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ment of further symptoms and in the loss of the social sentiments as expressed in the desire for social and economic adaptation.

The history of these men is often as follows: a short period of service is followed by an illness which may be ascribed to a minor accident, exposure, the stress of training, typhoid inoculation, or any trivial cause which provides an opportunity for a neurotic flight from reality. The original symptom is an isolated physical complaint-myalgia, laryngitis, gastritis, contused back, will serve as examples--but as time passes others are added and the symptom-complex grows till the final result may be an anxiety state (veiled perhaps by the hysterical symptom) identical with that reached by the shell-shock patient. The cause of this accretion of symptoms might be profitably discussed, but at present I only draw attention to the process.

The loss of the social sentiments runs a parallel course but in the shell-shock group we are dealing with a type of man who is less likely to suffer this loss and who often succeeds, though under great difficulties, in facing the realities of life. The other type seems to deteriorate steadily, and I emphasise this deterioration because it forms a great part of our problem.

A disturbing phenomenon is the occurrence of nervous break-down among ex-soldiers at varying periods after demobilisation. It seems a paradox to ascribe this to the strain of civil life; but army life away from the front line was to some extent and for some men well-ordered and free from worry. A man's position and pay were secure, his family received their allowances and he needed to take but little thought for the morrow. Demobilised and faced by the need for initiative and personal responsibility, he takes flight from reality in a neurosis. That is one explanation, but there is another; he has passed through the stress of war and is, more or less wittingly, trying to forget it. If his repressed memories have sufficient affective content any stimulus may suffice to produce symptoms. I will describe a case of this nature.

A man of the regular army went to France in August, 1914, and was in the fighting from that time till the armistice; he reached the rank of sergeant, was mentioned in dispatches, and was always a brave soldier on whom his officers placed great reliance. Demobilised early, he bought a motor-car and set out to earn his living with it. He carried on for a time and then began to be afraid of an accident; this nervousness increased till he had to give up driving and finally he sold the car and had to live, with his wife and child, partly on the charity of his father. In October, 1919, a neighbour sent him to me to see if I could help him.

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He then had a “hysterical' limp, was full of strange fears, afraid to come alone to my house at night, and in his own words “scarcely knew what he was doing.” His wife described fugues which the man himself hardly remembered.

I could not undertake the whole treatment of the case and as the wife was an intelligent woman I tried an experiment. In her presence the man quickly went into a hypnoidal state in which he abreacted part of his experience, and she undertook to carry on the same treatment at home. She succeeded very well and between them they recovered a great part of the repressed material with appropriate abreaction; it included apparently every emotional incident that had occurred during over four years of fighting. At intervals he came to me and I recovered memories which had defeated the wife. He is now free from distressing symptoms and is at work, but has regressed so that he has a feeling of dependence, has little initiative and has a curious habit of going to haunts of his boyhood and sitting there in meditation. I spent about twenty hours upon the case, even with the useful and time-saving help of his wife, and mention this to show one practical difficulty in treatment—that is, the time involved.

In this case there was no doubt concerning the main factor in the production of the psychoneurosis—the War. The case also suggests that when break-down occurs after demobilisation a superficial interrogation about a man's war experiences may enable one to judge how far war repression is responsible for the symptoms. A positive result may be very striking, something approaching to an abreaction being produced quite readily.

When we consider the difficulties inherent in the treatment of the psychoneurotic patient of civil life--the evasions and rationalisations, the wilfulness and conscious resistances, as well as the influence of friends and relatives--we are prepared to meet similar difficulties with the neurasthenic pensioner; and they are not lacking.

It is hardly necessary to say that treatment must be directed by psychological principles, and whoever has seen a strong abreaction on the revival of a war memory can have no doubt concerning the importance of the mental processes involved and the need for treatment along the lines indicated. But the patient must be willing to go through a process which is extremely unpleasant and even painful; hence often arises a clinical difficulty when a man bluntly refuses to take his share in the work.

Here I will note a curious observation:—if you meet a patient who J. of Psych. (Med. Sect.) i

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has been treated by abreaction or by the discussion of his war experiences and ask him how he was treated he will hardly ever tell you that he was made to talk about the war, but will give all kinds of evasive answers. In fact, the tendency to repress again is almost constantly present. Some explanation appears necessary in regard to the position of psycho-analysis in this connection; abreaction and a re-arrangement of the man's attitude to his symptoms and to life generally are not psycho-analysis, though they depend upon psycho-analytical technique and are based upon the theory of the unconscious. I believe that very few war cases have been psycho-analysed in the sense in which that word is used by competent psycho-analysts, though in many cases the mental exploration has to be carried past the war material.

But it is not my intention to discuss methods of treatment except to point out how necessary are the goodwill and active assistance of the patient and that in this respect the psychotherapist in a military hospital, especially after the armistice, was in a more favourable position than is he whose duty it is to treat pensioners.

Not only were the men more under control but resistances tended to disappear by the example of successful results; moreover, the prospect of discharge on a cure taking place led to the same end. This last factor sometimes acted detrimentally, for the hiding of symptoms in response to a stimulus is not equivalent to their removal by analytic means.

A large proportion of pensioners are willing subjects, especially, in my opinion, those with a low assessment, for their effective disability is often low on account of their efforts towards recovery, though their symptoms may be really serious and distressing.

But in many, especially those with a history of early break-down,good results are more difficult to obtain for there is obviously a more powerful neurotic tendency to deal with. In some it becomes clear that the neurosis has mastered the situation; the pensioner is practically at liberty to refuse treatment and often does. Or he may clamour for it and the remorseless urge of the neurosis uses the opportunity for its own ends; the man presents himself insistent upon his desire to be cured and yet opposes the process of cure at every turn; then the failure of treatment further strengthens the neurosis. The cult of the rest-cure and of massage and electricity as standard treatment for ‘nerves' has now reached all classes of the community, and in the absolute passivity required of the patient they appeal particularly to the man who wishes to demonstrate his desire for treatment.

There are others more unfavourable still who were ne'er-do-wells and

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failures before they enlisted. I was familiar with one type in the army; he would join up and be quickly discovered to be useless, be discharged as “unlikely to become an efficient soldier,' and almost as quickly enlist again. In one case four enlistments from the outbreak of war up to March, 1916, had each resulted in the man being invalided out of the service. I have no doubt that his disability is now fairly high.

But even in men who now have the appearance of the ne'er-do-well we find some who have good records and respond to treatment. It is sometimes almost impossible to believe that a man who looks as if he has never been anything more than a querulous loafer should once have been a good citizen and a brave soldier; yet I have seen a few such men-only a few-restored to decent citizenship.

This deterioration of a good soldier is so hard to believe when we see the man at his worst that I will quote some fragments from a description of a case by Mr Page:

A tall powerful man was in a very severe and destructive collision. He received a few bruises and fractured the bones of his nose; he was not stunned. A friend beside him was killed; this seemed to prey constantly upon his mind. He lay for several days in a state of great depression.

Nine weeks later he was in a most feeble and wretched state. His mental condition showed extreme emotional disturbance. (Here hysterical symptoms are described.)

Four years after the accident, long after his claim for compensation had been settled, his medical attendant writes: His appearance is much altered: his voice is weak, almost gone at times; very depressed spirits, palpitation, loss of sleep, bad dreams, very easily tired, can't walk more than two miles. Has lost all his energy. Great dread of impending evil. Can't drive without feeling frightened all the time. (This description closely fits the symptoms of many neurasthenic pensioners.)

His doctor adds, “I knew him well before the accident, and he was a very energetic and very honourable man."

Three years later, i.e. seven years after the accident, his symptoms were still subsiding. Since he began regular work he had continued more markedly to improve.

This account may enable us to appreciate the real deterioration that may follow shell-shock and to picture the probable original condition of some of our socially useless pensioners.

There are one or two types that give trouble in particular directions. Pathological irritability is a very real trouble, of which a man may complain whilst recognising its inadequacy. In some of those cases where shell-shock is pleaded in extenuation of crimes of violence I believe the plea is well-founded though I express no opinion as to how far it should be judicially recognised.

The pathological confabulator is to be reckoned with, and many complaints concerning treatment arise from such men. I give one example, in my book on the psychoneuroses, of a joint confabulation, almost delusional, which affected several men. In another case a young man of good family caused great distress to his father (a very old friend of mine) by a heart-rending account of maltreatment and starvation in a hospital to which I was attached and which was managed upon the kindliest and most efficient lines.

So much for the problem as it concerns the individual patient: now I come to what I call the pension dilemma. We have no concern as clinicians with the rights or wrongs of pensioners, but we have to consider the relation of the pension to the maintenance of symptoms, a relation which does not exist in regard to organic conditions.

One frequently hears the word “pensionitis,' coupled with the suggestion that to reduce or stop a neurasthenic's pension will aid in his recovery. In considering this point we may divide the symptoms into two groups: one the direct result of the repression of war experiences such as could be removed by abreaction, and it is difficult to see how a pension could affect them in either direction, though one must admit that even such symptoms may disappear, temporarily at least, under strong stimuli.

In the other group are those symptoms which are an expression of the inability to face present reality; this is difficult ground indeed, for we know that the supposedly healthy man feels the curse of Adam and even if he has the urging of creative or other socially useful impulse he tends to avoid the unpleasant and seek the pleasant task. Some stimulus is needed for him to face the unpleasant, and how much more necessary is a stimulus to the neurasthenic. This was seen in practice in special war hospitals, where good results often followed a gentle intimation that proof of ability to work was a preliminary to discharge.

So far, then, as a pension removes the need for work it may be harmful; but except in cases of severity the amount of the pension is not sufficient to remove the need for work, though it may serve as a strengthening of the plea, or a feeling of, unfitness.

I will put the question plainly. Are there many cases in which the stopping of a pension would in itself lead to recovery? The answer, in my opinion, is No. (From this discussion I exclude malingering, or the conscious simulation of disease for a definite end; though I am aware that the pensioner, neurasthenic or not, is no more free than other people from the promptings of a conscious self interest.) In so far as the neurosis is a flight from reality, the pension aids in the flight; but that is not to say that the pension maintains the disease. If it were possible to place certain men in such an environment that there would be no gain

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