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process of correlating all kinds of indications given by the test with knowledge as to their import derived from various sources. The ease and certainty with which the physician can sum up his patient must be strictly limited by the extent and accuracy of this knowledge; it is all important that he should know, as precisely as possible, which indications are noteworthy and which are not.

So far as the form of the association goes there can be no doubt, in my opinion, that the most significant characteristic is the degree of idiosyncrasy of the reaction word. Stereotypes and multiverbal reactions (my class VIII) and very indirect, 'personal associations (class VII) are the most significant of all; then come predicate forms involving an expression of personal opinion or judgment of value. Outer associations, especially those verbal forms constellated by common phrases of everyday life, are quite insignificant, though I think it probable that the true clang'-as opposed to the rhyme-is often a complex indicator.

In attempting to ascertain the general tendency for stimulus words to elicit emotionally toned reactions the best guide, so far as the form of associations is concerned, is probably the percentage of inner associations, the word 'inner' being defined as I have advocated above.

316

THE PROBLEM OF THE NEURASTHENIC

PENSIONER.

BY MILLAIS CULPIN.

The war neuroses have been discussed freely from all points of view, and although in some respects unanimity of opinion is not attained yet one simple conclusion has emerged—they showed no phenomena that had not been met before in cases occurring under peace conditions. Hitherto the neuroses had occupied a very small part of our professional interest; their number was comparatively small, their etiology was obscure, and their treatment accordingly little understood. The patients were difficult to handle and generally received scant attention; to diagnose a complaint as 'neurotic' led often to perfunctory placebos, to drugs the nastiness of which was presumed to have therapeutic value, or to neglect. Instruction in the subject was almost entirely lacking in the curriculum of the medical student.

This was the state of affairs when thousands of cases appeared in our armies. The subject is better known now, and indeed this branch of Medicine has received a greater stimulus through the war than has any other.

The interest aroused by acute cases during the war diverted attention from the probable results, and few of us expected a large number of men to be disabled by mental symptoms which would persist indefinitely after the war had ceased. Yet that is what is happening, and since factors are involved other than those present during the war it seems opportune to consider the subject of the neurasthenic pensioner.

I use the word neurasthenic in the broad sense in which it is commonly and, one may say, officially used. It embraces a heterogeneous group which it is not necessary to classify in clinical terms. In that group are, on the one hand, men with records of long and valuable service, men who have gone through the stress and horror of modern warfare to a degree which perhaps only a few can realise. On the other hand are men whose histories are a record of hospital life varied by periods spent with a unit when they performed no useful work whatever, till they were invalided out of the service with a pensionable disability; and other men who had been as great a failure in civil life as they proved to be in the army. Add to these a sprinkling of men with a record of crime both within and without the service, as well as congenital psychopaths of various kinds, and you will understand that the problem of the neurasthenic pensioner -how to deal with him and what will happen to him-is no simple one.

1 Read before the Medical Section of the British Psychological Society, Jan. 26, 1921. . wrote in 1881:

In the recognition of the neuroses and psychoneuroses as existing in large numbers we were behind our French allies, who were already familiar with hysteria as a common disorder in a conscript army, and the ever-growing number of hysterics in our home hospitals escaped notice whilst we were fixing our interest upon shell-shock as a new disorder arising from the use of high explosives.

The writings of Roussy and Lhermitte and of Babinski were the first systematic studies of the functional nervous disorders arising from war conditions, though these writers were limited in their etiological views and seemed little influenced by their compatriot Janet-still less by the teachings of psycho-analysis. We may congratulate ourselves that in the understanding of the psychological processes involved in the production and maintenance of symptoms we are now in advance of our French colleagues.

Wonder is sometimes expressed that neuroses did not occur in previous wars. Gavin in his work on Feigned Disorders (published in 1843) showed familiarity with many of the symptoms of what has been called 'shell-shock,' and my own experience has taught me that during and after the South African War men received pensions for war neuroses, though the conditions were called by other and varied names.

Although I have emphasised our unpreparedness to meet the immediate problem of the war neuroses, yet a curious parallel to them is to be found in the history of that condition which used to be called 'Railway Spine. This was for a long time regarded by many people, professional and lay, as due to organic injury, and it needed the controversial efforts of the late Furneaux Jordan and of Mr Herbert Page to demonstrate its emotional nature. A quotation will illustrate the parallel and show the insight these surgeons had obtained into the condition. Furneaux Jordan Modern Warfare has enabled us to conceive more terrible circumstances than those of a railway accident, but even to the emotional aspect of modern warfare the description I have just quoted can be properly applied.

The incidents of a railway accident contribute to form a combination of the most terrible circumstances which it is possible for the mind to conceive. The vastness of the destructive forces, the magnitude of the results, the imminent danger to the lives of numbers of human beings, and the hopelessness of escape from the danger, give rise to emotions which in themselves are quite sufficient to produce shock, or even death itself1.

1 Quoted from Railway Injuries, p 28.

The identity of the chief factor in the two conditions being established, we need not be surprised to find all the symptoms of shell-shock described in Mr Page's book on Railway Injuries, which was written in 1890.

The period of amnesia after shell-shock, sometimes accepted as due to concussion, can be recognised in this description: “I have myself regarded this as a dazed condition, the result of fright, and have never thought it strange that some persons should have been unable to give any account of what transpired, or what they themselves did after a collision” (p. 70).

Scarcely a symptom of shell-shock or war. neurosis escapes notice in this book; even the cardiac disturbances—the official ‘Disordered Action of the Heart'-are noted. It would be waste of time to enumerate all the symptoms, but I shall find it useful to refer again to this work in dealing with some aspects of our subject.

The problems of medicine and surgery produced by the war were all to be solved by an extension of ordinary methods, whether of investigation or technique; trained men were in plenty and every well-prepared and efficient practitioner could understand and take part in the work. But although recent developments of analytical psychology had thrown much light upon mental disorders yet the application of the new ideas was far from being generally accepted, and even the diagnosis of the neuroses and psychoneuroses had been neglected in our medical training. There was in the army a disinclination to admit their existence-except as shell-shock—a disinclination fostered by the fact that when they were diagnosed the problem of the patient's disposal and treatment became a difficult one. It was far easier to treat them as organic diseases, and the medical officer who recognised the hysterical character of a supposed organic disease could do very little unless he were able to treat it himself. I became aware during the war that our hospitals contained large numbers of men suffering from hysterical conditions which were diagnosed as organic, and tried as far as possible to draw notice to the state of affairs so that 'the rot' might be stopped; but I did not foresee what would be the ultimate result of invaliding these men out of the army with a pensionable disability.

When the treatment of shell-shock became an insistent problem the function of the psychotherapist was recognised and the War Office

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established centres at Maghull and Seale Hayne to which cases were sent and where medical officers were trained in psychology and psychotherapy. Some of the needs of the occasion were thus met in the middle of the Great War, but even now the Ministry of Pensions finds it necessary to train men for the treatment of pensioners. Thus we find that in this important speciality medical men have to be trained practically ab initio under a Government department.

The mere boarding of pensioners and the just assessment of the disability calls for special knowledge and understanding. It is, I think, only after treating on psychological lines a fair number of pensioners that one can understand the disabling nature and unconscious origin of symptoms which at first sight are fantastic and imaginary. Speaking for myself, I am aware of the great difficulty of forming a correct judgment, at a single interview, of a man's symptoms, temperament and attitude towards reality. The untrained observer often brings to bear upon the subject a breezy dogmatism which is rarely justified, and he tends to fall into several errors: to accept a functional disease as organic, to overlook that tendency of the psychoneurotic, even before a pension board, which makes him stress his bodily and say nothing about his mental troubles, and finally to regard anxiety symptoms as something that can properly be ignored. The Ministry is meeting this difficulty by the scheme of training mentioned above.

Having given this brief survey of events I now come to consider the present situation. The numbers involved cannot be statistically investigated, for many are still hidden under diagnoses which give no hint of the true condition; but I am ready to believe that about one-third of all pensioners are suffering from symptoms which, whatever the diagnosis may be, are largely neurasthenic.

Although it is still convenient to talk of a shell-shock group yet with the lapse of time the shell-shocked men become indistinguishable from those whose conditions arose from other and different presumed causes; they only differ by their symptomatology being to some extent still related to war repressions. I can produce no evidence, but I believe that the shell-shock patient tends to recover better than the man who broke down at home, even though his symptoms were at first very severe. I would make the generalisation that the amount of stress endured before break-down is a measure of the man's original stamina and hence of his likely response to treatment. The tendency to spontaneous recovery seems lacking in the men who broke down early; it is in them more particularly that we see deterioration taking place in two directions—in the develop

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