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symptoms which he presents are curable, quickly curable; he must be made to note the progress he has made; and he should be granted privileges he asks (visits, walks, participation in common amusements, etc.) only as rewards for further progress, and, as the crowning reward for complete recovery, a real convalescence. One should avoid, as the worst danger, giving him a glimpse of the possibility of retirement, especially retirement on a pension: this would but switch him on a sinister course.

The patient, as has been said, should remain a soldier, subject to discipline. He should keep his uniform and maintain a correct bearing. He should remain in touch with superiors, towards whom he should observe the same deference as if he were normal. Finally, as was very properly recommended by Grasset," he will gradually be placed on the road back to a soldier's life, by being made to take part in military drill in formation under command of non-commissioned officers. This military therapy—the association of these two words has nothing in it that is shocking-is essential. It is enough that the soldier has lost his adaptation to life at the front. It would be a grave error to let him lose also his adaptation to military life.

When the pathological condition has lasted many months, when the emotional balance remains gravely affected, and when hope of an early cure has to be given up, what course should be taken?

Retirement should not be considered. Indeed, what form of retirement could here be applied? One could not think of Retirement No. 2 for a condition unquestionably caused by the war. Nor could one resort to Retirement No. I with pension for a condition which has all the chances of cure once the war is over. As to temporary retirement, it is no longer used in such cases: temporary retirement assumes, in effect, that the patient might be cured at the expiration of his retirement period, but we know that he will not if the war is then still on. The patient must, therefore, be kept in the army. But he must also be eliminated from hospital wards where his presence constitutes for the really sick a cause of discouragement and for the others encouragement in persisting. What then should be done? Certain subjects, when Grasset.

Le traitement des psychonévroses de guerre. Presse médicale, Oct. 28, 1915, No. 52.


sufficiently improved, can be transferred to the auxiliary troops. This solution commends itself particularly for the older retired men or men of the old auxiliary troops who have been—though to but a slight extent–brought into the service of the army. For the others, for those who retain grave symptoms and must still be in institutions, it will be best to provide services for chronics, a sort of lazarettos, where they might be kept until a solution for their case might become available, that is to say, until the end of the war. However, it is probable that if not more than a minimum of

a emotional psychoses are evacuated into the interior and if, in the hospitals which receive this small number, the authorities will proceed with firmness and prudence, this remnant of incurables or, more correctly, pseudo-incurables, will be quite limited.

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Assistant in Neuropathology, Harvard Medical School; Temporary Investi-
gator of Brain Syphilis, Massachusetts Commission on Mental
Diseases; Chief Medical Officer, Psychopathic De-

partment, Boston State Hospital.
It is axiomatic that the border line between sanity and insanity
is very difficult to draw, but the distinction between insane and
not insane is much complicated if there exists in the patient any
mental disease-psychopathia, psychoneurosis or psychosis. The
question of insanity is a legal matter-one of evidence and law.
To the law one is insane or sane—the dividing line (however un-
certain the medical or other definition may be) is absolute.

Among the psychoneurotics one finds not infrequently cases in which there can be very little doubt of insanity in the legal sensecases such that, by reason of their mental state, anything approaching a normal conduct of life is impossible. Their conduct is socially inefficient” (White), and due to a mental disorder. In many such cases there is a definite doubt between psychosis and psychoneurosis; in other words, the differential diagnosis is very difficult. Some cases which seem purely psychoneurotic run a definite course with recovery, much as do the manic-depressive cases. In many of these there is a very real danger of suicide ; others have other complicating factors, some of which will be pointed out. Study of this group seems to bring out more clearly than in any other the great importance of a thorough analysis of the entire life of the individual, since it is only by this method that the sequence of events can be correctly obtained, the primary and secondary phenomena in the mental state determined, and the causes for the mental maladjustment laid bare.

Because of the practical importance of these several points, ten cases illustrating various phases of the question have been chosen at random from the records of the hospital; limiting the choice to cases in which psychoneurosis was important in the diagnosis, and

* Contribution from the Psychopathic Hospital, series of 1918.

the cases either ran a manic-depressive course, were insane in the legal sense, committed suicide, or the differential diagnosis was obscure. All of the cases have been thoroughly studied, and all but one presented at staff meeting, which means that a great deal of time was spent in working out the case—so the opinions recorded were not formed in haste, but were subject to considerable debate and correction by the entire staff.

Merely for convenience, the cases have been taken in the order in which they appeared at the hospital. Many more could be added to the list, but without revealing any additional information.

THE CASES. Case I.–A successful business man, 48 years of age, salesman in the furniture business, constantly advancing in his salary until within two years; married, with two living children. No history of lues, but gonorrhea at 39. Heavily alcoholic until eight months before admission.

He first came to the out-patient department of this hospital January 3, 1916, when he said that about three years previously he had a period in which he was somewhat agitated, miserable, had numbness in the head, dull headaches and dizzy spells. People moving about confused him. These had continued more or less until the time of his visit, when the symptoms were somewhat worse. Physical examination was practically negative. He continued to visit the out-patient department with some relief, but finally entered the hospital voluntarily on July 5th, at which time he was depressed, emotionally unstable, and much worried over his physical condition. He showed no major psychotic symptoms; complained a great deal of nervousness, of a fear of sickness; was worried; emotionally unstable ; somewhat depressed. No delusions; no hallucinations; no loss of memory. He thought that he might be dwelling too much upon his physical condition. A week later was pleasant and cheerful, not anxious, and in fairly good condition. Physical examination was practically negative. Partial deafness of right

No other abnormal neurological findings. Blood-pressure 128-70. Urine negative. Wassermann reaction on the serum negative. He was discharged to the out-patient department, and on October 17, 1916, on the advice of the out-patient department physician, he entered a state hospital as a voluntary patient.

In the meantime his wife had complained that several times he had sharpened knives apparently with intent to commit suicide. His wife gave a family history of both grandfathers being insane, and an uncle and sister insane. The patient knew nothing of his grandparents. Said his mother was inclined to be hypochondrical, and thought that some of her people were insane. He had a feeble-minded sister.

At the state hospital the patient laid his trouble to the fact that another man had been showing his wife attention for about three years, that fol


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