Psychologist Norman Fenton served in the army medical corps at Base Hospital 117, an American facility established in 1918 in the foothills of the Vosges to treat soldiers suffering from “war neuroses”—mostly cases that would later be labeled “post-traumatic stress disorder.” In 1919–20 and 1924–25, Fenton performed follow-up studies to see how former Base Hospital 117 patients had adjusted to the postwar world.
EXPLANATION OF THE CATEGORIES FOR PRESENT CONDITION OF THE WAR NEUROTIC GROUP:
1. “Normal:” Back on the Job.—The first category to be used in discussing these cases is “Normal.” Under this come those men who upon return home went back to work and readjusted themselves to civilian life and have been able to support themselves and their families. Many of them note certain novel tendencies in themselves, such as tendencies to become angry or excited easily, some little nervousness, restlessness, forgetfulness, and occasional slight headaches or dizziness (seldom sufficient to incapacitate them from work) and other like mild neurotic symptoms. A typical answer from this type of man was the following one: “Health excellent with the exception that loud noises, such as a band, a blast, a factory whistle, a passing train, and particularly a thunderstorm, will set my nerves aquiver for periods ranging from five minutes to three hours. Am trying to gradually get control of myself and I think I will.” Another wrote: “Any excitement or anything which causes anger leaves me kind of weak. Outside of that I do not notice anything wrong with me.” Somewhat in the same vein was this note: “I have not as much patience as I originally had and am inclined to be snappish and say something quick that I regret a week afterwards.” Yet the general health of these men is good; they are able to be self-supporting and are normally happy.
2. “Neurotic:” Work Full-time but Nervous.—The second group called “neurotic,” consists of those who made practical readjustments to their old way of living, yet continued to suffer from one or more rather severe nervous difficulties. Most of these men were under a physician’s care, or else had at least consulted one about their condition. They were able to work fairly well, but their own personal lives were unhappy because of these neurotic troubles. Some of these men were assigned to lighter and easier work in their old places and were very sensitive about their lowered status. One finds among them the residue of symptoms shown in France—occasionally fine tremors and tics, more often speech defects, weakness, insomnia, jumpiness, distressing inability to concentrate, memory disorders, and “spells” of all sorts. One case, that of a man with combined concussion and gas neurosis, working as an express helper, fainted away in a railroad station when a nearby locomotive puffed suddenly. The following are sentences taken at random from the replies of this group: “I make mistakes I ordinarily would not make.” “Sometimes I find myself between here and France.” “It looks to me as if I had lost some of my sense.” One man who was formerly a chauffeur returned to his old position and now finds that when he gets into a crowded part of the city where there are many other vehicles about he loses his head—so far he has had two accidents, fortunately not serious ones. Another patient returned to his old work as printer. Several dizzy spells at this work interfered with the quality of his product; the last spell led to a serious injury to one of his fingers.1 A great many minor injuries are reported by men in this group as the result of their nervous condition, and several serious accidents. This group tended also to lose considerable in weight upon working hard, especially during the summer. In all men who carried over symptoms to civilian life there was a marked reaction to changes of weather, especially damp weather, which called out moods and depression, seriously handicapping them. In this “neurotic” group there were many men who upon return home tried their former work in machine shops or factories but could not control themselves and became nervous and tired. As one man put it: “I used to work a pneumatic drill but I cannot any longer; the constancy of action is so much like a machine-gun. I tried my best but could not stick it out. I had a semibreakdown.” In the cases of some of the men when gas or ideas of gas were involved, indoor work was difficult. Many of these men, especially during the warm summer months, took positions as salesmen, farmers, sailors, laborers—any position which would give them outdoor work. This change in many cases was the basis of cure, for some later wrote that their new work agreed with them and they were gradually getting back to themselves. With difficulty in standing indoor work came the same inability to remain in noisy places, especially machine shops or factories. Also some men who were in school or college reported that they found it very difficult to concentrate upon their work and that their memories were bad.
3. “Fatigued:” Work about Half-time.—Third comes the group called “fatigued.” Most of these men cannot work regularly without suffering and being confined to bed. The symptoms here are ready fatiguability, severe headaches, lack of ambition and depression (general neurasthenic coloring.) Whereas the “neurotic group” are able to work, though with much discomfort, this group can only work on the average about one-half of the time. Some of them are fortunate in having easy jobs or considerate employers and so manage to support themselves after a fashion. In some cases where the men are married, their wives are also working to meet the expenses of living.
4. “Disabled:” No Work.—The fourth group consists of those at this time actually rehospitalized for psychoneurosis or reporting a “nervous breakdown” or some incapacitating medical disease, such as tuberculosis. One would anticipate many physical disorders occurring as an aftermath of the conditions to which the men were exposed in France, and indeed, many of the men have had some difficulty or other as a result of these experiences. There may also be some men in the “fatigued” group outlined above who have disabilities of an organic nature. A study like the one reported here made by correspondence naturally cannot make adequate clinical differentiations. Intensive neurological and physical examinations of these cases would unquestionably bring to light many interesting clinical facts.
The question might be raised—why include organic conditions in a discussion of neurosis aftermath? It is not suggested, of course, that the tuberculosis or heart trouble is a direct outworking of neurosis; yet it is to the point in considering the relationship of organic conditions to neurosis to recall that an “anxiety” case at the hospital was greatly improved when a tapeworm was removed, and that a splendid young officer with a supposedly hysterical condition diagnosed as astasia-abasia in France turned out to have a spinal cord lesion. Likewise another unfortunate man (never a patient at Base Hospital 117), whose life has been ruined by inadequacy of diagnosis, and who was paraded around at clinics as an interesting example of hysterical gait, proved to have a displaced hip-bone. Southard2 well makes the point “What needs emphasis is that just because we have concluded that the statistical majority of the cases of the so-called Shell Shock belongs in the division of the neuroses, we should not feel too cock-sure that a given case of alleged Shell Shock appearing in the war zone or behind it is necessarily a case of neurosis.”
Likewise, it should be noted that a corollary fact makes this inclusion advisable. Because one of the former patients of Base Hospital 117, who was discharged as a psychoneurotic, is now said to have tuberculosis (only 4 of the cases reached in 1919–20 were so defined and 6 in 1924–25) does not necessarily mean that the neurotic factors are no longer prominent. Quite on the contrary, the principal disabling factor may indeed still be the neurotic rather than the tuberculous elements. In fact, one expert of the Veteran’s Bureau who has had considerable experience with this type of patient has stated that: “The tuberculosis patient on discharge from hospital is almost without exception a mental case because of worry over his condition . . . At least four months of training passes before this condition is overcome.”3 If this is true of the ordinary case, how much more significant in the case of the practiced neurotic. Southard4 has defined another aspect of this problem under the concept of “periorganic” symptoms. A slight wound, not serious in itself, may serve as the focus about which are grouped seriously disabling conditions, for instance, paralysis, contracture, etc. There are so few patients (one per cent) who have reported themselves as disabled from organic disease that their inclusion will be permissible since we have no definite assurance of the insignificance or nonactivity of neurotic factors even in those cases.
5. “Psychotics.”—Fifth is the psychotic group, including such conditions as dementia precox, psychopathic personality, epilepsy, etc. An interesting commentary of theoretic interest is the infrequency of psychotic outworkings among the former patients of Base Hospital 117 as a group. In the 1919–20 study, only one suicide was reported—this a man of poor stock and make-up, never at the front, who entered the hospital after the Armistice and was evacuated with the diagnosis neurasthenia. Otherwise there were relatively few men (ten, or about 1 per cent) whose condition had changed by 1920 from the psychoneurosis diagnosed at the hospital to a psychosis. By 1925 there were four deaths reported as suicides. Twelve others were definitely psychotic, another fourteen were returned as either “in hospital; parents uncertain of address” or “lost” with a fugue or psychopathic coloring attaching to their disappearance. For instance, one boy enlisted in the navy under his brother’s name causing the family considerable trouble when he later deserted. The outside total of possible psychotics was 28 cases, diagnosed psychoneurotic in France or 3.4 per cent of the group. This is striking evidence favoring the psychological conception of war neurosis, for the mere possibility of insanity developing in 830 men over a period of seven years would probably not be less than this total.5
From Shell Shock and Its Aftermath (1926)
1 This man was referred to Federal Board for Vocational Education and given a course in salesmanship.
2 Shattuck Lecture, 1918, p. 55.
3 Report U. S. Veterans’ Bureau, Washington, U. S. Govt. Printing Office, 1923, p. 934.
4 Shell Shock, W. M. Leonard, Boston, 1919, p. 873, and elsewhere in the book.
5“Few physicians are aware that one person in ten in this state (New York) who reaches adult life is admitted to a mental hospital before he dies, or that the number of beds in public hospitals for the insane in this country equals those occupied by all other sick persons combined.” Salmon, T. W.: Mind and Medicine, New York, Columbia Univ. Press, 1924, pp. 4–5. The Mental Hygiene Bulletin, January, 1926, p. 4, gives the probability of insane hospital admission for school and college students as “about 4 per cent” “at some period in their lives.”