of consciousness.

These two types—the transference neurosis following trauma and defensive tics and ceremonials—represent, therefore, the most highly organized forms of response to the unconscious activity of the trau- matic event. It may be well to mention here certain anomalies of posture and gait assumed by soldiers, much to the amusement of lookers on. Gaupp (12) records that these soldiers would walk with the torso bent sharply forward, the upper extremities hanging limply down. This is an unmistakable attitude of defense under fire. Others walked ‘‘on all fours.”

AuToONomiIc DisTuRBANCES

The type of case in which autonomic disturbances constitute the presenting symptom is extremely common in civilian life and is frequently found in individuals who have been subjected to a series of external hardships, shocks, fright, and so on. These cases were particularly frequent during the war. In the fresh state they received the name of “neurocirculatory asthenia,” “effort syndrome,” “sol- diers’ heart,” “war neurasthenia.” Indeed, very likely a large num- ber of the cases were described as Graves’ disease. Many of them, prior to the use of basal metabolism as a criterion, were mistaken for true Graves’ disease. It has recently been shown that a continuous series of stages exists between those cases which are merely autonomic disorders and true Graves’ disease, with all its characteristic symp- toms and increase of basal metabolism. It has, moreover, been pos- sible to observe patients passing from one to the other. Kessel and Hyman have noted that a large number of these cases begin in civilian

22 THE TRAUMATIC NEUROSES OF WAR

life after a period of economic stress or shock, such as the news of the death of a relative, a robbery, a business failure, and so forth. In all these cases the usual physiological accompaniments of anxiety persist long after the occasion which released them has ceased to op- erate. They differ from the civilian neurasthenias only in that the autonomic disturbances predominate.

In the acute stages vomiting, enuresis, diarrhea, and sweating were common. One case I saw was a man with sweating from the left hip down to the toes. His symptom, six years old when I saw it, yielded to no treatment including hypnosis. In the acute stages occurred dermographia, aerocyanosis, abnormal blushing and pallor, edema, trophic changes in finger nails, dryness of hair, sudden grayness of hair, and sudden falling of hair. Among the secretory disturbances were anomalies of salivation and swelling of the parotid gland. Very few of these latter carried over into the period of chronic illness.

Case 7. The patient had been injured six years previously when buried by a shell. The symptoms of which he complained were gas- tric disorders in the form of spasms, evidently pyloric and cardiac spasms which occasioned vomiting. In addition he had the anxiety dreams of sudden crashes and of houses falling, from which he, of course, awakened with the customary terror.

Of chief interest in this case was the fact that, on external stimula- tion, he developed a new phobia which seemed to have no connection whatsoever with his traumatic experience. This occurred at the time when the Yokohama earthquake was being described in the news- papers. Ihe patient was seized with a fear that the same thing might happen to New York. This fear obsessed him even at the time of treatment. The relation of the fear to his trauma is, of course, quite obvious,

This case shows that autonomic disturbances may coexist with dis- placement phenomena.

Case 8. The patient, aged thirty, reported that his first symptoms began in France. He stated that they began after he was struck by a hand grenade, resulting in a wound in his right thigh. He was hos-

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 223

pitalized for five weeks and discharged without any permanent in- jury. His service in the trenches was of rather long duration. An unusually brave soldier, he received two citations. His first symptom was a choking attack which, from his description, at first sounded like a globus hystericus. But these choking attacks were not always in the same location; at times they were rather high up in the esophagus, at other times in the epigastric region. Stammering was one of his chief symptoms. Prior to service he had a slight stammer, the origin of which he could not remember but thought that under conditions of stress he had been inclined to stammer ever since adolescence. Fol- lowing his hospital residence the stammering became so intense that he could hardly talk. Tremors of the hand were very pronounced, becoming especially more marked on intention. There was a tachycar- dia and an inclination to profuse sweating. Sexual power was much diminished. Extremely irritable, sensitive to loud noises, and very irascible, he flew into a temper at a slight provocation and suffered from insomnia associated with dreams of exploding shells, falling from high places, and so on.

As a result of these symptoms, the patient’s working efficiency was greatly diminished. His prewar occupation was that of a tailor, and since his release from service, he had been unable to hold a needle in his hand. Having recently been married, he was much concerned about his loss of efficiency. He had no prospects of being able to earn a livelihood and was, for this reason, under considerable stress most of the time. He began to show a diminishing interest in his environ- ment and occasionally had spells of mild confusion, so that he did not know where he was. His memory for recent events was poor. He often found himself unable to recognize people on the street, al- though they were his intimate friends. His face was constantly flushed, his pulse rate varying between 120 and 140. Basal metab- olism, determined several times, showed plus 1, plus 7, plus 9, and on one occasion, plus 21. His thyroid was not enlarged. Most of the symptoms, such as palpitation, sweating, tremors, vertigo, fatigabil- ity, and irritability, were constant. The intermittent symptoms were mildly confused states, smooth muscle crises in the form of pain, belching, choking sensations, and occasional vomiting. These smooth

24 THE TRAUMATIC NEUROSES OF WAR

muscle crises were apparently aggravated by fright or excitement of any kind.

The symptoms which caused him the greatest amount of distress were the spasmodic phenomena, the tremors, the stammering and the nightmares. Important to note is the absence of phobias. More- over, the patient’s ability to perceive anxiety was decidedly limited. He never complained of anxiousness or apprehensiveness, but he be- haved as though constantly under the influence of fear. He was uncommunicative, there being no urge to talk, inaccessible to sugges- tion, and unresponsive to psychotherapy. He was somewhat improved when given moderately large doses of atropine. An important feature in this case was the fact that the traumatic experience reactivated a former handicap, namely, his stammering.

Case 9. The patient was twenty-five years old. His symptoms were of eight years’ duration. Until two years prior to examination the patient was subject to frequent fainting spells. These fainting spells began shortly after a hospital residence, but diminished in frequency after discharge from service, and for the past few years had prac- tically disappeared. His symptoms were headache and vertigo, hot flushes, spots in front of the eyes, noises in his ears, violent anxiety dreams from which he would awaken frightened, irritability, and sensitivity to noises. More recently he had been subject to gastric crises in the form of pain, pyloric spasms, nausea, vomiting, inability to take food and occasional hemorrhages which proved on examina- tion to be due to retching. He was sometimes unable to retain food for days. His pulse was consistently rapid, varying from 120 to 150, accompanied by weakness, palpitations, and occasional flushing.

The patient did not notice most of these symptoms until he re- turned home. The only symptoms which troubled him prior to his return were his fainting spells. During service he was long exposed to trench warfare. On one occasion he was “blown up” by a shell and remained unconscious for some time. Under hospitalization, he began to have spells of unconsciousness. While in the hospital, he began to note his irritability; previously of a very friendly and sociable dis- position, he now became extremely cross to his superiors and refused

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 25

to put up with treatment. He deserted the hospital and returned to his regiment, which we very clearly identified with his home. He remembered having, when in line of duty again, none of the symp- toms he had had while in the hospital, but they all returned after the cessation of hostilities. This is another instance of how these symp- toms are of some economic service during a period of stress. Their continuation after this period into normal activities gives them the character of symptoms.

The spells of which he complained were not accompanied by anxiety and were not of long duration; though he lost consciousness completely, he did not bite his tongue or relax his sphincters. The dizziness of which he complained was not, apparently, connected with any external stimulus or situation.

When originally seen, he was well nourished, his face flushed, his eyes injected; his thyroid isthmus was considerably enlarged, but the other two lobes were palpable as well. His heart was normal in size; the pulse rate, 100 to 150. Blood pressure showed 100/70. He had a negative Stellwag and a negative Von Graefe. There were fine tremors of fingers, face, and tongue and profuse sweating of the hands and armpits. He had a marked dermographia and a slight exophthal- mus of the right eye.

On original examination it seemed possible that he might be a case of hyperthyroidism. During the period of observation, over a year and a half, the patient’s basal metabolism varied between minus 5 and plus 12. Therefore, this was evidently not a true Graves’ disease but a general disturbance of the autonomic system, beginning with his war experience. However, in view of his unilateral exophthalmus, periods in which his basal metabolism was considerably increased were not unlikely. The only medication to which the patient made any response was atropine. This had some effect in slowing the heart action and diminishing the sweating and the visceral crises.

He had no anxieties or phobias. His irritability was provoked easily by obstacles encountered in the performance of routine activities and in the presence of persistent noises. He had gradually become some- what seclusive because he could not stand the strain of social rela- tionships. The interesting features of this case were the persistence

26 THE TRAUMATIC NEUROSES OF WAR

of aggressiveness, irritability, and the typical nightmares and the dis- appearance of his fainting spells which were unaccompanied by auras with or without convulsions. The probability is that all the symptoms of which he now complained were present on the battlefield. He took no note of them there. They became particularly prominent after the severe vertigo and fainting spells subsided.

Between this type of autonomic disturbance and true Graves’ dis- ease lies every gradation. The true Graves’ disease differs only in that the basal metabolism is much increased. Moreover it is likely (Kessel and Hyman) that many cases of Graves’ disease have periods of nor- mal basal metabolism. Theoretically, these cases of autonomic dis- turbance are of great importance. They terminate either in true Graves’ disease or in association with epileptoid phenomena. But I have never seen a case which showed both increased metabolism and epileptic phenomena. These cases are material for fruitful research; apparently the rdle played by the thyroid and increased metabolism has much to do with the reason for the absence of epileptic manifesta- tions.” ,

Most authorities make no distinction between the autonomic and neurasthenic types. I think it expedient, however, to do so, inasmuch as each of these types represents a fixation on a different phase of the adaptive process to danger. That a group of neurasthenic symptoms is a pure fixation phenomenon is beyond question. The following case is an instance.

Case ro. The patient was thirty years old, a British subject, and had served in the Far Eastern campaign. Prior to service he was a healthy individual and had had no neurasthenic symptoms at any time in his life. During the campaign in the East he suffered untold hardships, chiefly in the form of starvation and sleeplessness. Lack of food and scarcity of men made it necessary for him to stay awake thirty-six to forty-eight consecutive hours over a period of eight months. During that time he had several illnesses which seem to have

*I regret that I could not further pursue this aspect of the problem. This case makes me strongly suspect that the increased thyroid activity is a process which is absent en-

tirely in the epileptic reaction types. Graves

” disease and the epileptic reaction type seem to stand at opposite poles.

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 27

been some form of colitis. Since then the patient had had persistent insomnia. He hardly obtained more than two hours sleep at night. He was also troubled with vertigo, exhaustion, constant debilitating feelings, anorexia, tremors, sweating, and frontal headaches.

The insomnia was apparently without content. No special thoughts kept him awake. He was very reluctant to talk about his experience in the East. Rarely did he have dreams; several which he brought were repetitions of something he had actually done during the day. Hypnotics had no effect.

In the acute stage exhaustive conditions were not infrequent. Gaupp (12) noted acute cardiac disturbances—low tension pulse rate, as low as forty per minute. Exhaustion and apathy were frequently encountered, but these improved after a few days’ rest. The neuras- thenic symptoms in the acute form were somewhat different from those of peacetime, according to Gaupp. The hypochondriacal fea- tures were much less emphasized during the war than after. This was probably due to the fact that the war situation placed a good deal more emphasis on the external dangers. Headaches, head pains of various kinds, vertigo, and exhaustion and inapplicability to work, poor memory, lack of interest in work, inability to concentrate, and a hopeless and apathetic attitude were some of the important symp- toms found with great frequency in these cases. It has, moreover, been noted that the autonomic and neurasthenic pictures alternate with each other, first the overstimulation, autonomic symptoms, then the exhaustion phenomena. Most of these cases became well after removal from the situation of war.

The temptation has ever been to explain all these symptoms on the basis of internal secretory disorders. We cannot, however, regard the neurasthenic picture in any way as a distinct type. The essential symptoms of neurasthenia are present in almost every traumatic neurosis. The subjective loss of interest in work, with its correspond- ing effect on the moods of the individual, his feeling of being sick and his lack of energy, the lowering of the threshold of stimulating factors, the sensitivity to noise are not specific. Neither is the emphasis on any special site, organ, or function specific. The hypochondriacal preoccupations usurp the clinical picture as more severe symptoms

28 THE TRAUMATIC NEUROSES OF WAR

become present. Thus, Case 10 is a typical neurasthenia with a marked hypochondria.

Case 11. The patient was aged twenty-nine. Sexually he was re- tarded, “not interested,” “only interested in electricity.” Shy with women, he had had no intercourse before service and only once or twice after service. He had never had a love affair. Before entrance into service the patient’s brother was killed in an accident in the sub- way. This affected him to a considerable extent. He liked the army life better than his previous civilian life. His health was always good prior to service; he was strong, swam well, and was generally a good athlete.

He reacted to service at the front fairly well. After repeated ex- posure to shell fire and loss of sleep he became fearful. He was in the artillery and used to go around without sleep for days. On one occasion he was unrelieved for twenty-five days and under heavy gun fire all the time. He was gassed mildly several times but was never blown up or buried by a shell.

He could not tell whether he had had any symptoms while at the front, but he had frightful dreams. After the armistice the following symptoms presented themselves abruptly: headache, anorexia, in- somnia, dizziness, faintness, irritability, crankiness—especially to noise or argumentation, choking sensations in the throat with difficulty in swallowing, profuse sweating, tremors, dyspnoea, rapid pulse, and palpitation. Personality changes were decreased sociability and obses- sion with his illness and his symptoms. When he came back, he fainted several times; he had horrible dreams which continued constantly for two or three years and after that occasionally up to the time he was seen by me. Otherwise his symptoms were no different from those he had before he returned from France. He was easily alarmed at any accidents which he happened to see and became dizzy at the slightest physical hurt.

The chief emphasis of this patient was on the exhaustion and the hypochondriasis, This emphasis is not found in the autonomic cases. The two types, however, have much in common and, as a rule, rep- resent two phases of the same condition.

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 29

SENSORY-MOTOR DISORDERS

In the acute stages sensory disturbances were extremely common, usually in association with motor phenomena. The sensory dis- turbances were frequent as accompaniments of wounds and injuries. In these latter cases the distribution of the sensory disturbance dif- fered very widely. In conjunction with localized wounds were fre- quently found a general hyperalgesia, involving at times the entire body surface. Eder (18) reports such a case in which the slightest pinprick produced spasms amounting almost to convulsions. Anesthe- sias and analgesias were extremely common, often being associated with trophic skin disorders. The hyperalgesias as a rule resolved themselves into hypalgesias. Of special note is the observation that sensory disturbances were usually unilateral, involving the left side in right-handed people and the right side in left-handed people. An- other very common complaint in the acute stages was pain, localized especially about the joints. These pains commonly accompanied monoplegia of the flaccid atonic form (Binswanger).

All the special senses were subject to serious disturbances of func- tion. Single and double amblyopia associated with photophobia and pain. Hysterical amaurosis was observed to arise suddenly in soldiers in whom the eye was a particularly aggressive weapon, such as sharp- shooters. Partial and total night blindness have been recorded. The commonest visual disturbance was the contraction of visual fields amounting at times to almost tubular vision. Binswanger also records central scotomata. These disturbances of vision were often associated with blapharospasm and strabismus. Among the disturbances of hear- ing were partial or complete deafness followed by pronounced hy- peracusis; these were often associated with sensory disturbances of the external ear. Disturbances of the sense of smell as well as the sense of taste were occasionally observed. Also occasionally were cases in which all five senses disappeared temporarily. In the chronic forms most of the sensory disturbances persisted as a diminution of function. In the skin hypesthesia and hypalgesia were the rule. The one note- worthy exception to this was the ear, where hyperacusis was per- sistently general. Of the disturbances of vision, contraction of the visual fields was the most common in chronic cases.

BO. THE TRAUMATIC NEUROSES OF WAR

The motor disturbances involved almost every possible function of the motor apparatus. In the acute stages perhaps the commonest of all were tremors, many of which arose from the condition of stress or shock and ran a comparatively short course. A large number, how- ever, survived their hospital residences and attained a prolonged chronicity. Even in these cases the tremors were intermittent. Accord- ing to Binswanger, these tremors were capable of imitating almost any organic condition; moreover they usually diminished on inten- tional effort. Most of them were very fine in excursion. The tremors of the hand sometimes attained a long chronicity. They were most often one-sided, involving the working hand. These tremors were a constant source of demand for vocational changes. Head tremors were a good deal more frequent during the war than afterwards. In the acute stages they showed themselves to be most refractory to treatment. The same is true of the chronic forms. In this type of tremor the patient usually had a weapon of great effectiveness in exacting from the environment any demand he chose. These tremors preserve in the chronic forms most of the characteristics they had in the acute stage. The hand may remain useful for gross operations; but for finer operations like shaving, buttoning a coat, or sewing, the hand is completely incapacitated. |

Hysterical disturbances of gait were very common. Helpless con- ditions which followed acute fright on the battlefield frequently gave rise to local weakness of the lower extremities with dragging and wobbling gait, sometimes to complete inability and incapacity for locomotion. These disturbances rarely occurred alone but usually appeared in conjunction with tremors and syncopal attacks. All va- rieties were found from mild hysterical paraparesis to the most severe forms, in which the patient could not get about without crutches. Astasia-abasia was extremely common. Flaccid and atonic paralyses in the form of spinal paraplegias were frequent but proved most accessible to treatment. Monoplegias with contractures were also ob- served. Monomuscular contractures, in the form of ptosis and con- tractures of the platysma, were noted, and torticollis was not infre- quent.

In the acute form speech disorders were extremely common. Most

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 31

of them, particularly the stammerers, were inclined to chronicity. The aphonias and mutisms in the acute stage usually resolved under treatment. Disorders of speech were most commonly associated with deafness; Eder (78) says four out of ten. In the acute form mutism was very frequent. These patients could, as a rule, write an accurate account of their experiences. In this state patients cannot cough, whistle, or make any sound when laughing and even have difficulty in putting out the tongue. These patients can speak under anesthesia or in sleep. Mutism may follow minor injury in some distant part like a leg. Stammering usually followed mutism in the acute stages.

Case 12. In February, 1918, the patient was on a transatlantic transport during some very rough weather. In the hold of the ship, where the patient was on duty, were a great many unattached trunks and boxes. Working in the hold was, therefore, a matter of con- tinually dodging these objects as the ship pitched and rolled. The patient evidently missed dodging one of the huge boxes and was struck and squeezed between a big trunk and a bulkhead. He imme- diately lost consciousness, and when he regained his senses, he found himself in bed. Sensation and motion were entirely gone on the left side of the body. He had remained in this same condition to the date of examination, about seven and a half years after the traumatic event.

When first seen, the patient had a spastic hemiparesis of the left side, with contractures, and a typical glove anesthesia over this entire side of the body, including the head. Reflexes were all present, how- ever; Babinski was negative, and pupils were normal. The entire side was subject to a trophic disturbance. Some atrophy was present from disuse, beside the beginning of contractures which yielded readily to passive movements. The patient was then able to use every muscle in the upper extremity but did not have any of the kinesthetic sen- sations which go with muscular activity. Through loss of deep muscle sense, he could not determine weight and shape. Heavy weights in the left hand would exert a pull at the shoulder, where he could appreciate it. He could consciously direct movements of his upper extremity.

32 THE TRAUMATIC NEUROSES OF WAR

These sensory disturbances remained unchanged. They extended up to the shoulder and consisted of loss of pain and touch, but he appreciated pain as pressure. He could not recognize objects by feel- ing them. When he attempted action with the right hand, the left was inactive; but when he tried to do anything with the left, his right hand usually executed the movements the left could not.

The patient was treated by suggestive methods; hypnosis was impossible. He refused absolutely to be hypnotized and had a re- sistance to anything that would remind him of a loss of consciousness. He refused to be anesthetized or to be given a few drops of chloro- form in order to produce an artificial hypnosis. He was given sympto- matic treatment for his contractures, and after several months of physiotherapy he made considerable improvement. He had no return of muscle sensation, however, or of sensibility, although, by dint of sheer conscious effort, he was able to manipulate his upper and lower extremities. This he did only on invitation, but what he could do left the limb still useless.

Interesting to note is that the patient had none of the usual symp- toms of traumatic neurosis. He had no disturbing dreams, no irritabil- ity, no sensitivness to sudden stimuli, no secondary character changes. His affect toward his disability was adequate, and he frequently lapsed into depression because he made no progress with his cure.

One day the patient returned to the Clinic and stated that he was perfectly well. Showing how he could use his upper and lower ex- tremities with agility, he said that this had happened to him as a result of having touched a relic. However, a month later his condi- tion was as bad as it formerly had been.

Case 13. The patient, aged thirty-two, prior to service had stam- mered slightly. The stammer became worse after one severe trauma in the army. The patient was advancing with his company when a shell burst about ten feet to the left of him. He was thrown down, but not buried; became dazed, but not completely unconscious. When he recovered consciousness, he found himself trembling violently, and upon attempting to utter some words, he failed completely. The patient’s older brother stated that, when the patient was five or six

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 33

years of age, he developed a stammer, either in imitation or through the influence of a stammering playmate who lived in the same house. Before service, however, the patient stammered only moderately. The symptom had become much more severe since that time.

He had been noted to talk frequently in his sleep; he used foul language fluently; he sang very well. Recently, while under the influence of ether for an operation on his left lower extremity, it was observed that he spoke with great fluency and swore at the surgeon.

In this case one must note a very common phenomenon. The traumatic neurosis will revive a symptom that has long since been dormant or aggravate one that already exists. Though it was impos- sible in this case to investigate the origin of his original symptom, it was probably not different from any case of stammering encountered in civilian practice.

An important feature in this case is the absence of neurasthenic, autonomic, epileptic, or displacement phenomena. The patient never had any disturbing dreams and did not react violently to external stimuli. Neither had he developed any of the secondary character traits so common in traumatic neurosis.

Case 1 4. When originally seen, he complained of a strange symp- tom from both lower extremities up to the umbilicus. The patient was subject to feelings of numbness, pain, coldness, but more espe- cially to sweating from the waistline down to the toes. This sweating, he said, was continuous, especially at night. When asked how old this symptom was, he said at least seven years. Among his other com- plaints were such marked irritability and instability of temper that he became aggressive and pugnacious very suddenly and without sufficient cause. He also suffered from spells of transient blindness, which lasted anywhere from five to fifteen minutes. Attacks of vertigo was a significant symptom. His sleep was disturbed continually by the usual dreams of drowning, being run over, receiving electric shocks. In some of his dreams he was the aggressor.

When inquiries concerning his traumatic history were made, he denied ever having suffered a serious shock. He casually stated that he was on board the U.S.S. “President Lincoln” when she was tor-

34 THE TRAUMATIC NEUROSES OF WAR

pedoed. He was then asked to narrate in detail the facts of this acci- dent, which were in substance: He was gambling in the kitchen with several of the mess attendants when he heard a shot. This he inter- preted as due to target practice and continued his game. Several minutes later another shot occurred and then another, the last one a distinct explosion. At this, all the men ran upstairs. The command was given to take to the lifeboats. He then realized that the ship had been torpedoed. It so happened that some of the lifeboats were dis- abled and thus not enough to go around. At all events, the patient and about eight other Negroes were obliged to take to the raft. He described the sinking of the ship and his lack of trepidation at the sight and his absence from panicky sensations. He said this was due to the fact that the retreat to the lifeboats and rafts was very orderly and that the ship did not sink until some hours later. At this point the patient became rather excited and began to swear profusely. His anger was roused, chiefly, by the incidents connected with the rescue. They were in the water for a period of about twelve hours when a torpedo-boat destroyer picked them up. Of course priority was given to the officers in the lifeboats. The eight or nine men clinging to the raft were allowed to remain in the water and had to wait for six or seven hours longer until help came. In describing his feelings while in the water, the patient emphatically denied having had any panic or fear. However, it was quite clear to the writer that, while narrat- ing these incidents, he was very much disturbed. The disturbance he acknowledged. He said that telling the story made him fearful. I made him revive many details of the story which had a harrowing effect on him. |

The similarities between the symptoms of which he complained, in the form of sensations and sweating from the waistline down, and his story of being submerged in cold water from this point of the body to his lower extremities, were pointed out to him. He admitted that, when he allowed himself to close his eyes and think of his pres- ent sensations, he still imagined himself clinging to the raft, half submerged 1 in the sea, Thereupon the patient stated that while ebinig- ing to the raft, his sensations were extremely painful ones and that he thought of nothing else during the time. He also recalled the

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 35

fact that several of the men had lost consciousness thus and were drowned. To a large extent, the patient obviously owed his life to his concentration on these painful sensations occasioned by the cold water. I'he symptom represented, hence, an hallucinatory reproduc- tion of the original sensations of being submerged in the water.

Concerning his remaining symptoms, it is of interest to note that he developed many of the secondary symptoms of traumatic cases which are epileptoid in character. The spells of transient blindness used to come on specific occasions—when he saw something in the nature of violence. Thus the patient was once walking on the road, and at the approach to a railroad crossing he witnessed an automobile colliding with a train. He became maddened with excitement, was blinded for ten minutes and was taken home in a state of extreme agitation. He alleged that it took him four months to recover from the effects of this incident, although the danger did not directly con- cern him. During these four months he was obsessed by the vision of the accident. He had, in fact, a profound reaction to violence of any kind and could not witness others being injured, hurt, or threat- ened. Prior to his service he never had fears or phobias. An employee of a railroad company prior to the war, he had seen a very serious railroad wreck without injurious consequence to his state of mind. In fact, he himself had assisted in extricating people from the wreck. He was also extremely sensitive to loud noises. This is remarkable because the patient heard very little shellfire during his naval career, yet he shared with patients who had come from the zone of active fighting this secondary reaction. He would yell and scream on a sud- den call or other abrupt noise and was subsequently troubled by the violence of his reactions to these stimuli. He claimed that he felt like suddenly striking people and that he had become very pugnacious toward his family. He remarked, “I wish I were dead; I make every- body around me suffer.”

The dream life of this patient consisted of the usual disturbing dreams, but recently his memory for them had been poor. However, he would start from his sleep several times during the night.

Of great interest is the fact that the patient had no sensory dis- turbance whatsoever in the lower extremities; however, he protected

36 THE TRAUMATIC NEUROSES OF WAR

them most tenderly with all kinds of ointments and with warm stock- ings in all temperatures. His reactions to water were quite typical. He did not like sea-bathing, and after his return from service, when- ever he had attempted to go into the water, he had always become nauseated and vomited. Now he was avoiding sea-bathing.

The conditions in the sensory motor group which tend toward chronicity are the spastic paralyses which usually develop contrac- tures, the course and fine tremors, the sensory hypochondriacal fixa- tions, the stammering, and the functional exaggeration of somatic injuries, especially in the region of wounds. Enuresis persisted in only a few cases. The vasomotor secretory disturbances in the form of sweating often attain a chronicity in most annoying forms. Thus one patient had a unilateral sweating, involving first the entire right side of the body, then only the region from the waistline down. This was unaccompanied by the usual dream life and irritability.

Tue Epiteptic SyMPTOM COMPLEX

In the acute stages a great many of the war neuroses were noted to have paroxysmal, recurrent symptomatology. The commonest forms were mild syncopal attacks, sometimes breaking out abruptly, but more often after a brief period of prodromal symptoms, such as nausea, weakness, and “blackness before the eyes.” The preéminent symptom was an unconscious state with flaccid limbs, closed eyes, and complete loss of consciousness. During the attack the face was pale, respiration superficial, and pulse slow. Patients were impervious to external stimuli and insensitive to pain; at times the eyelids fluttered. The eyeballs were mobile and on forcible opening were usually rolled outward and upward. These spells, lasting anywhere from minutes to hours, would overtake the patient in the midst of activities and most frequently after exertion or effort. The spells corresponded in every way to the hysterical syncope noted in peacetime. However, during the war they were exceedingly frequent, and their content, as judged by the dream life and the secondary reactions, had really no resemblance to the hysterical attacks of peacetime. This condition was very frequent during active warfare, particularly during forced marches and active campaigns, but was not altogether unknown be-

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 37

hind the lines. Soldiers who were once subject to these attacks and were then sent back to the lines most often had recurrences of the attacks when reassuming their former line duties. A most interesting feature of these conditions is, according to Binswanger, their occur- rence in the form of epidemics in hospitals. In other words, they were very easily imitated. Once this reaction was initiated, such patients would resort to it in the face of any frustration. The attacks never occurred at the beginning of a furlough, but very frequently at the end. This type of soldier was absolutely lost as regards his capacity for further service.

Besides this form was a group of hysterical lethargic states in which the paroxysmal changes in consciousness took the form of a profound, stuporous sleep. These patients would gradually stop their activities and fall to the floor in a deep, narcoleptic sleep. This could be differ- entiated easily from natural sleep by the response to external stimuli.

The more common twilight states occurred in their simplest form as abrupt changes from the state of sleep to a somnambulistic trance. They were, to all intents, fully enacted dreams. The patients would live through their war scenes very vividly while in these trances. Every detail of warfare was reéxperienced, accompanied by the ap- propriate mimicry and at times intermingled with reminiscences of their former lives.

Another form of twilight state occurred abruptly during the wak- ing state, usually in a form similar to that of the nocturnal twilight states and with active hallucinatory experiences and mimicry. On these latter occasions the relationship with the external world was completely severed. Sensory stimuli on the skin and verbal sugges- tion had no effect. The attack gradually wore itself out. In a few cases, some contact with the external environment appeared to exist, except that the patients mistook situations and called individuals by wrong names. The sick chamber was often represented in hallucina- tions by a burning castle or a chateau surrounded by soldiers. Many of these hysterical deliriums were, to a certain extent, amenable to influence. The amnesia for these episodes was, as a rule, complete, though they could sometimes be recalled as dreams. These patients were amnestic for their war experiences, sometimes for only individ-

38 THE TRAUMATIC NEUROSES OF WAR

ual episodes, sometimes for an entire war period, and occasionally even for long periods prior to entrance into service. [his amnesia was usually persistent. During these episodes cataleptic states in- volving the entire body or parts of it were encountered. These cata- leptic states were sometimes of a complete rigidity and sometimes of a waxy flexibility.

Finally, there was a group of true convulsive states with very deep disturbances of consciousness, following immediately on an acute shock or an exciting experience. In many of these attacks, instead of a convulsion, wild gesticulations of the limbs, spasmodic stamping of the feet, and crying were its substitutes. Also, a partial tetany of all the limbs was noted.

The immediate reactions to shock or fright deserve our attention, particularly because of the sequelae we see in the chronic cases. In the first place is the reaction to fright or shock, known in peacetime, but not called pathological, since it leads to no permanent fixation. This consists of pallor, trembling, stiffening of the body; inability to speak or move the limbs; disturbance of cardiac rhythm, of the pulse, and of blood pressure; gastric and intestinal disorders; vomiting and diarrhea; changes in the respiratory activities, in the sweat glands, urinary bladder, and gastric juices; diminution in blood supply to the various organs; and dimming of consciousness even to exhaus- tion and inability to think sequentially. In these phenomena we are still within the limits of normal biological reactions to shocking ex- ternal stimuli of body and mind. Such reactions are, as a rule, tem- porary, or else they give rise to death through paralysis of the vagus. This latter result, however, is very rare.

In the pathological cases and in those having a tendency to fixate upon the trauma, the effects are much deeper and much more lasting. For the frequence of these conditions during the war, the persistent trench warfare with its dull expectancy and its weapons of unprece- dented power is undoubtedly to blame. When the reaction to shock and fright persisted instead of disappearing, as is normal when a condition of safety is attained, these conditions acquired a certain amount of psychological elaboration after the patient was out of danger. In most of the chronic cases observed, the symptoms first

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 39

took shape in the hospitals rather than on the battlefields. Some authors, I feel, have emphasized too much the acquisition of these symptoms in hospitals as a result of suggestion, that is, from seeing other patients in the same condition. This cannot be so, for we ob- serve in almost every persistent case of this type that the disease is kept alive eight years or more after the traumatic event, by a very distinct dynamic group of forces which no suggestive power can simu- late. Furthermore, we find in the symptoms themselves, parts of the original traumatic experience attached to or a part of the symptom itself. The fact that symptoms of a traumatic neurosis make their appearance some time after the traumatic experience can be verified in every case. On this account the reference to the contagiousness of the disease in hospital wards is somewhat exaggerated.

In the acute stages many of these shock cases were accompanied by unilateral motor symptoms, either paralyses or sensory or secre- tory disturbances, such as hemiplegias, hemitremors, hemianesthesias, or deafness on one side. This was also the case with the vasomotor and secretory disturbances. In fact, the more closely a symptom ad- hered to the autonomic classification, the more likely it was to be unilateral. Differences in the size of pupils, unilateral sweating, der- mographia, unilateral grayness of the hair, and so on, were of fre- quent occurrence.

Many of the acute reactions to shock terminated in what may be termed “shock psychosis.” Upon being picked up immediately after the shock and placed in hospitals, many of these soldiers had initial anxious deliriums, during which everything in the environment was regarded as hostile and anybody who approached excited violent fear reactions. Wild motor activity with mutism, depression, and dis- turbances of sleep sometimes followed.

Perhaps the most common form of this psychosis was the acute, passive, negativistic stupor with mutism, complete immobility, total anesthesia with inability to take food, incontinence, total unconscious- ness at first and later cloudy states, and inability to stand or to walk. Gradually these patients had to relearn sphincter control and enuncia- tion of words—at first saying only “yes” and “no” and then answer- ing to their names. Very gradually they were taught how to grasp

40 THE TRAUMATIC NEUROSES OF WAR

objects and how to feed themselves. Familiarity with the environment was also regained slowly; some time elapsed before the patient began to take an interest in his destiny. Of interest is the fact that most of these patients were able to recall the traumatic event; they remem- bered some details of their behavior such as making certain efforts to save themselves just before consciousness disappeared. Gaupp quoted a case without recollection of the traumatic circumstances beyond the optical and acoustic accompaniments of the exploding shell which caused him to lose consciousness. This latter observation is important because the psychic experience—the feelings and ideas excited by the explosion—called forth the powerful action of the entire organism, that is, unconsciousness and other symptoms of fright, as a defense against it. Gaupp believes that, between the moment of the explosion and the following psychic disturbance, an interval exists during which the perception of the effects of the explosion, the sight of mutilated comrades, the excitation of fright, aggravate the reaction to the trauma (12).

Often these cases of fright stupor were not always passive and without feeling. Very frequently the patients in their stupor shouted: “The enemy is coming!”; “They are coming!”; “Get ’em!”; “Fight 2em!”

In addition to these stuporous states and hypochondriacal anxieties are a great many delirious states, dimmings of consciousness, dream- like periods, complete disorientations of time and place. A queer form of behavior resulting from acute shock conditions was one in which the delirium took on a strange infantile character, in which the individual spoke ungrammatically, played with toys, clung to his sister’s coat tails, mistook things in his environment as a child does. This type of behavior often gave the impression of simulation. These patients would answer: “Two times two are five;” “The sky is red;” “Grass is blue;” The examining doctor was his mother, Fantastic confabula- tions were also in this type of case. Some authorities see in this a pseudomanic picture. In some cases the deliriums were like manic excitements, and the patients had to be confined in padded cells or strait jackets for long periods,

Most of these acute cases recovered. A large number, however,

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 41

remained chronic in forms such as we have described under the autonomic disturbances. The more severe forms will be described below.

The term “epileptic symptom complex” is designated to describe a syndrome of frequent occurrence in the chronic forms of traumatic neurosis. [his particular wording was first used by Stekel in connec- tion with cases which clinically presented symptoms of essential epilepsy. I do not intend to convey, by the use of this term, that these — cases are true epilepsies. They correspond more to what has hitherto been described in literature as “affect epilepsy,” “reflex epilepsy,” or periodic recurrent disturbances of consciousness. I believe that this symptom complex is very closely related to what occurs in other cases as pure forms of severe vertigo. The epileptic symptom complex may be found in cases which show, clinically, no resemblance whatever to epilepsy and in others which can hardly be differentiated from them. All these fluctuations and variations of symptoms seem to be differ- ences in quantitative reaction rather than differences in kind.

A most frequent complaint among veterans six or seven years after return from war is the continuance of periodic disturbances of con- sciousness. This takes either the form of severe headaches and intense vertigo, sometimes so severe as to lapse into unconsciousness; twilight states, periods of dazedness, confusion; various somatic and peripheral paresthesias; or else complete loss of consciousness, with or without convulsions. In not a few cases one finds these twilight states ac- companied by special modes of behavior before, during, or after the disturbance of consciousness. Thus patients will describe attacks that come on specific external provocation. Others occur with specific forms of aura; others, not initiated by auras of any kind, show instead of the typical convulsions, outbursts of violence, in which the patients break and tear objects around them or assault people. The convulsive states may or may not have biting of the tongue and relaxation of the sphincters. In addition to this central complaint, one often finds insomnia associated with the typical dreams of the traumatic neurotic, a symptom which continues unchanged despite the many years of removal from the seat of danger. A series of secondary defense re- actions in the form of irritability to auditory stimuli or other specific

42 THE TRAUMATIC NEUROSES OF WAR

sensory irritability also exists as an evidence of a severe sadomasochis- tic conflict manifesting itself in extreme variations of temper, from undue tenderness to outbursts of cruelty and violence. In these latter cases is a variable amount of displacement, usually in proportion to the amount of anxiety. As a rule, these anxieties are devoid of content. That is, the patient does not fear a state of being or a situation; he is more prone to fixate his complaints on somatic or physiological ac- companiments of fear. The variations in quality seem to depend chiefly on the degree of disorganization and are in part determined by the reaction to the orginal traumatic event. The whole epileptic symptom complex appears to be in the nature of a repetition phenom- enon. The following case shows the mildest form in which the epileptic symptom complex may exist.

Case 15. The patient was thirty-two years old. He seemed always to have been a normal individual prior to service, well adapted in his sex life and social activities, and had apparently a normal attitude toward work. He was examined in a routine manner and did not regard his complaints as meriting the attention of a physician. He complained of periodic attacks of faintness, a dazed, numb sensation “as if all the blood in his body had stopped circulating.” He also had a sensation of numbness, tightness and tingling about the mouth, a feeling of weakness, and a sinking sensation in the epigastrium. He never lost consciousness but felt dazed for a few minutes. After this was over, he was usually overtaken with intense panic; sometimes this panic came upon him without his feeling dazed, especially when he rode in the subway and the train happened to stop midway between stations. He had great difficulty in falling asleep and was usually aroused in a panicky condition just as he was about to fall asleep. This might occur as often as six or seven times a night. Frequently he was awakened from sleep by typical war dreams or other dreams of disasters about to overtake him. He was sensitive to noise and inclined to be alternately cruel and intolerant and extremely tender. These fluctuations of temper were unknown to him prior to service. The only trauma he suffered was that of being mildly overcome by gas. The sensations of panic and the tingling sensations about the mouth and

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 43

epigastrium he readily identified as the sensations he had had on the battlefield immediately before he lost consciousness from gassing. He thought, moreover, that his present episodic attacks were much more severe than the ones he originally had while on the battlefield.

This was a mild case persisting eight years after service in a person who had been fairly well adapted and who was so at the time of examination. If he had not been ordered, in a routine manner, to be examined, he would never have applied for medical help. I regard this type as being fundamentally of the same nature as the most severe cases, those which cannot be differentiated from essential epilepsy.

This series of cases shows certain characteristics by which we can judge the severity of the case, the depth of internal disorganizations, and the prognosis. Many of the cases manifest the same constant picture; the spells of unconsciousness are provoked chiefly by external factors which prove under close examination to be exactly the same factors causing the original loss of consciousness on the battlefield. In short, we have here a typical “conditioned reflex.” It differs, however, in one important respect: conditioned reflexes are learned. Moreover the affective accompaniments of this reaction are different from those associated with conditioned reflexes. In another group of cases, the provocation is endogenous or endopsychic, and its connection with the original trauma is indicated only by a hallucinatory reproduction of some circumstances originally associated with the trauma. This has, in every way, the structure and the function of an aura.

A second distinguishing feature is the variable amount of anxiety which is perceived as such, displaced or utilized in connection with the attack. We find that this anxiety is really the nuclear phenomenon of the entire syndrome and that the more readily the anxiety is uttlized in the form of displacement or incorporated into the attack in some way, the less does the disease take on the characteristics of essential epilepsy. In other words, when the anxiety is displaced, the condition has less resemblance to epilepsy; when the anxiety 1s lack- ing, completely repressed and in its place a group of defense mecha- nisms in the form of rigid tension states, the function of which seems to be to prevent the anxiety from becoming conscious in any form, the

44 THE TRAUMATIC NEUROSES OF WAR

resemblance to epilepsy is greater. The factors releasing the individ- ual attacks may be of either external or psychic origin. Among the former the commonest is unanticipated noise and undue physical effort. The intrapsychic factors cannot be identified except by the traces left in the form of an aura.

Concerning the seizures released by external factors, we find that this sensitivity to release by noise or effort is merely an exaggera- tion of the characteristic found in all traumatic cases, namely, the generalized irritability and intolerance of effort. Instances of this type are too common to note, but perhaps the following will indicate how severe the reaction can be. A patient of about thirty years of age came for a routine examination and warned me, before I began, to be sure that I made no sudden noises; that, if he were to hear a sudden noise, he would not be responsible for his actions. He then proceeded to tell me that on several occasions as he was walking on the street, a passing automobile gave rise either to some backfire or a “blowout.” The patient stated that he immediately lost consciousness, but during this state of unconsciousness he attacked the nearest passer-by and began to strangle him. On another such occasion he assaulted a traffic police- man and the latter, in order to protect himself, had to club the patient and bring him to the police station. He was released when his condi- tion was investigated.

Whereas many of these cases at first react violently to noise, the older the neurosis grows, the less likely are they to respond violently to this stimulus. As a rule, the older it becomes, the more likely must

the stimulus be something very specific, something directly associated with the traumatic experience.

Case 16. The following case is an interesting example of the repeti- tive mechanism provoked by external stimulus.

The patient was twenty-seven years old when first seen, his neurosis, six years in duration. He gave no history of neurotic traits in childhood. The disability from an attack of rheumatism while he was in training in this country was not serious enough to prevent his continuing military duties. While on duty he was with a detachment which took possession of a shack one night and was obliged to spend

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 45

the night there. He woke up in the morning and found that the entire company had been gassed while sleeping, several very severely. He himself escaped with a mild gassing. After hospitalization for six weeks he returned to his battalion. By that time hostilities had ceased, and in several months he came back to the United States. On a few occasions during this interval—the cessation of hostilities and the embarking for this country—the patient remembered getting the spells from which he now suffered.

The spells were described by him as follows: On certain occasions he would become violently flushed, his heart would beat rapidly, he would become dizzy, would vomit, and then lose consciousness. His loss of consciousness usually lasted from one half to one hour. He noticed that these attacks always followed exposure to certain odors, from volatile oils; thus an attack could be set off by perfume, lemon oil, banana oil, ether, chloroform, and so on. He also remarked that certain odors, such as musk, were offensive to him. Volunteering all this information, he came to the conclusion in the following way. At first, he said, the spells overtook him without any particular provoca- tion. He was employed in a butcher shop frequented by fashionable women. Many of them came heavily perfumed. When they would enter the butcher shop to place an order, the patient would become dizzy and begin to vomit. Often being able to inhibit the symptoms at some stage, he would not always go through the entire spell to unconsciousness. However, his reactions interfered with his occupa- tion so much that he asked for help.

He was then asked to recall his symptoms on that morning when he awoke in the shack and discovered that he had been gassed. He re- called a similarity to those which he now had on the stimulus of perfume; in fact, he remembered that what weakened him was the nausea, the vomiting, and the giddy feeling. In short, the flushing, the rapid pulse, the dizziness, and the vomiting were a repetition of the original traumatic event which overtook him in his sleep. The stimu- lus was always exogenous.

In addition to these symptoms, the patient had the usual secondary defense mechanisms of the traumatic neurosis in the forms of irri- tability, restlessness, ill humor, aggressiveness, and so forth. Five

46 THE TRAUMATIC NEUROSES OF WAR

years after the war had ceased, his dreams were also the typical dreams of the war neurotic. Their content took the usual form—being killed either by means of weapons, drowning, falling off buildings, and so on. Naturally his sleep was very much disturbed. His physical examination was negative, and no symptoms of a constant disturbance of the autonomic system were found.

That the patient was asleep when gassed is an important feature. It emphasizes the unawareness of the stimulus; and the awakening to find himself unprotected had much to do with the original traumatic impression.

The following case is of special interest because it illustrates the remarkable specificity with which the repetition mechanism manifests

itself and the photographic manner in which it reproduces the original trauma.

Case 17. The patient was twenty-seven years old, a Negro of limited intelligence. He was accustomed to unskilled labor prior to service. Very little of his past history could be ascertained beyond the usual diseases of childhood. As is usual in his race, there existed neither a history of neurotic traits nor any history of venereal disease.

The patient made only one complaint, “spells.” He described them as follows. They began with a feeling of itching in his face; this would last several minutes. “It feels like pins and needles. I get ‘blown,’ and then I become unconscious. Whenever I come out of the spell, my face is always swollen and scratched. The funny thing is that I only get these spell when it rains. I never get a spell when I am in the house; always when I am out-of-doors. I am terribly afraid of the rain. | am not afraid to take a bath, and I am not afraid of water, but I am afraid of the rain.” The patient stated that in former years he used to get his spells whenever he was frightened or whenever he would hear loud noises; but of recent years he had them only in the rain; in fact, they occurred only when he became drenched or when his feet got wet. The aura described as itching of the face was present on every occasion when he lost consciousness.

From the history of these spells, this was obviously a repetition phenomenon. He was, accordingly, asked to describe the loss of

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 47

consciousness which he originally had on the battlefield. The patient had at that time a partial amnesia for the events of the morning of September 26, 1918, when the traumatic event took place. It was a very stormy day, and he was in a company charging a position along a river. He remembered rushing forward in the violent rain and being drenched through to the skin. He also remembered the sensa- tion of the rain beating down on his face. He recalled having passed through two towns and also having received a head wound which, however, did not cause him to lose consciousness or to retreat. He continued, notwithstanding his wound. Although it had penetrated his helmet, the wound was evidently very superficial. At the time he was Wearing a gas mask which was leaking. The point at which his memory grew dim was the race down a steep incline and his falling to the ground.

Aside from the small scalp wound, the patient received no other in- jury. He woke up in a hospital several days later. It is reasonable to suppose, therefore, that, due to the violent storm and the patient’s falling to the ground in an unconscious state, he must have been ex- posed to the rain for a long time and to the sensation of water’s beat- ing upon his face and perhaps to fragments of dirt and sand. More- over, his face was also burned by the mustard gas.

The neurotic reproduction was, therefore, photographic. The itch- ing of the face was undoubtedly a reproduction of the sensation of the splashing of mud upon his raw skin and the burning of the mustard gas. The scratching executed in his trance was again the effort to remove the offending stimulus.

The patient likewise emphasized the change in his character from normal behavior reactions to violent tantrums, a tendency to aggres- siveness and irritability, and the feeling of great commiseration when anybody was exposed to danger. When he saw a child either injured or “almost injured,” he became completely unnerved and had to go somewhere for a drink to brace himself. During the time of observa- tion, the patient happened to be out one Sunday when it began to rain. He had a tendency to forget that his spells would come when it rained, Interesting to note is that he did not always protect himself against the rain. On this occasion his feet became wet, and a spell

48 THE TRAUMATIC NEUROSES OF WAR

ensued, thus accurately repeating the phenomena as above described. The patient was sometimes able either to control the spell or inhibit it. He suffered from feelings of anxiety, panic, and helpessness just prior to the spell, but in the intervals he had no such symptoms. I never observed the patient in one of his spells nor the special char- acter of them.

A- remarkable feature of this case was the nonprojection of his phobia. In his neurosis, so different from the ordinary transference neurosis which erects many defensive barriers before the dreaded situation, this patient really did not “know enough to get in out of the rain.” He did not feel compelled to carry umbrellas, rubber shoes, or raincoat. Moreover, one must remark the inadequacy of anxiety as a protection altogether, since it preceded every attack but had no influence in arresting it.

Case 18. The patient, of meager education, was twenty-six years old. The only thing noteworthy in his past history was his not being a neurotic individual. He was sociable, a steady worker, and always healthy. He married young, was much attached to his wife, and had two children of whom he seemed to have been very fond. His previ- ous sexual development appeared to have no bearing on his present difficulties. He was a volunteer in the army and served two complete enlistments with good records. During the war he participated in the Saint-Mihiel drive. There he was gassed and sustained a slight shrapnel wound which was taken care of at a dressing station.

The symptoms of which he now complained had persisted unabated for seven years after his original injury, despite repeated attempts at treatment. The symptoms were as follows: He was subject to dizzy spells, periods of confusion, occasional fainting spells, and shortness of breath. The patient’s greatest complaint was, however, the loss of his former evenness of temper and gentle disposition. He stated that he would lose control of his temper easily, pick quarrels on the slightest provocation, was threatening and abusive upon small cause, got into arguments, was very irritable, and reacted violently to any environmental physical pain or stimulus which annoyed him. His symptoms had interfered with his efficiency and comfort to a marked

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 49

extent. He had also had dreams frequently. Their content was: a) that dead people were speaking to him; b) that he was either attack- ing or being attacked; c) that he was falling; d) that he was drown- ing; e) that he was being run over by trains; f) that he was being bitten by snakes, and so on.

The patient stated that during the past seven years certain changes had taken place in his symptoms. Whereas he was formerly subject to frequent fainting spells, these were now almost entirely displaced by attacks of vertigo. Formerly the attacks of vertigo always preceded the spells of unconsciousness. In other words, the dizziness of which he now complained had been, heretofore, the aura of his fainting spells. It now became his chief symptom. The patient spontaneously realized that these spells of vertigo were frequently precipitated, though not always, by certain stimuli in the environment. Again, they bore a very striking resemblance to the occasion on which he orig- inally lost consciousness in battle, namely, volatile odors; ether, chloroform, and gasoline used to provoke either dizziness or faintness. Thus the patient had to give up positions in which he was exposed to irritating odors. He took work as a starter for a taxicab company but gave it up because of his standing near a group of automobiles which continually exuded gasoline odors. Loud noises did not seem to provoke his attacks; but continuous stimuli of any kind, sometimes in the shape of persistent noises, made him irritable and aggressive.

It was quite natural, in this case, to find that the patient had been gassed on the battlefield in the following way. He was in a gas bar- rage, and his mask evidently had a leak. He remembered feeling, at first, rapid pulse and then dizziness; then everything became dark, and unconsciousness ensued. He awoke in the hospital after an un- conscionable time. An important fact in this case was that the patient did not stress the attacks of vertigo and fainting as the main symptoms. What most distressed him was his irritability and his aggressive tendencies. He stated: “I now have a very bad temper, and I will tell you what I am accustomed to doing. Once while working, the foreman said something to me; I got into an argument with him and picked up a crowbar and went after him. I dropped the bar, but I used my fists, so that I knocked him unconscious; and I ran away and never

50 THE TRAUMATIC NEUROSES OF WAR

came back.” The patient, deploring his state of mind profoundly, said

that he feared he might kill somebody in one of these fits of anger when he really did not desire it.

The repetition mechanism was easily understood by the patient, although after several months’ treatment the spells of dizziness still occurred. However, the dreams which used to disturb his sleep ceased almost entirely. No changes were effected in his temper. He was still irascible and violent. He was able to work steadily for some time, however. He had no anxieties, no conscious representations of fear, and practically no transference symptoms.

The case also illustrates an important fact, that the unconsciousness may be replaced by one of its prodromal symptoms, the aura. In other words the spell is inhibited at the aura. This is seen only in chronic cases and usually goes with improvement in the patient’s condition.

The second point of orientation in this group of cases is the presence of and disposition to anxiety. The anxiety problem, from a clinical point of view, has an important bearing on the prognosis and therapy of the case. The manifestations of anxiety vary widely. Very few of

‘these cases complain of phobias, and even when they do, the phobia

never has the organization or the elaborate ramifications it has in the transference neuroses. As a rule, the patients are subject to vague unmotivated anxieties, and one usually hears great emphasis placed on the somatic accompaniments. It appears erroneous to call this state one of anxiety; it is much more a state of defense and expectancy, in which much of the emphasis goes to create adequate defense against its emergence. Neurotic phobias, such as those encountered in trans- ference neuroses, are absent. I can recall only about three cases of a very large number who feared epilepsy, insanity, or heart disease. Of these phobias, claustrophobia was the most common; but, as a rule, the claustrophobia was more in the nature of a conditioned response then a displacement symbol. I have noted earlier in the chapter a case in which the patient had a phobia that New York would be visited by an earthquake. ‘[’his was not so much a symbol of his traumatic experi- ence as his direct fear of a recurrence: he was buried in a trench. This particular type of anxiety in a displaceable form is rare among patients showing the epileptic symptom complex.

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES | 51

A not infrequent form which the anxiety takes is the fear of the unconscious spell itself, a fear similar to those encountered among the “A ktualneurosen” of peacetime. The only connotation of the fear is a dread of impending death. Occasionally some of these patients dis- place their anxiety in the form of a fear of high places. Many of them have anxieties after their seizures. The anxieties, on these occasions, most frequently concern the seizure itself, a dreaded recurrence, and include the fear of leaving the house lest an attack overtake them in an unprotected place.

A convenient place to look for the evidence of anxiety, in these cases, is in their dream life. All of them, excepting only those in whom the clinical pictures cannot be differentiated from essential epilepsy, have the typical dreams of the traumatic neurotic, in which they are being annihilated in one way or another and from which they awaken in terror. In cases which resemble epilepsy clinically, one usually elicits a history of having had such dreams over a long period of time, but of the dreams’ having since ceased. Others will say that, whereas they have dreams of this type, they no longer awaken from such dreams, Asa rule, patients subject to these horrible nightmares have some representations of the anxiety in their waking life. The anxiety can usually be revived. When these dreams have completely ceased, the patient shows an apathy to his spells of unconsciousness and a lack of interest in his rehabilitation and cure, which is equaled only by the true epileptic. The disposition of the anxiety is an important theoretical consideration to which we shall return again.

In this group of cases lies one further point of differentiation. Some patients, in their unconscious state, relive their traumatic experiences; others have the typical kind of tonic and clonic convulsions seen in essential epilepsy. The following case is of interest because it shows one of the types of traumatic neurosis allied to epilepsy. It manifests in a very marked manner the fear of the environment, the sado- masochistic conflict, the presence of intense anxiety during spells, and the fact that anxieties may at times entirely displace the spells of unconsciousness.

The patient reveals this type with aura, anxieties, displacements, and ability to transfer repressed anxiety.

52 THE TRAUMATIC NEUROSES OF WAR

Case 19. The patient, first seen in March, 1924, was thirty-six years old, and was born in the United States. He stated that prior to the onset of his present illness he had never had a nervous symptom. He was brought up ina rural environment and was an active individ- ual. Before service he had become connected with the motion picture business as director for a small firm. During service he was a private. He once suffered concussion by a shell and spent six months in the hospital.

His chief complaint was unconscious spells at intervals varying from one month to three or four. Their onset was not abrupt; in fact, loss of consciousness was always gradual, usually accompanied by an aura which the patient identified as the sound of barrage. The external environment gradually became feebler in outline, the detonation of his auditory aura more and more violent; panic seized him; he felt as though he were about to die and very often lapsed into unconscious- ness. In most instances this was accompanied by violent fear and a struggle to emerge from this state; occasionally he succeeded, but more often he succumbed. He sometimes relaxed his sphincters. He did not know whether or not he had convulsions. He had been told that he lay limp. He awakened from these spells with a feeling of exhaustion and panic and did not recover from this sensation for days. After the spell he usually had a fear of going out of the house and a marked sensitivity to noise, an extreme irritability, and so on.

Occasionally the spell was provoked by some incident in the environment, and on two occasions the incident was very char- acteristic. He was sitting in a restaurant, his mind unoccupied and in a rather indolent mood. Two things occurred simultaneously. He was watching the man behind the counter cut a piece of meat. The idea of cutting, that is—that something was being cut—was associated in his mind with a great deal of panic. As he was thinking of this, some- body dropped a cup and saucer on the floor, whereupon the patient gradually lapsed into unconsciousness and had to be carried home. When asked to describe this spell, he said that it was not accompanied by the aura of a barrage but that the idea of cutting was painful to him; that was all he could remember. Loud noises occasionally threw him into a spell and often accidents that “almost happened” on the

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 53

street threw him into similar panics. When the patient was asked to describe the struggle against the spells, he said, “It is like struggling against death.” This isa common expression used by soldiers suffering from this condition.

The patient had almost a complete amnesia for the events concern- ing his original trauma. He stated that he was on an ammunition train at about two o’clock in the morning and was waiting for a bar- rage to quiet down. He remembered that a shell came across, striking somewhere in his vicinity; nothing further could be recalled by him until he woke up in the field hospital where he was being treated by a physician. While in a hospital as a shellshocked victim, he had his first fainting spell some weeks after the shock.

As a result of these spells, the patient felt insecure and was not able to keep any permanent occupation. The spells seemed to come more frequently when he was at work than at any other time. Extremely affable and agreeable, he showed no outward signs of irritability. However, loud and unexpected noises would excite him. Of the transference symptoms, the chief was agoraphobia, together with claustrophobia.

He was under observation for over a year. During this interval he had about six spells, some of them very severe. Abreaction to the original trauma was not very successful, although when the incident was revived, the patient had a good deal more anxiety than formerly. During intervals between the attacks he was entirely free from fears or anxieties associated with his spells. He had some transference symptoms in the form of fear of crowds, subway, noise, and large buildings.

The patient was observed in one of his spells by some friends to whom he was talking. He became weak; his forehead began to per- spire; he became panicky, fell down on his knees, heard a noise of barrage, and lost consciousness. His friends related to him that during the attack he did not froth but that he trembled all over and shouted, “Look out! Look out!” |

Also interesting to note is that this patient never had any of the typical dreams of the traumatic neurotic but that he frequently awoke from his sleep with a start. He remembers none of the content of

54 THE TRAUMATIC NEUROSES OF WAR

his dreams. Possibly the ease of displacement renders these anxiety dreams less insistent.

The following case is of chief interest because it demonstrates a type of epileptoid reaction following upon traumatic events with the usual secondary features of irritability, aggressiveness, and something resembling deterioration.

Case 20. The patient was thirty-one years old. From several members of his family it was ascertained, as far as they knew, that he was a normal person prior to service. He was never very enterprising or active, and from his own accounts had a marked apathy in his deal- ings with women. He was never in love with any of them, but he had been accustomed to a heterosexual life since his early twenties. He had no severe masturbation conflict. The patient was never fearful in situations of real danger, and in service he was an unusually brave soldier. His long career of exposure to severe shelling had not under- mined his confidence or bravery.

It is opportune in this case to describe a feature very commonly found in those complaining of syncopal attacks. His gait was fairly steady, but he had a rigidity in his carriage. This stiffness was most pronounced in the movements of the head, motions executed with rigidity and slowness, at least half as rapidly as in the normal individ- ual. This rigidity of posture was most conspicous when he was execut- ing movements attendant upon stimuli. The eyes would move in the direction of the stimulus, but the head would not follow the eyes. Moreover, he had a marked absence of the facial mimicry associated with emotional expression, a parkinsonian facies. Here the petrified blankness was most pronounced. Vocal inflections conveying the usual feeling tones were likewise diminished in excursion and intensity, a general characteristic of all these cases. Though I treated this patient for over three years, I never heard him laugh aloud, and his smile was generally stiff and forced.

He complained of spells of unconsciousness at intervals, varying in duration from two days to several months. These spells were preceded by intense vertigo, initiated at times by an aura of sparks in front of the eyes but more frequently by nothing at all. He fell down pre-

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 55

cipitately, occasionally hurting himself. He made twitching move- ments with his extremities, did not bite his tongue nor relax his sphincters, but frothed at the mouth. After the spells he sometimes felt drowsy and went to sleep. He also complained of severe head- aches, persistent dizziness, extreme irritability, attacks of violent temper, tantrums, assaultiveness, and marked sensitivity to noise.

When the patient was first seen, he had the usual stony, parkinson- 1an masklike expression on his face. Feeling or emotions did not seem to disturb the immobility of the facial muscles. He came into the room limply, sat down on a chair, and made no spontaneous state- ments. He answered in monosyllables: “Yes” or “No,” and so on. His behavior was very rigid. He would look out of the corner of his eyes rather than turn his head. He hardly looked round the room to notice any of the objects in it. Conversation held no feeling of contact or interest for him; he was completely detached. However, any noise that occurred or any monotonous stimulus, like the tapping of the pencil on the table, made him extremely irritable. After he had been under treatment for some time, the expression of his face relaxed and became more mobile. He appeared more interested; he smiled oc- casionally and seemed to be less fearful of his environment.

His stream of thought was always relevant and coherent. His associations were extremely shallow, but whenever any stimulus arose, he would make an association and then stop. The following 1s quite typical. The patient brought a dream, which will subsequently be described in detail. The chief subject of the dream was sand. He was asked to associate subjects with the idea, and the only reply ob- tained by me was, “I don’t know.” After much prompting and urging he could only say, “Sand is what we find on the seashore.”” Whenever he was asked to describe some of the details of the day’s events, he would do so in the most cursory manner, something to the effect of, “T got up in the morning; I walked around; and at night I went to sleep.” After some urging he might inject another detail, stating that he went to the movies. He seemed utterly impervious to any of the things in his environment. They seemed to make no impression. He had no trends, worries, or concerns, except that he wanted to get well,

56 THE TRAUMATIC NEUROSES OF WAR

The patient denied having had, at any time of his life, spells of any description. This statement was corroborated by his sister, consider- ably older than himself. Neither could she describe any traits indicat- ing an epileptic tendency. The patient himself, however, stated that after he had been in service for some time, he had several minor spells of unconsciousness, one after a severe gastric disturbance and another when he was accidentally struck on the face. But he remembers that these were not complete lapses of consciousness and were nothing like the spells of which he subsequently complained.

The first real major spell occurred in the Belleau Woods. The patient was in an engagement and was surprised by a shell exploding near him, near enough to tear his clothes and frighten him badly. However, he was able to go on fighting just the same. Several days later another shell came over, and this time he was actually lifted into the air and was unconscious for an indefinite period. All he remembered was waking up in a hospital, a three-day journey distant from the place where the shell exploded, altogether representing an interval of six days or more during which he was completely ob- livious to his environment. He said that he was “paralyzed” for a month from the head down, that he could not move any of his limbs, and that he stammered intermittently. After a month the pa- tient was able to move a bit; after two months he was able to get around on crutches. He then began to show all the symptoms of which he now complained. He was very fearful, especially of noise; the slightest movement of any object in the room would be enough to throw him into a fit. Any sudden stimulus, such as someone’s touching him on the back or suddenly passing him by, would throw him into a state of complete unconsciousness. When he was prepared for the stimulus, he did not mind it nearly so much. He remembered also having been tube-fed in the hospital because he could not swal- low. He occasionally would have fits as a result of gastric disorders after the spells.

These spells continued up to the time of examination, a period stretching over seven years. There was frequently no aura, but some- times dizziness. Sometimes the aura would be a rotating wheel; sometimes color hallucinations, which occurred without loss of con-

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES = 57

sciousness. “But when I saw black, I would always go off.” He often imagined that the sidewalk was coming up to meet him. Trying to protect himself from danger by grabbing a near-by object, he would fall down. His sister volunteered the information that frequently in these spells the patient would say things about the war, such as: “Go and get ’em;” “kill ’°em;” and so on. Concerning the dizziness, the patient stated that it was common and often merged into a spell of unconsciousness. He described the dizziness as a sensation of being revolved in a chair. During these dizzy spells he saw blotches of color —purple, red, green, and sometimes black.

The irritability was constant and usually directed toward loud noises or unexpected stimuli of some kind. Closely related to this irritability was the aggressiveness which the patient described as an entirely new trait and one foreign to him before the onset of his ill- ness. His aggression was very frequent in his sleep. He knew this from the fact that his brother, with whom he used to sleep, would fre- quently wake him up with the query, “Whom are you fighting with?” or “What are you fighting about?” And on many occasions he struck his brother in his sleep. This aggressiveness would fre- quently occur after his spells, when he would be seized with a desire to fight and to break up objects in the room. His sister stated that he had smashed many articles of furniture and innumerable dishes. Ac- cording to the patient, these aggressive impulses were not preceded by anger.

The dream life of this patient was typical of the traumatic neurot- ic, but it also showed some new interesting features. As usual, the dreams were concerned with fighting or with being attacked. Their content varied: dreams of falling, burning, drowning, being electro- cuted, reproductions of war scenes. He used to remember his dreams vividly, but now he remembered very few of them. Only after a great deal of effort could some of his dreams be collected. The dreams of this patient dealt with the “sado-masochistic” conflict but were almost entirely concerned with being annihilated. During periods in which the patient was relatively free from symptoms, he would have dreams in which he was the aggressor. “I dreamed I was fenc- ing with someone, and I stabbed him.” He would awake frightened.

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The anxiety problem in this case is of great interest. The dreams all indicate a marked activity of anxiety which, however, the patient was incapable of displacing on any situation in the outside world. He had no anxiety except that associated, in a general way, with the feeling of being killed if he had a spell in a dangerous situation. Aside from this was no conscious representation of anxiety. The patient had no agoraphobia. He would spontaneously avoid exposing him- self to danger. The violent anxiety from which he would start in his dreams would not disturb him in his waking life. For short periods after waking from his dreams, he would have transient fear of the dark, fear of loud noises, fear of burglars, and so on; but this seldom lasted more than a few minutes, and then he would promptly go to sleep again, only to be awakened by another dream of the same kind.

The relationship between the anxiety and the loss of consciousness was explained to the patient, and he was urged to anticipate the at- tacks of unconsciousness by actually fearing them. After considerable persuasion, the patient brought certain phenomena to indicate that the anxiety so active in his unconscious could be brought into closer re- lation with his spells of unconsciousness. He came to the clinic very excited, apprehensive, fearful, and trembling and stated that for the past four days he had been in a constant state of apprehension but that it was not displaced upon any situation in the external world. It was, however, displaced upon his spells. Thereupon the patient recalled that he had, on many occasions, been in apprehensive states during the past seven years but had feared nothing in particular. It had never formulated itself as a definite phobia. Moreover, he said, the presence of these anxieties did not guarantee or prevent the oc- curence of his spells, because he would frequently go from one of his anxiety states directly into one of his spells. Several days later the patient brought an interesting phenomenon. He was awakened by one of his typical dreams and switched on the light to get a pencil to describe his dream, as he would otherwise completely forget it. He remembered nothing beyond switching on the light; he then went into a spell. In short, an attempt to bind the anxiety to a special situa- tion failed. Certainly the inability to make transference to the outer world was responsible not only for the fact that the patient had no

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 59

phobia but that the spells persisted in their original form, together with these violent dreams. In these dreams repressed anxiety con- tinually emerged in conjunction with the original situation but left no trace in his conscious life.

Although prior to service a steady and industrious worker, he had not been able since service to apply himself to any work. Whatever interests he showed on fleeting occasions were directed along mechani- cal lines. He had several times attempted to devise various implements of a mechanical nature, usually labor-saving devices. The patient could not work because he could take no interest in any activity. As he put it, “Whenever I make any attempt to work, I am thrown into spells more frequently.”” Other features of this case have been re- served for later treatment.

The following case is an excellent demonstration of epileptoid reaction to a traumatic situation. The interesting feature in it is that anxiety dreams and all conscious traces of anxiety have completely disappeared. There are no transference symptoms, and all consequent spells are unusually severe and persistent.

Case 21. The patient, now thirty-three years old, had been under more or less constant treatment for about eight years and hitherto had noted practically no improvement in his condition. He had abso- lutely no history of convulsions or of fainting spells at any time in his life. Not a neurotic child, he was not afraid of the dark and had no animal phobias. In childhood he was a sociable, affable boy, fond of sports appropriate for his age. He was not subject to tantrums or severe states of obstinacy. At the age of seventeen he hurt his left elbow when he was injured by a streetcar. No after effects were noted. His love life developed in a normal way.

After a brief training in the United States, he was sent abroad. He was just preparing to enter the front lines when he received a small shrapnel wound in the thigh. He stated that at this time he was not particularly apprehensive or fearful in any way and did not take his wound seriously. He was sent to an English field hospital. On the evening of the day he was wounded, the patient was napping in the hospital when an airplane dropped a bomb on it, and the patient was “blown up.”

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The next thing he could recall is his waking up in Boulogne a long time afterwards. He could not talk, he was all tremulous, and his feet would not support him. During this period the patient did not maintain consciousness continuously, but kept “dipping”— that is, intermittently he kept lapsing back into a state of unconsciousness. He had to be confined for a long period in a padded cell or strait jacket. For this period the patient had now almost a complete am- nesia and a well-marked resistance to talking about anything con- nected with it. His conduct during this time was evidently delirious. How long these states of unconsciousness continued, the patient does not know; but when he was finally able to maintain consciousness, he stammered, trembled, was subject to anxiety dreams pertaining chiefly to airplanes flying over his head, was very sensitive to loud noises and abrupt stimuli. This condition remained up to the pres- ent time.

When he came to the clinic, his symptoms were periodic spells of unconsciousness, sensitivity to noise, inability to apply himself to work, and restlessness. He had no transference symptoms of any kind, did not fear riding in the subway except that he did not like the noise, had no phobias of any description, no anxieties, no anxiety dreams.

The patient was observed in one of his spells in which the following occurred. The spells were always preceded by headaches which “began low down in his spine and traveled up” and which were very severe in character, more like muscular cramps of the neck muscles. The first thing he noticed was the inability to maintain a forward position of the neck. The patient became cyanotic, losing consciousness at the time, but was able to perform voluntary movements. On one occasion, during this phase, the patient was able to walk about twenty paces to a seat. The next phase of a spell was an outburst of violence; the pa- tient threw up his hands, fell to the floor, but did not have convul- sions. The movements seemed to be codrdinate and very like the movements of a person fighting someone. This phase lasted for about two or three minutes, during which time his fists were clenched and he was striking and tearing violently while on the floor. There would be occasional relaxation of the sphincters; sometimes he would bite his tongue. Frequently during this phase the patient would break

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 61

and tear objects around the house; he broke many chairs, tore up sheets and pillows, but never harmed any person or injured him- self.

After this violence had subsided, he lay mumbling with his eyes open but did not hear anything said to him. When he was touched, he made defense movements; in fact, he was hypersensitive to this type of stimulus. Some time after this subsided, the patient made some remarks or inquiries concerning his whereabouts and concerning some member of his family. He had no persistent aura, and the attacks occurred at intervals varying between one to three weeks. His stam- mering had continued unchanged for the past three years.

The patient’s lack of emotion concerning the original trauma was unusual. He related it as a matter of course. During the entire period of treatment it was impossible to reactiviate any anxiety in connec- tion with the original accident. However, he showed unusual strength and emphatically refused to enter into any discussions about it, al- though he denied that such discussion would be painful for him. In other words, the original trauma and all its secondary ramifications seemed to be entirely encapsulated and to have no apparent con- nection with the patient’s other psychic spheres. The prognosis, there- fore, appeared to be practically hopeless, since no bridge remained be- tween the patient’s conscious life and the activity of the trauma in un- consciousness. It must be noted that the secondary so frequently found in these cases, namely, the withdrawal of interest from the outside world and from other people—particulary members of his family— were very much less marked than is customary in these cases. He was intensely devoted to his wife and child and was extremely tender, never showing any signs of irascibility or temper toward them. To- ward the physician he never assumed an attitude of dependence, and hence anything in the nature of a transference was impossible.

The following case is a typical case of epilepsy developed after a traumatic event and difficult to differentiate from essential epilepsy. Case 22. The patient was thirty-two years old. The chief complaint he presented was spells of unconsciousness. These spells corresponded, in every detail, to those of essential epilepsy. He had an occasional

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aura in the form of pain in his chest. He would fall abruptly, fre- quently cutting and injuring himself. His convulsions were typical. Several were observed in the clinic. He would not always relax his sphincters but would bite his tongue. The spell was invariably fol- lowed by a stuporous sleep of variable duration. The first of these spells occurred while he was in a hospital convalescing from a shrap- nel wound in his left buttock and an attack of gassing. The patient stated that he was “knocked out on the battlefield.” He gained con- sciousness in the hospital. Originally, he stated, he had the typical war neurotic phenomenon of dreams of the war scenes from which he would wake in great fright. He used to remember some of these dreams, but they had become so stereotyped that he no longer re- membered their content. However, they were infrequent at the pres- ent time, although originally they occurred night after night.

The patient had some fears, but they were secondary to his all- important spells. He feared riding in the subway. Because he feared the oncome of a subsequent attack, he carefully avoided exposing himself to any danger. This type of fear is frequently found in true epilepsy. The spells were not accompanied by anxiety, and at the pres- ent time there existed almost no representation of the consciousness of fear or anxiety. There was no evidence of deterioration. The pa- tient’s affect was entirely normal toward his illness.

He showed some typical features of epilepsy. He was hard, rigid, immobile. He had no conversation; he volunteered no information. His illness, had, however, few displacements, with no evidence of conscious conflict. When he talked about his former anxiety dreams, he usually laughed them off, saying, “Oh, they used to be terrible, but Iam so familiar with them now, I don’t mind them.”

From his history it was difficult to decide whether or not the patient lost consciousness on the occasion of his original trauma. His first attack in the hospital was not a convulsion but an attack of acute excite- ment, during which he ran out of bed, tore his clothes, smashed the furniture, and had to be led back and tied to the bed. The attacks which followed, however, were true convulsions.

His dreams were typical of traumatic neurosis: being attacked, trampled on, electrocuted, drowned, and so on. During his seizures he would wet the bed occasionally.

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The above presented case is that of a typical epileptic who, al- though his illness was eight years old, did not show any sign of de- terioration. He had no auras preceding his seizures, and no neurotic displacements of any kind. He had a rational fear that something might happen to him in one of his spells; he continued to have some disturbing dreams, not unlike those frequently encountered in es- sential epilepsy without traumatic provocation.

In order to demonstrate the independence of the resulting symp- toms from the character of the traumatic experience, organic or other- wise, I have selected two cases, one of which followed a fractured skull. The other was unprovoked by any trauma in the ordinary, ac- cepted sense of the word.

The interesting point in this case is that “fractured skull’? was the diagnosis made on his original condition.

Case 23. The patient’s previous life was uneventful. In Siberia he had a prank played on him. He was awakened in the morning and tossed up and down in a blanket in his nightclothes. Falling out of the blanket, he landed on his head and was in a state of unconscious- ness for about a month. He had a complete amnesia for all the events preceding the accident. The story, as he now told it, was reconstructed by the patient from fragments related to him. During the month of unconsciousness he was said to have set fire to the hospital several times. Since then, the patient had been subject to lapses of uncon- sciousness lasting for twelve hours to eleven days. He was later told that he was taken toa hospital and that he was fully awake during these lapses, was active, smoked, read, and talked but was not his conscious self. He was also told that he did not appear to be his “right mind.” These major lapses of unconsciousness occurred at intervals for five years. Since that time he had had only minor ones. They usually be- gan with a feeling of paralysis in one extremity, either an arm or a leg. Sometimes it was only an attack of vertigo.

The only other symptom elicited was a compulsive urge to attack or strike people. He could not stand on high places or ride horses; he had a compulsion to jump from high places. He never had trans- ference symptoms nor the usual type of annihilation dream. More recently he had been subject to transient spells of blindness which

64 THE TRAUMATIC NEUROSES OF WAR

lasted four or five minutes. When he was well, the patient went about his activities.

The loss of consciousness, transient blindness, and amnesias are quite like those in true traumatic functional cases. The sadomasochistic conflict is also present in the form of a compulsion to strike people.

The following case is of interest because it demonstrates to what extent the symptoms of true epilepsy may resemble those of traumat- ic neurosis.

Case 2 4. The patient was twenty-seven years old. In 1918, while on duty, the patient was in the kitchen with five other men when the shack they occupied was struck by lightning. All of them were dazed. He alleged that his own dazed state lasted only two or three minutes. During this time he did not know where he was, nor had he any idea of what had occurred. Although he had no pain or sensation of any kind accompanying the shock, his arms and legs were discolored and blue. He was given some form of physiotherapy, and the discoloration disappeared after a few hours. Within two hours after the accident he was as normal as ever before. He did not recall that he suffered from disturbances of sleep.

Within a short time the patient began to have symptoms referable to his gastrointestinal tract. Severe pains sometimes “doubled him in two.” It was diagnosed as “acute appendicitis,” and he was operated upon. His hospitalization lasted for thirty-six days, his convalescence being uneventful except for a superficial opening of the wound. He did not fear the operation, he stated.

About a year and a half later he began to have a repetition of the symptoms which initiated his acute appendicitis, the severe pain, and so forth. On one such occasion this pain attacked him on the street; he lost consciousness and was brought home by some strangers. He was told by an observer that during this spell he dug his nails into his stomach. Since then these spells recurred on an average of two or three times a week. At first they were preceded by the characteristic aura of gastric colic; after two years this aura disappeared, and his loss of consciousness came abruptly. With regard to these spells, he did not know just how long they lasted, whether or not he relaxed his

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 65

sphincters, bit his tongue, or whether or not the convulsions were tonic and clonic in character.

About a year after his first spell, the patient began to suffer from a disturbance of sleep. He would have difficulty falling asleep; the slightest noise would awaken him. After such an awakening he could not get any sleep for the remainder of the night. He became particu- larly sensitive to loud noises during the day.

About 1921 he began to have the typical “sadomasochistic”’ dreams —being trapped by fire, being chased by someone, fighting, being beaten and annihilated. Often his sleep was disturbed two or three times during the night. Of late, although these dreams continued, he had so learned to control his sleep that he did not awaken. How- ever, on awakening he often found that he had been injured during his sleep. His spells were often nocturnal, passing from a dream into a spell. He shouted, struck the wall and the bed, and was usually bruised on the head and arms.

During the day he suffered from spells of dizziness with black blotches in front if his eyes. These spells occurred sometimes as often as three or four times during one day. They occurred especially when he made a sudden move, got up out of a chair, bent over or stood up from a reclining position; in fact, any and every locomotor change affected him similarly. He was not sensitive to loud noise in the day- time.

Another important change in his character was his extreme irrita- bility. “If things do not suit me, I get very crabby. I must have my own way.” He also suffered from amnestic states and had been ap- prehended by the police several times. The last incident was probably typical. He remembered leaving the office at six o’clock but had no recollection of where he went. He kept on walking, was found by an officer, and sent home. He had often been found fifteen or twenty miles away from his home. His behavior after his spell was note- worthy. His limbs ached, he was disorientated, and he had a desire to sleep. Somnambulistic states were a frequent occurrence with him, that is, the psychic equivalent.

Very sensitive to the sight of suffering, the patient could not bear seeing others injured or hurt. He had no transference symptoms, no

66 THE TRAUMATIC NEUROSES OF WAR

anxieties of any kind, and was not fearful of any situation, such as theatre or subway. He was also not afraid of the consequences of his spells, As far as he knew, he was not more religious than formerly and was not dishonest or selfish.

This is a case of essential epilepsy, the chief interest of which lies in the similarity between it and typical cases of traumatic neuroses. The aura which initiated his attacks was a distinct reference to a traumatic experience, the symptom which initiated an organic illness. Of course, another and more likely interpretation is that the patient never really had appendicitis and that the gastric symptoms were the result of a spasmophilic crisis, so often found in isolated forms of traumatic neuroses. This aura has since dissappeared, and the only trace of anxiety is to be found in his dreams. The diagnosis of epilepsy is confirmed by the absence of transference symptoms and the pres- ence of somnambulism, twilight states, and amnesias. During his hospital residence he complained chiefly of headache and dizziness lasting for days at one stretch. He would wear an agonized expres- sion all this time. He was observed in one of these states to be cyanot- ic and rigid but without complete loss of consciousness.

The “epileptic character,” so-called in this case, appears to be en- tirely lacking. His past history does not bring out any tantrums, in- tolerance, impatience, egocentricity, overscrupulousness, or religiosity. His behavior during observation showed these traits to be com- pletely absent. Neither was he obliging to a saccharine degree as many of these epileptics are. His intelligence was not as keen as it had formerly been, and his emotional tone was decidedly low. He spoke with very little force, was pleasant, though not particularly engaging. His attitude toward work was normal, although when he did work, his spells occurred much more frequently.

SUMMARY

A traumatic experience can precipitate any of the well-known types of neurotic or psychotic disorders. However, irrespective of the nature of the resulting clinical picture, there are always the distinc- tive features of the traumatic neurosis.

SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 67

The presenting symptoms of this neurosis vary according to the time of observation. There are acute, transitional and stabilized forms. The type which stabilizes most rapidly is the one concerned with sensory-motor disturbances. The other stabilized forms vary only in the degree to which one feature is emphasized over another. In some cases—the defensive ceremonials—the organization of the neu- rosis is very high. In others the sensory-motor phenomena predomi- nate; instill others autonomic, or epileptiform phenomena occupy the facade. It often happens that the emphasis will shift in the same case from epileptiform to autonomic symptoms. The neurosis also brings with it certain definite alterations in the character of the subject, and this change is almost uniform, irrespective of the symptomatology. The one exception to this occurs in those cases with motor paralyses. The combination of a varying symptomatology with a uniform alter- ation in the character of the subject indicates a neurotic process which can be studied systematically.

PSYCHOSOMATIC MEDICINE MONOGRAPH II-III

_

Ill, ANALYSIS OF THE SYMPTOMATOLOGY

Our FIRST PROBLEM is to decide what kind of entity the traumatic neurosis is. To this end a comparison with hysteria and compulsion neurosis would be helpful. These latter neuroses deal with certain unsuccessful types of integration, some of which constitute the charac- ter of the individual and others which terminate as symptoms. The most noteworthy feature of these character traits and symptoms is their interrelation. Morover, both character traits and hysterical symptoms are related to definite aspects of the personality—those aspects of adaptation which deal with relations to others; attitudes to oneself; problems of status, connected with the question, ““What do I think of myself?”; and finally, certain drives toward satisfaction of biologically determined needs—sexual—and those determined by social values,—prestige.

To anyone acquainted with the clinical manifestation of the hys- terias, obsessional neurosis and character disturbances, the contrast of these traumatic neuroses is very striking. We have already pointed out the lack of displacement phenomena, a fact seeming to indicate that the psychic elaborations of the forces creating the symptoms is very poor. And this in turn would lead us to suppose that aspects of adaptation not involved in the hysterias and obsessional neuroses are touched on. If this is the case, we must proceed at once to examine the nature of the traumatic experience.

WAR AND THE TRAUMATIC SITUATION

One of the facts clearly established by the clinical phenomena is that the symptoms make a series, many features of which can be found in all cases, irrespective of the nature or severity of the traumatic experience, We are, therefore, dealing with specific reaction types which are responses to an alteration of the entire problem of adapta- tion. What, then, is the nature of “trauma” which ushers in these altered forms of adaptation?

ANALYSIS OF THE SYMPTOMATOLOGY 69

Certainly the war situation—particulary modern warfare—creates these traumatic situations’ more frequently than peacetime conditions. Even when the finer differential diagnosis of traumatic neurosis was not known, certain sequelae of war could always be noted. Thus Awto- kratow (12) reports that one of the most noteworthy consequences of the Russo-Japanese conflict was the inordinately high increase in epilepsy.

The war situation definitely contributes to the frequence of inci- dence of traumatic neuroses and allied diseases and is undoubtedly responsible for the difference in character between these neuroses and those which occur in peace time in a more attenuated form.

Modern war has introduced certain conditions conducive to neuro- ses in those so predisposed. The resulting traumatic situations are more numerous. This above-mentioned high incidence of postwar epilepsy is due entirely to the epileptoid character often assumed by the traumatic neuroses. The use of high explosives, gas, submarine, airplane makes the dangerous situations in modern warfare more fre- quent and more difficult to escape. These unpredecented and horrible situations in modern warfare, as is reasonably believable, have some direct relation to the severity of the neuroses that ensue; some trau- matic situations are more conducive to violent neurotic types than others. One cannot, however, but feel that the war situation, with all the accompanying horrors, rather colors the intensity of the neurosis than gives it its essential character. This follows from the fact that the traumatic neurosis is primarily a fixation phenomenon, accompanied by repetitive process, with a group of secondary defense mechanisms. A patient blown up by a shell and remaining unconscious for forty- eight hours is more likely, in the ensuing neurosis, to have symptoms which reproduce certain conditions of the original trauma than 1s a man exposed to a whole series of petty insults.

*A neurosis named after the situation which provokes it, rather than from some general characteristic of the reaction, is misleading. This we shall try to remedy. Mean- while, we must preserve the name “traumatic,” and use it to cover all those syndromes which are variously designated according to the provoking situation, as was the case with “shell shock,” lightning neurosis, railroad spine, etc.; or according to the specialist to whom the case was assigned, depending on the nature of the presenting symptom, @.g., neurocirculatory aesthenia, autonomic imbalance, etc.

70 THE TRAUMATIC NEUROSES OF WAR

Thus, while the war cannot be said to have produced any specific neuroses, the modern military situation with its inexorable weapons creates more difficult situations to escape and thus activates disorgani- zation of the ego. But a direct continuity exists, as we shall see, be- tween the mildest and the most severe of these reaction types.

Another situation concerning the late war, that is, the issue of post- war compensation, also conduces to the special character of the chronic forms. This compensation becomes an overt secondary gain of illness. But even here, it may be anticipated, the indemnification issue does not in any way create the neurosis. The demand for and the depend- ency upon compensation is an essential and unconsciously determined defense mechanism and cannot be considered a prime factor, although it is often an obstinate source of resistance in treatment and rehabilita- tion. As a matter of fact, this situation is not restricted to war. Hardly a civilian situation exists in which traumatic neurosis is not compli- cated by the issue of compensation for damages.

Although peacetime traumatic neuroses may differ in no qualita- tive manner from those encountered in the war, several conditions prevailing in the war situation and absent in peace may, in those so disposed, make the neurosis easier to become stabilized. These fac- tors deserve consideration as quantitative and aggravating rather than causative agents, though their exact effect on the intensity and frequency of the neurosis is indeterminable.

On superficial examination, so far as the “instinct”? life of the indi- vidual is concerned, the war situation is very different from that of peace. Perhaps the most striking dissimilarity lies in the apparent difference of the goal of activity. The general assumption is that the goal of activity in war is the annihilation of the enemy and the pres- ervation of self. This is apparently a wide departure from the goals and the pursuits of peacetime. But the difference diminishes on closer examination. The egoistic pursuits of peacetime are, for a large num- ber of individuals, purely self-preservative in character. They are obliged to work in order to exist, and this statement becomes truer perhaps in proportion as the work involved is of a cruder character. In the case of peacetime pursuits, the self-preservative issue has no ur- gency and no immediate danger. It takes time to starve, and with our

ANALYSIS OF THE SYMPTOMATOLOGY 71

modern social organization starvation becomes a rather difficult pro- cedure. The self-preservative issue in peace is implied rather than apparent.

Our social organization has conferred upon the individual a high degree of culture and differentiation of activities (originally used to fight beasts and enemies) into the refinements of labor. On the sur- face these latter seem to make little claim upon the same elementary drives activated in the fighting of wild beasts and enemies. Social organization has removed some elements of immediate danger. It has made possible the remarkable and systematic conquest and ex- ploitation of the physical environment and has thus transformed the primitive egoistic anxiety to the form of constructive work.

The state of war is therefore at the very outset an anxiety-provok- ing situation. Though similar to those of peacetime, the activities of war represent a stripping of the refinements built up by social organi- zation, with the effect of releasing a great deal of anxiety in the form of fear of impending danger; thereby incurred is a greater burden upon those impulses which ordinarily find their outlet in the primitive fight against the environment.

In addition to this is another important consideration, namely, that the war situation strips the individual of the protections of peacetime activity. During the conditions of peacetime the work of the individual is regulated as regards intensity, duration, and character by certain conventions which rest eventually upon the essential and unalterable physiological characteristics of man. Thus, in peacetime, the hours of labor are regulated with due regard to the normal conditions of fa- tigue and the normal fluctuations of diurnal efficiency. Moreover, in peacetime the character of the work to be done is, to some extent, sub- ject to individual option for the greater number of men. We need not emphasize the absence of sexual gratification in war, the paucity of entertainment, poor food, or unhygienic surroundings, all of which make the environmental conditions of war and the demands on the psychic organization of the soldier enormous.

A large number of the factors above considered—those regulating fatigue, efficiency, hygiene factors, and even sexual outlet—appear to be physiological rather than psychological problems. Yet although

72 THE TRAUMATIC NEUROSES OF WAR

the physiological hardships of warfare are undoubtedly alike for those who get neuroses and for those who do not, one is tempted, in this regard, to take issue with the point of view of the organicist who explains all these phenomena with the formula of “organic insuffi- ciency.” That is, a soldier is supposed to have an unstable autonomic system, therefore he succumbs to a neurotic disturbance involving the autonomic system. This type of explanation is one of the oldest and illustrates one of the most persistent of psychiatric forms of begging the question. Accordingly, the organicist explains the phenomena of a neurosis by the mere assumption of an unstable, inadequate, or in- ferior nervous system and postulates that the reactions resulting there- from are psychological reactions to the inadequate functionings of these various systems. The fallacy of this argument can be under- stood by contrasting the following situations: When a person, through the urgency of the situation, is obliged to avoid a stronger adversary than himself and must continue to do so until he falls down exhausted, we have a phenomenon generally understood without more explana- tion. He reaches the limits of physiological endurance. This, we may say, represents primarily a physiological problem. But on the other hand, when such an individual continues to have the same symptoms of exhaustion, rapid pulse, easy fatigability, fainting spells, and epi- leptoid symptoms long after the urgent situation has ceased to exist, we have a right to question the belief that these symptoms are physio- genic. The fixation phenomenon, with all its psychological accompani- ments of inhibition and reaction formation, ceases to be a physiological problem.

The problem of adaptation in the war situation is a wide departure from the conditions of peace. The soldier is, to be sure, a member of a group and is, to a variable extent, identified with the other members of it and with the nation and the cause for which the enterprise is launched. This latter feature, the identification of the individual with the cause of the war, is likely to be subject to a great deal of varia- tion in modern wars, where conscription is the rule. The average sol- dier feels the war to be the seat of the danger. Rarely does he know or perceive the original causes of the war which is being waged, pre- sumably, for his protection. He is seldom touched by these issues di-

ANALYSIS OF THE SYMPTOMATOLOGY 73

rectly. He is much more touched and intimidated by the military regime, its rewards, and punishments. The extent to which the soldier can identify himself with the cause is important only insofar as it enables him to be interested in the activity. When the remote rewards of personal advantage are absent and the cause of the war is abstract patriotism and the supposedly hated qualities of the enemy and when he is held in check by a discipline more or less inflexible and inescapa- ble, one must say that the soldier suffers in the modern war situa- tion a privation hard to equal in any situation in civilian or even primi- tive life. Undoubtedly the ability to be interested in the activities of war depends, in part at least, on the narcissistic objectives which the individual soldier is able to anticipate. When war has the tangible objectives of profit, security, defense of an ideal, and rewards not too remote as far as the individual is concerned, it would be easier to endow the activity with interest. But in modern war this is possible to limited degree. A state of affairs exists very like that in modern in- dustry. A man who works in a factory does not have the objective of the completed product of which he makes or adjusts a single part. He cannot have much “pride of workmanship.” Such work is tedious, and the interest must be shifted entirely on the reward in the form of money. In war the enforced replacement of his own ego-ideal with that of the group precipitates an egoistic conflict of great violence and creates an ambivalence toward the group, at once as his persecutor and protector. The more completely the soldier is identified with the cause and the leaders and the more firmly he is bound by ties of in- terest to the group, the better able is he to take care of the unprece- dented violence of the anxiety released by the war situation. A situa- tion not dissimilar to this, although entirely lacking in urgency, exists in certain labor conditions of peacetime.

This, together with the fact that the violence of warfare creates conflicts which in peacetime must exist in lessened form, plus the ur- gency, the inescapable character, and the rapid succession of events— all of these conditions foster disorganized adaptation types which under ordinary civilian conditions cannot arise except in great public calamities like pogroms, extensive fires, earthquakes, tidal waves, volcanic eruptions, and so forth. War is therefore a situation which

74 THE TRAUMATIC NEUROSES OF WAR

necessitates radical changes in adaptation as compared with that of peacetime. However, none of these changes would be effectual with- out the actual traumatic situation which exists in the form of exposure to severe shocks and injury. It therefore becomes essential to define the concept trauma.

WHAT Is A LRAUMA?

Trauma means injury. When used in a psychological sense, this connotation of injury must be altered, for we must define what is injured; here we encounter some difficulty. Properly speaking we would say that an adaptation is injured, spoiled, disorganized, or shattered. We can also speak of an injury to the ego, merely another way of saying that adaptive processes are altered. A trauma can- not be defined either in terms of the provocation or the reaction to such provocation alone, but as a relationship between an external stimulus and the resources immediately available to adjust to, side- step, or otherwise master the stimulus. This is very different in the traumatic situation occasioned by an external stimulus as against one created by an autochthonous stimulus like wishes, urges, or drives from sexual sources. Among other things is a time factor, for most traumatic situations are sudden and overwhelming. Let us try this working definition of trauma on a few situations.

The act of attention. . Fatigue.

. A sudden pain.

. Aslight accident.

. A fractured skull.

. Arteriosclerosis.

. A brain tumor.

Anuhwor a

~I

1. An act of attention. Perhaps all the situations mentioned in this list may be considered “traumatic,” but why include the commonest phenomenon of conscious life in this category?—because it arrests an existing equilibrium, makes necessary a new adaptation, and sets the organism in a state of preparation for a new change in certain adjustive mechanisms. It narrows or focuses the field of consciousness

ANALYSIS OF THE SYMPTOMATOLOGY 75

and is accompanied by some muscular immobilization which can be considered a preparation for new activity consequent upon the new perceptions involved. The immobilization phenomena are most con- spicuous in the case of auditory stimuli, less so with visual, tactile, olfactory, and gustatory stimuli. Therefore an act of attention in- volves perceptual, codrdinative, and executive capacities and is gen- erally not traumatic because in most instances it leads to an adequate adaptation, whether it be flight from an offending stimulus or the solution of a mathematical problem. In many disorders of attention it is not difficult to trace the origin to anxiety, which means that the adjustments demanded are beyond the ready capacities of the indi- vidual.

Thus a boy of fourteen suffers from an inability to comprehend anything connected with algebra though his intelligence is otherwise average. [he inability to be attentive to mathematics began with very early impressions about its difficulty. When it became necessary for him to do a mathematical problem, be became confused and anxious. His only adaptation was to ask someone to do it for him. His incapac- ity was an inhibition of attention premised by the unconscious idea, “T cannot do that,” and it went to a complete paralysis of any execu- tive capacities with respect to this circumscribed activity.

2. Fatigue. A more complicated picture is presented by fatigue. This phenomenon hardly corresponds to the general concept of trau- ma. The only reason to include it is that we stressed in our pre- liminary definition a reduction of resources. Many of the phenomena encountered in fatigue closely resemble those of the traumatic neuro- sis—the irritability, lack of codrdination. The dream life of the fa- tigued shows some characteristic features which, though minus the catastrophic character of the traumatic neurosis, do show the inability to consummate effectively some activity like running but never reach- ing the destination. (See for further details pp. 88-89.)

3. A sudden pain. Let us now examine a phenomenon more obvi- ously traumatic—a sudden pain. Many individuals under these condi- tions faint. This is a complete withdrawal reaction through cessation of consciousness. Other reactions are crying, jumping. If the pain is produced by an individual, some bit of aggression against the ob-

76 THE TRAUMATIC NEUROSES OF WAR

ject is most likely. In the case of fainting we have, therefore, instead of a tonic state of preparedness, a complete collapse of the whole per- ceptual and executive apparatus.

4. A slight accident. For the following case I am indebted to the late Dr. Monroe A. Meyer. It concerns a young woman, quite a nor- mal individual. One day, while she was combing her hair in the bath- room, the flushing apparatus suddenly became dislocated and, as it fell, struck her a glancing blow on the shoulder. Though she was not hurt, the suddenness of the accident frightened her. She felt rest- less, uncomfortable, and could not pursue the normal routine of her daily activities. She lay down to rest but was “nervous,” irritable, and apprehensive. She succeeded in falling asleep only to be awakened several times during the afternoon by dreams photographically re- peating the incident of the bathroom. For several days she was some- what “jumpy” and the dream recurred a few times; then it was com- pletely forgotten.

5. A fractured skull, Another case concerns a man of twenty-six, struck in the left temporal region by a bus which suddenly swerved out of line. He lost consciousness and, when revived, noticed that five minutes had elapsed since the moment he was struck, for he had noticed the time a second or two before the accident. He noted also that he was bleeding from the left ear and, being a physician, thought that in all likelihood he had a fractured skull. He directed some people who picked him up to notify the friends expecting him for dinner and argued with the policeman about the hospital to which he was to be taken. He had his danger clearly in mind, knew all the symptoms he might expect as a result of a fractured skull, but was not panicky. When removed to the hospital of his choice and cared for by his own physician, he began to feel worse. He became mildly dazed and slightly stuporous, but when examined watched the neurological ex- amination carefully. He inferred from the absence of a left abdominal reflex that he had a contrecoup laceration of the brain.

During the first few days he continued in this dazed, semistuporous condition induced partially by use of narcotics and slept most of the time. During the first few nights he had violent nightmares from which he awoke fearfully frightened and considerably dazed; more often

ANALYSIS OF THE SYMPTOMATOLOGY a7

he could not remember the exact dreams, although he knew they were terribly harassing and involved some threat of annihilation. During the following days he was extremely excitable, irritable, and sensitive to persistent noises, though he was completely deaf in the left ear. On the sixth night he had a dream of a nude woman pass- ing before him, but in the dream he remained completely unmoved by it. His interpretation of this dream was: “I suppose this is no time to be thinking of women. I have other interests to preserve.” From the seventh to the twelfth nights he continued to have disturb- ing dreams. Their content included combats, police, race-riots, Jews fighting Chinamen, and so on, although in the dreams of this period he was not in any personal danger. He then began to dream of foot- ball games and baseball games.

During this last period his fantasies in the daytime were occupied entirely with his desire to get back to work and with the wish to re- cover rapidly, since he was extremely anxious to resume his normal routine activities. He often had dreams in which he was back at his work but was interrupted by continuous frustrations. Finally a dream which took place in a schoolroom was accompanied with some anxiety connected with examinations. This terminated by his saying: “Why worry about school? I don’t go to school any more.” This was the last dream of any kind he remembered. His convalesence was un- eventful, and he recovered completely, save for a partial deafness in the left ear.

A psychologist friend sent him a toy Fifth Avenue bus as a gift, toward which he had a typical fear reaction at first; but after he left the hospital, he showed no fear of passing busses, though he was more careful than he had formerly been. Of the residual symptoms, irri- tability, fatigability, and irascibility persisted for some time and then disappeared. These traits were all foreign to his native character.

6. Arteriosclerosis. A man of forty-three had begun to suffer from arteriosclerosis at the comparatively early age of thirty-six. During the last year of his life his symptoms were so severe in their mani- festations that he felt himself constantly threatened by death, and he often spoke about it to his friends. Though he rarely dreamed, for several months prior to his death he was constantly visited by hor-

78 THE TRAUMATIC NEUROSES OF WAR

rible nightmares, the content of which was fighting, bloody scenes, threats of annihilation; he would awaken with sweating anxiety. The dreams in this case corresponded in all respects to those of the trau- matic neurosis, yet no obvious trauma had occurred. He never had any stroke, nor did he consciously have any fear of death, but he often had spoken of the threat to his ego which his disease involved and against which he was powerless. His dreams were evidence of the severe curtailment of resources occasioned by his illness.

7. A brain tumor. A student of twenty-three was sent to me for treatment of hysteria after a most trustworthy neurologist had found no evidence of organic disease. The presenting symptom was a certain type of convulsive seizure without loss of consciousness. The symptom appeared abruptly. One night without any relevant antecedents, the patient was awakened with terror out of a sound, dreamless sleep, and his body began to convulse all over. Able to speak, he called to the adjoining room for his brother, who tried to hold the patient in bed. The attack subsided after about twenty minutes. The patient was not confused but amazed by the experience and depressed. A fortnight later he had another such attack. The patient remarked that he also began to have vertigo, particularly on change of posture, and became extremely susceptible to noise. He had several nightmares in which he was being annihilated in some catastrophe and from which he awakened. He did not have any phobia of disease.

I took him for analysis and found a rather banal situation. True, he had a little neurosis, chiefly in the form of character traits, but I could establish no connection between his neurotic traits and these nocturnal phenomena. They seemed quite disconnected. Moreover, in the transference reactions I could see no reflection of this part of his neurosis. After these nightmares and epileptoid phenomena had continued for some time, I again asked the neurologist who referred him to me to examine him again and expressed my suspicion of an organic disease of the central nervous system. Examination was again negative. I proceeded with analysis for another month and sent him back for another examination. This time the neurologist told me he had found unmistakable signs of a temperosphenoidal brain tumor. He had an absent abdominal reflex and a Babinski on the right side.

ANALYSIS OF THE SYMPTOMATOLOGY Be ie

The neurologist told me it was apparently a very slow growing affair. Naturally I turned the patient over to the neurologist for further care.

The purpose of demonstrating these various types of trauma is to indicate generally the direction in which we are to look for an ex- planation of the symptoms, that is, of the changes in adaptation. This direction is obviously not the same as that concerned in the hysterias, compulsion neurosis, or ordinary character disturbances. The simi- larity between the reactions produced by pain, fatigue, a mild accident without tissue damage, arteriosclerosis, brain tumor, indicates that the province of adaptation involved has to do with the body (that is, soma), with executive functions dealing with accommodation to the outer world, and with those internal somatic organizations sup- porting this executive apparatus.

Trauma, therefore, is an external’ factor which initiates an abrupt change in previous adaptation. The particular domain involved is that dealing with the outer world, and any function connected with this aspect of adaptation can be involved. One way in which such an adaptation can be interfered with is by actual injury to the bodily part concerned (a limb or a sense organ) or to any part intermediary to its functioning (injury to nerve paths). A traumatic neurosis is a type of adaptation in which no complete restitution takes place but in which the individual continues with a reduction of resources or @ contraction of the ego.

However, when such a trauma involves all the adaptive processes, the result is death; but when only a portion of the total body ego is involved, the necessity still persists to accommodate to the outer world with those portions still intact or to some extent modified.

To illustrate this point, let us examine the change in adaptation caused by the fracture of a limb. In this case, however, alteration of the process of adaptation is so self-evident as to merit hardly any explanation. The specific limb involved ceases to be effectual and in fact ceases to be a part of the executive apparatus. When any call is made upon this particular member, its activity must be deleted.

* The word external is not used as a spatial concept, for a brain tumor interfering with neuronic pathways, though locked within the skull, is also external.

80 THE TRAUMATIC NEUROSES OF WAR

However, since most of the organism is still intact and since external and internal stimuli continue to impinge on the individual, customary tensions must be relieved. This must be done with the rest of the organism taking up the slack created by default of one part. The new adaptation is like the old in quality, except that, for example, what the individual formerly did with the right hand, he now has to do with the left. Thus we can say in this instance the quality of the adaptation is not changed, only the executive technique. This is a point we must watch, namely, whether or not the quality of the adapta- tion 1s changed.

Some features of the actual injury to a limb we must note. The limb is functionally useless. The musculature about the injury is in spasm. Pain is present, and all posture and attitudes are designed to pro- tect and immobilize the injured part. This immobilization is the first step in a complicated healing process, which facilitates certain cellular plastic processes with no relation to the conscious ego. The cessation of function and immobilization are, therefore, one of the first steps in the restitution.

In the case of a broken limb the change in the adaptive processes is very easy to follow. But in the case of a broken adaptation—to labor the analogy a bit—the restitutive processes are not so easy to follow because we are led to suspect qualitative changes in adaptation not present in the case of a broken limb. The principle of immobilization produces clinical indicators which we call symptoms. This, for ex- ample, is the case with muscular spasm in acute appendicitis or the diminution of respiratory excursions in pulmonary tuberculosis.

Whereas we are under no necessity to examine further these im- mobilization processes in internal medicine, for the concept “reflex spasm” takes adequate care of these phenomena, the case is differ- ent in the complicated trauma which involves highly complex integ- rative processes including psychosomatic interrelationships. But we are justified in singling out one series of unmistakable phenomena, namely, those which correspond to the concept of immobilization. This concept does not, however, do justice to the facts. A limb may become immobilized, but a sense organ cannot. We must, instead, therefore, use the concept of inhibition, which means that the func- tion in question ceases.

ANALYSIS OF THE SYMPTOMATOLOGY 81

Exactly how an inhibition operates is not well understood now, but we can assume that each organ will have its characteristic manifesta- tions when its functions become inhibited. The relation of the organ to the sensorium and its accessibility to voluntary control will surely affect the manifestations of inhibition. The structure of the organ will determine its manifestations. But most important of all, the function may become blocked at any place along the line of its functional de- velopment. This is a complicated process, consideration of which will be deferred until a later chapter.

This concept of inhibition seems, however, to account for only a small number of the actual symptoms recorded. It can explain only the paralyses, the loss of consciousness, the sensory disorders, the fatigue, the disturbances in motility. The other symptoms recorded seem in no way due directly to inhibitions. However, we can expect them to be at least indirectly related to such inhibitions.

In conclusion we may, therefore, say that a ¢rawma is an external influence necessitating an abrupt change in adaptation which the organism fails to meet, either being destroyed entirely by the external agency or in part, and that this destruction may involve not tissues but adaptation types. The predominant alteration of adaptation found in the stabilized forms of the traumatic neurosis are inhibitory proc- esses which can destroy the utility value of an organ or its functions. The practical result of a trauma is, therefore, its interference with a completed function as an executive weapon.

What we study, then, in the traumatic neurosis are the new adapta- tions, which make up the bulk of the symptomatology. No individual function can undergo interference without altering the adaptation of the entire organism.

THE ALTERATION OF ADAPTATION

The clinical types described in the previous chapter show that the alteration of adaptation, which we now call the neurosis in its stabi- lized form, may place the emphasis in different directions. According to the predominant symptom these traumatic neuroses can be thus classified:

1. The simple restitution in the form of the repetitive tic or organ-

82 THE TRAUMATIC NEUROSES OF WAR

ized ceremonial. This is a truly remarkable qualitative change in adaptation. The subject acts as if the original traumatic situation were still in existence and engages in protective devices which failed on the original occasion. This means in effect that his conception of the outer world and his conception of himself and his resources as related to it have been permanently altered. The symptom is periodic, but the alteration in adaptation is constant, though its character may not be conscious. One could describe this as a “fixation on the traumatic event;” but this formulation does not tell us what has actually hap- pened, though it has some descriptive value. The most highly organ- ized form of the traumatic neurosis, the adaptive processes of this type retain an advanced degree of purposiveness and organization. The remaining types do not show any such traits.

2. The sensory-motor phenomena can exist in a highly organized or disorganized form. Some types of sensory disturbances are ac- curate hallucinatory reproductions of sensations originally experi- _ enced in the traumatic event. In this instance the symptom contains the idea, “I am still living in the traumatic situation,” as we found to be the case with the type described above.

Most other forms of sensory-motor disturbance are pure contrac- tile phenomena—obliterations of functional portions of the ego. Oc- casionally there are cases in which all sense organs ceased to func- tion. In the paralytic phenomena no principle of selection could be found, whether monoplegia, paraplegia, or hemiplegia.

Other types of motor disturbances involved neither limbs nor func- tional units but activities, in the performance of which special diffi- culties were encountered such as tremors, all varieties of gait dis- turbances, and speech disorders. Cases in which paralytic phenomena prevailed noticeably lacked irritability, aggressiveness, or typical dream life.

3. [he cases in which the predominant symptoms were sympathetic and parasympathetic phenomena are at times the original stabilized form of the neurosis and at other times the tail end of a convalescence from severer forms characterized by syncopal phenomena. The cases in which autonomic disorders predominate have constant irritability, sweating, tremors, tachycardia, and smooth muscle crises in every

ANALYSIS OF THE SYMPTOMATOLOGY 83

possible location. Their dream life is stereotyped and of the typical catastrophic variety. Their sex life is impaired; impotence or di- minished sexual interest, a constant feature. They are subject to fre- quent episodes of confusion and intense vertigo. A diminished capacity for sustained effort and easy fatigability are present; efficiency is markedly impaired through general inhibitions to activity of any kind. The autonomic disturbances often appear after a long period of syn- copal phenomena. I have observed several cases of Graves’ disease which arose after syncopal attacks ceased, but I have never observed both together.

4. The group of cases characterized by syncopal phenomena shows every possible variation from vertiginous attacks, confusions, and fugues to loss of consciousness with and without convulsive phenom- ena. I have seen nothing that resembles petit mal in these traumatic cases. [he attacks are often provoked by external stimuli which resem- ble the occasion of the original loss of consciousness. For example, a patient who had been gassed would be thrown into an attack upon per- ceiving any volatile oils, as in perfumes or gasoline, and no other stimuli would produce an attack. Another patient had his seizures only when his feet became wet. These cases behave as if their attacks were finely conditioned reflexes. In other instances the “aura” of the attacks is the repetition of the last sensory impression before they originally lose consciousness—the sound of a barrage, the flashing of an exploding shell, and so forth.

A very interesting point of orientation in these epileptiform cases is the presence of anxiety. Generally these patients do not have any great facility in projecting their anxiety; the greater the anxiety, the fewer the epileptiform episodes. The symptom that stands in closest relation to anxiety in these cases is irritability. Phobia formation is completely unknown. Occasionally we encounter, not a projected phobia, but a fear of the epileptiform attack itself, as we often do in essential epilepsies.

From the standpoint of alteration of adaptation we can survey these clinical types A) from the point of view of their organization; B) from the point of view of the constant and variable features; and C) from the point of view of the fabric of new adaptation, that is, are the

84 THE TRAUMATIC NEUROSES OF WAR

newer adaptation forms regressions in the sense that we have used this concept in the obsessional neurosis and hysteria?

A. THE ORGANIZATION OF THE NEuROSIS

From the point of view of organization the type characterized by compulsive rituals is one in which the adaptation of the individual shows an organized effort at restitution by continuing the protective devices used on the original occasion of the trauma. However, that is not all. This evidence points very strongly to the fact that the in- dividual is really in a continuous state of heightened vigilance and that his conception of the outer world and himself have undergone con- siderable change.

A second type of organization is to be found in the sensory-motor disorders. In those cases characterized by hallucinatory reproductions of sensations experienced on the original occasion, we again find the constant feature that the conception of the outer world and com- mand of his own operating resources have changed permanently. In the case of the paralytic forms the new adaptation seems to be much on the basis of those principles illustrated by a fractured limb. The problem of adaptation is solved by casting out certain portions of the ego permanently and rejecting them for use in the newly reorganized ego. Therefore, although the individual’s conception of himself has been profoundly altered, the change is apparently accepted completely by the individual, and he continues to live on the same level of adap- tation as an individual with his limb amputated.

A third type of organization is illustrated by those with periodic syncopal crises. In these instances the problem seems to be solved by retaining all functions at a diminished operative level with peri- odic crises of complete contraction of the ego.

From the point of view of these three types of organization we can now examine the symptomatology with the idea of finding out whether or not all these symptoms have a serial relationship. This brings us immediately to a question in connection with symptomatol- ogy: What is a central and what is a secondary symptom? If, for ex- ample, we consider a symptom like insomnia, depression, or amnesia, we can conclude that these are all reactions of the personality as a

ANALYSIS OF THE SYMPTOMATOLOGY 85

whole to another situation which we must attempt to identify. Depres- sion may be a reaction to diminished resources; insomnia, one of the many manifestations of continued state of vigilance predicated by a constant anxiety due to a new conception of the outer world or of one’s own resources. [he amnesia is surely not a direct evidence of damage but obviously a defensive process of the personality as a whole.

Moreover, the real damage does not possibly always occur in the form of a symptom, like a paralyzed limb, but by inference we can understand the damage by examining the restitutive processes, parti- larly those common to all the traumatic neuroses. However, one ex- ception to this is the paralyses. Highly significant is the absence in this type of all the evidences of tension and discomfort which charac- terize all the other types of traumatic neuroses. This may be due to the fact that the damage to the adaptation is complete but localized in this case only. We are therefore justified in assuming that the real dam- age in the traumatic neurosis is essentially an inhibitory process, that this is the primary symptom, all the others being secondary.

This central damage may, however, be only partial in some in- stances, Let us consider the contrast between mutism and stammer- ing; the differences between complete paralysis, fatigability, and weakness; vertigo and tremors; a localized permanent paralysis and periodical losses and consciousness. If we regard the differences be- tween these series purely quantitatively, then we are in a position to group a large number of symptoms as secondary to this primary cause. The whole irritability syndrome and the whole series of auto- nomic (sympathetic and parasympathetic) symptoms group them- selves as secondary to these partial inhibitions. However, these partial inhibitions are always notably accompanied by symptoms of height- ened vigilance and timidity, such as the insomnia and the catastrophic dreams.

Our working scheme, therefore, is to make the inhibitory phe- nomena nuclear and the others secondary to this primary change.

Thus far we have introduced one essential feature of the psycho- pathology, namely, inhibition of function, and have predicated that the remaining symptoms are manifestations of adaptive attempts on

36 THE TRAUMATIC NEUROSES OF WAR

this new basis. In addition to this we have introduced the idea that inhibitions vary quantitatively, complete (paralyses) or partial. Thirdly, in these partial inhibitions the resulting adaptations will differ qualitatively.

B. ConsTANT FEATURES OF TRAUMATIC NEUROSIS

We now proceed to examine those features common to all the trau- matic neurosis characterized by partial inhibitions, which include all except those with motor paralyses. Such features are:

1. Fixation on the trauma—altered conception of self and of outer world.

. Typical dream life.

. Contraction of general level of functioning.

. Irritability.

Proclivity to explosive aggressive reactions.

Ap wD

The one variable is the extent to which anxiety and apprehension of situations in the outer world are consciously appreciated. Clinically the observation is borne out that the more the patients are subject to conscious anxiety, the less likely they are to have syncopal attacks. This is an extremely complicated phenomenon, but the explanation suggests itself that the existence of anxiety is an indicator of the ex- tent to which the individual has resources at his disposal for escape from and combat against the anxiety-provoking situation. Further- more it suggests that those cases in which the syncopal phenomena predominate are also those in which a repression-like defensive proc- ess is operating—the function of such a defensive process being to forestall or side-step the constant discomfort of the tension state created by incessant anxiety. These patients are, therefore, less pro- tected and hence more subject to complete ego collapse on the occa-

sion of certain crises. On the other hand, one may raise the question in this point whether or not anxiety is of much value in warning against a danger situation inescapable in fact—inescapable because the only alternative is practically a complete cessation of life itself. The reason for this is that the disturbed, inhibited, or blocked functions cannot be substituted. This feature was also brought to our attention

ANALYSIS OF THE SYMPTOMATOLOGY 87

by the fact that displacement mechanisms so prominent in phobia formation of ordinary civilian hysterias are practically absent in the traumatic neurosis. One notes, for example, that the defensive rituals described in the case on page 16 are not symbolic in character but actual reproductions. Furthermore, those instances showing some phobia formations are not characterized by elaborate and remote sym- bolizations but by actual resemblances to the original situations which provoked the neurosis. In other words, we do not find anxiety ex- pressed in the form we find it in the ordinary phobias, but we discover in its place another feature which points directly to the locus of these partial inhibitions. This feature, irritability, consists of a constant ten- sion state, a readiness for defensive attitudes on the occasion of any sudden stimulus. We see, therefore, that the absence of both anxiety and elaborate displacements serves to narrow down the probable locus of the inhibitory processes. Moreover, a feature of the traumatic neurosis is the nonaccumulation of new features with time, as in the ordinary neuroses. The psychological fabric of the neurosis remains very thin. This is also confirmed by the stereotypy of their dream life.

If we regard the essential pathology as an inhibition and if we also must assume that the individual continues to adapt himself to the outer world with his diminished resources, then we can regard the other features of the neurosis as discharge phenomena. At least this is one way of looking at the disturbances of the autonomic system and the syncopal phenomena. Before we examine these “discharge” phe- nomena we can examine those features common to all these neuroses, namely, “fixation on the trauma,” which merely means that the con- ception of the outer world and the individual’s resources have under- gone a change; the typical dream life; the sensory irritability; the proclivity to aggressiveness; and the constant reluctance to activity.

Fixation on the trawmatic event. This concept of “fixation” was introduced by Freud and after considerable maneuvering came to mean an arrest of development. This concept “fixation” is useful in the traumatic neuroses only to describe the fact that the effects of the trauma have made a permanent alteration in adaptation but not neces- sarily an arrest in development. It is barely possible we will eventu-

88 THE TRAUMATIC NEUROSES OF WAR

ally be able to detect such an arrest early in life, but at present we have no means for locating this type of arrest. What is more obvious is that the adaptation of the individual has undergone a change in quality and organization.

It is notable in this connection that either the patient has a com- plete amnesia for the trauma, the amnesias extending over the period after the event and rarely for the pretraumatic period, although such amnesias as the latter have been noted, or else the trauma is remembered with many of the details missing, but the appropriate affect is either completely absent, as in some epileptiform cases, or not associated with the trauma at all. There is reluctance to think of the trauma or of anything which resembles it. However, the effects of the trauma are constantly active in the patient’s dream life. This am- nesia is a crucial symptom. It indicates not merely that certain events of the past were painful but that the effects of the trauma persist in the form of an altered ego organization. The proof of this hypothesis is suggested by the fact that when the pretraumatic ego organization is restored, the amnesia lifts, as is the case in the ordinary neuroses.

The dream life. As we have said above, the dream life of the trau- matic neurotic is one of the most characteristic and, at the same time, one of the most enigmatic phenomena we encounter in the disease. Unlike the dreams in transference neuroses the traumatic neurotic 1s given to a strange stereotopy in his dream life. A special difficulty confronts the investigator in attempting to study the dream life of the traumatic neurotic. These difficulties are inherent in the nature of the neurosis. The attempt to get associations to dreams is usually futile. This is partly due to the general braking of all intellectual associa- tive functions. Furthermore the dream, as a rule, only begins to say something but never completes it. Instead of the condensation and the compactness of action in the dreams of the psychoneurotic, we have here a process of dilution and retardation, like the picture of a normal piece of action slowed down by the motion-picture camera, the film’s being cut off before the action is completed. The images are redundant and perseverative.* Indeed amazing is to hear a patient

“This type of slow and perverse miscarriage of gratification is most prominent in the comic, more particularly in what is known as slapstick comedy. The release in

ANALYSIS OF THE SYMPTOMATOLOGY 89

whose illness is nine years old state that night after night, with most monotonous regularity, he has dreams which take him back to the war scenes or which consist of feeble transformations of those battle scenes. We reproduce here a series of dreams narrated by a patient eight years after the original trauma.

1. I went somewhere, and we were discussing some things. After this I went home. On my way home I was coming down the elevated stairs. I dropped dead and rolled down the stairs. I woke with fear and found myself almost out of bed.

2. I was talking to a few fellows about different things. I got into an argument with one. I picked up some things and hit him with them and killed him. I ran away and hid myself and woke up frightened.

3. I was at a party and a fight started. Someone began shooting and shot me dead right through the head. I woke up frightened.

4. I saw my folks. They told me that my grandmother had just died and had come to see them, and they asked me why I do not come to see them. (Father and mother have been dead for three years; grandmother is still living but is paralyzed. )

5. Someone threw a match into the cuff of my pants, and they started to burn. I woke up scared.

6. I was on the Woolworth Tower and looked down, and as I did SO, I slipped and fell to the ground. I made a hole in the ans and was smashed to bits.

7. I was in a garden somewhere, and there were large roses, larger than myself. I climbed up a ladder to smell them, when a large bee stung me on the back of the ear, and I woke up with a sharp pain which lasted about half an hour.

8. I was a keeper of a lot of birds in a great big place.

9. I was on the subway station. Someone pushed me off, and I was thrown on the tracks. A train came along and ground me up.

10. I was in swimming and I was drowned.

these comedies is, however, laughter, because the victim is never hurt; in other words, a successful overcoming of the trauma. Also to be remarked is that generally all mishaps which terminate in disturbing normal upright posture—a man’s slipping on a banana peel or even lesser accidents like a strong wind’s blowing a man’s hat off—always carry a comic and ridiculous tone, thus provocative of laughter. The relationship between laughter and fright reactions is very close in the infant. The comedian is interminably shot in the pants, but he keeps on running; innumerable custard pies strike and smear his face, but he keeps up the harmless combat. The explosive tension in slapstick laughter is caused by the fantasy of triumphant invulnerability together with a deep conviction of the falsity of the situation.

90 THE TRAUMATIC NEUROSES OF WAR

11. I was taken sick on the street with a spell. When I woke up you were there to give me some medicine, and you told me to take it.

12. Somebody was sticking me with hot irons, and I tried to run away from him and could not.

13. I was riding in an elevator in a big building. It went up so fast, it went right through the roof. I was on a large boat with a lot of people, and all were on one side of the boat. It capsized and we were all drowned.

14. I went up to see my aunt who has been dead for six years. It took me two days to get there, and when I got there she was sick. She told me to get out. (Patient’s association in this dream was that he was very fond of this aunt and, that he used to go to visit her often.)

15. I was fighting with a lot of dead people, sticking knives at them, shoot- ing them with a gun, but they didn’t do anything. They got scared.

16. I was fighting fish at the bottom of the sea. They got frightened.

We note that the most common content of the dream is the threat of annihilation. The next type of dream in frequency is the aggression dream, in which the patient himself is the aggressor but is usually defeated.

These dreams are capable of several typical transformations. The first of these may be called “the Sisyphus dream” or the frustration dream. In this type the individual is usually confronted with a per- sistent and unshakable frustration. Whatever activity he engages upon is greeted with a certain stereotyped futility. Thus, the same patient whose dreams were recorded above dreams also the following:

“T was in the room, and everything I touched or grabbed was turned into sand. I put my hands in my pockets, and there was sand in them. I took off my coat, and there was sand in it. Everyplace I looked I saw sand; every place I walked, I was in sand. I tried to get away, but the harder I tried, the deeper I would sink into it.”

Some time later the patient brought another dream of the same vari- ety, but instead of sand everything turned into water, and he awoke as he was almost drowned. Though the patient could not help me with associations, the symbol of sand and water is typical for situations in which fatigue sets in very easily.

From this type of dream to the next one is an obvious transition. This second type of transformation may be called “the occupational dream,” which has hitherto been described by MacCurdy and others

ANALYSIS OF