physiological, as well as psychological functioning. In the case in question this improvement is beginning to take place.

The second case to which I wish to refer is that of a sergeant-major, aged forty-five, who developed an anxiety condition towards the end of the war. He had not been abroad but was instructor in a training centre in England. His chief trouble before his breakdown seems to have been due to the fact that his officers had not quite such rigorous ideas about discipline as he himself had. He felt he was unsupported by the officers in his efforts to maintain discipline. At the same time he complained of being blamed for incidents which he considered arose out of the inattention to discipline which he deplored. It was certainly a difficult position. It ended in a breakdown. He had been sleeping badly, worrying over trifles, ever since. Lately he had had suicidal ideas. The first dream he brought was, "I saw ballet-girls dressed in large shield-like arrangements, walking in half-sections, a policeman escorting them." Unfortunately this is a dream which I did not analyse, so I cannot throw any light on the shield-like arrangements. But I think, taken as it stands, it gives a clue to the situation. It is possible to regard this manifest content as a representation of his own jockeying, disciplinary and regular attitude, symbolized by the policeman, towards his own feelings of a more free, spontaneous and irregular character, symbolized by the ballet-girls. I shall not attempt to elaborate this idea further. Much emerged in the course of treatment which would support and confirm it. In fact it may be said that in a realization of this lay the way to a cure of his neurosis. It is also a significant fact that on the two nights succeeding this dream, he dreamt of policemen.

Both of these cases of war neurosis in my opinion have arisen in consequence of an already existing neurotic attitude. They bear out Jung's dictum that in the greater number of ordinary cases of neurosis there is no traumatic aetiology, in the sense that the origin of the neurosis can be traced back to one specific incident. This view has been and still is very widely held and the so-called buried memory is often ardently searched for and usually found! But to quote Jung's paper already referred to: "In order to create the impression that the neurosis is derived from a traumatic moment, inessential secondary occurrences must, for love of the theory, artificially be brought into prominence. As a rule these traumata, when they are not mere artefacts of medical phantasy, or from other reasons dependent on the compliancy of the patient are secondary events, consequences of an already existing neurotic attitude." (Here it may be said that the sergeant-major found

the actions of his officers unbearable. In a sense therefore they were traumatic or causative but only effective in so far as a one-sided neurotic attitude already existed in the form of an over-sensitiveness to authority in others, and an over-valuation of authority in himself. They were therefore only secondary.)

"The neurosis is, as a rule, a morbid one-sided development of personality, arising from very slender, indeed ultimately invisible beginnings, which can be followed back, as it were indefinitely into the earliest years of childhood. An arbitrary judgment could alone decide where such a neurosis really begins. If its determination were shifted back into intra-uterine existence, thereby involving the physical and psychical disposition of the parents at the time of pregnancy and conception—a view which in certain cases seems not improbable such a standpoint would, in any case, have more justification than the arbitrary selection of a definite point of neurotic origin in the individual life of the patient."

The danger of the trauma theory seems to me that the physician's preoccupation with the need to find a specific incident in the past, blinds him to the general attitude of the patient towards the 'here and now,' in which the main cause of the neurosis lies. The truth is that the idea of the 'buried memory' has been pushed to ridiculous extremes. It makes the problem of war neurosis appear so easy that one might well wonder why there are any neurotics left at all.

To quote again from Jung's article: "It is self-evident that the cathartic method (abreaction), when dealing with ordinary neuroses, will, as a rule, meet with poor success. Since, in general, it has nothing whatever to do with the nature of the neurosis, the schematic application of the method is, in such cases, quite ludicrous. Even when apparently partial success is obtained it can have no more significance than would the success of any other method that admittedly had nothing to do with the nature of the neurosis. The success is due to suggestion. It is often of very limited duration, and clearly accidental. This success arises always out of the transference to the physician, which is established without too great difficulty if only the physician has an earnest belief in his method. Because it has just as little to do with the nature of the ordinary neurosis as, for instance, hypnosis and other such remedies, the cathartic method has with only a few exceptions long been abandoned and replaced by analytic methods."

In conclusion I should like to say that in my opinion the stress and strain of war simply unmasked a tendency to neurosis or rather fulfilled the potentiality of neurosis in a great many people, who up till that

time had been considered 'normal.' No one theory will satisfactorily explain all the facts of the war neuroses. In the end in many cases we are brought face to face with the ultimate consideration of the personal factor, after we have dealt with the factors of environment and experience as far as may be. This factor is particularly evident in the case of those nondescripts who under the all-embracing shelter of the term warneurosis, cloak an innate ineptitude and feebleness in face of the ordinary problems of life. In an article written two years ago1, Dr Nicoll and I stated that any form of treatment which gives some adequate explanation-one carefully adapted to the intelligence-will be of use. A good transference and a suitable explanation will effect relief in a great many cases. I am inclined to think, however, that a certain proportion must be allowed to find their way back into life in their own way.

1 "Functional Nerve Disease." (H. Crichton Miller.)

NOTE ON THE MENTAL AFTER-EFFECTS OF
SLEEPING SICKNESS IN SCHOOL CHILDREN.

BY CYRIL BURT.

IN a recent article in The Lancet1, Dr Donald Paterson, the Medical Registrar at the Great Ormond Street Hospital for Children, working in collaboration with Dr Spence, of the Children's Department at St Thomas's Hospital, has published and discussed some interesting records of the after-effects of epidemic encephalitis lethargica in children. In such diseases the question invariably arises as to what is the chance of complete recovery, and what is the likelihood of some degree of physical or mental impairment. In previous epidemics no records appear to have been kept which enabled a satisfactory answer to be given to this question.

Dr Paterson and Dr Spence selected 25 cases between the ages of 3 months and 11 years in which the diagnosis appeared to be incontrovertible. They carefully excluded all patients who, before the onset of the illness, were not of normal health or intelligence. The selected cases they followed up for a considerable period after leaving the hospital. Their conclusions are as follows:

In the majority of cases epidemic encephalitis in children is followed by permanent after-effects, either physical or mental. In only 25 per cent. of the cases in their series was the recovery complete.

In about 30 per cent. of the cases organic residual paralyses persisted after the original illness, the cases showing such conditions as hemiplegia, spastic diplegia, symptomatic paralysis agitans, muscular rigidity and tremors. In general, however, all the children seem well-nourished and have preserved the ability to gain weight and thrive.

The most significant results, however, are to be seen in the mental condition of the children. These observations are of especial interest. Recently, imbued with the importance of inherited mental defect, psychologists have been prone to attach less weight than formerly to diseases of the nervous system supervening during childhood as a factor

1 "The After-Effects of Epidemic Encephalitis in Children," by Donald Paterson, M.B., B.Ch. Edin., M.R.C.P. Lond., Medical Registrar, Hospital for Sick Children, Great Ormond Street: and J. C. Spence, M.C., M.D. Durh., M.R.C.P. Lond., John and Temple Research Fellow, Children's Department, St Thomas's Hospital. The Lancet, Vol. II, 1921, p. 491.

238 After-effects of Sleeping Sickness in School Children

in the causation of mental deficiency. Here we seem to have definite evidence that children, who would otherwise have grown up into normal and intelligent adults, are converted into mental or temperamental defectives by the misfortune of brain diseases in early years. Among the 24 surviving cases the mental condition was affected in 18. Of these, seven are grossly mentally deficient and in a state of permanent and hopeless idiocy. Others show minor degrees of mental derangement.

The eventual condition seems to depend very largely upon two factors: firstly, the severity of the initial illness, and, secondly, the age of the child when first attacked. After a short illness, the stupor lasting for a few days only, the child as a rule completely recovers. If the lethargy persists for three or four weeks, then mental deficiency may be expected, at any rate if the child is young.

Even more important seems to be the influence of age. The younger the child, the more serious the after-results. If we analyse the table of results which the investigators publish, it would appear that in children under 3 years gross mental deficiency is likely to ensue. With children aged between 4 and 8 the milder degrees of dullness, backwardness, and such lighter grades of mental deficiency as are characteristic of special schools are apt most frequently to be found. With children aged between 8 and 12 there may be a slight retardation in general intelligence, but the chief disturbance is one of temperament and character. The child may become emotional, irritable or restless, or develop delinquent propensities, such as petty violence, mischievousness, and perpetual pilfering.

Those who have to deal with cases of juvenile delinquency will realise the importance of these results. In a small but appreciable proportion of such cases that come under official notice on the ground of criminal tendencies there is a history of encephalitis or similar disease, and before this investigation was made it was difficult to know how much weight should be attached to this incident as a causative factor in the mental change.