As a complement to this case let me cite that of the ex-soldier S. He reached the age of twenty-two with a very creditable history. Born of middle-class parents he went through high school and ranked in the upper third of his class for scholarship. His physique was good; he was a joyous, popular young fellow; and wherever he went was pointed out as the clean young American so representative of our country. That means he worked hard as assistant executive in a production plant, was ambitious to get ahead, took special courses to fit himself, read a good deal about "success" and how to reach it, dressed well, liked his fellow men and more than liked women, enjoyed sports, a good time, the theaters, slept well, ate well and surged with the passions and longings of his youth. Had any one said to him, "What is there to live for?" he would have had no answer ready merely because it would have never occurred to him that any one could really ask so foolish a question.
Came the war. Full of the ardor of patriotism and the longing for the great experience, he enlisted. He took the "hardships" of camp life, the long hikes, the daily drills, the food dished out in tins, as a lark, and his hearty fellowship identified him with the army, with its profanity, its rough friendliness, its grumbling but quick obedience and its intense purpose to "show 'em what the American can do." He went overseas and learned that French patriotism, like the American brand, did not prevent profiteering, and that enlistment in a common cause does not allay or abate racial prejudices and antagonisms. This, however, did not prey on his mind, for he took his Americanism as superior without argument and was not especially disappointed because of French customs and morals. He took part in several battles, made night attacks, bayonetted his first man with a horror that however disappeared under the glory of victory.
One day as he and a few comrades were in a front line trench, "Jerry" placed a high explosive "plump in the middle of it." When S. recovered consciousness, he found himself half covered with dirt and debris of all kinds, and when he crawled out and brushed himself off, he saw that of all his comrades he alone survived, and that they were mangled and mutilated in a most gruesome way.
"Pieces of my friends everywhere," is his terse account. He lay in the trench, not daring to move for hours, the bitterest thoughts assailing him,--anger, hatred and disgust for war, the Germans, his own countrymen; and he even cursed God. When he did this he shuddered at his blasphemy, became remorseful and prayed for forgiveness. A little later he crawled out of the trench and back to where he was picked up by the medical corps and taken to a hospital. He was examined, nothing wrong was found and he was sent back to duty.
From that episode dates as typical an anhedonia as I have ever seen. Gradually he became sleepless and woke each day more tired than he went to bed. The food displeased him, and he grumbled over what were formerly trifles. He wearied easily, and nothing seemed to move him to enthusiasm or desire. He gave up friendship after friendship, because the friends annoyed him by their noise and boisterousness. He dreaded the roar of the guns and the shriek of shells with what amounted to physical agony. He brooded alone, and though not melancholy in the positive insane sense, was melancholy in the disappearance of desire, joy, energy, interest and enthusiasm.
Fortunately the armistice came at this time. S. was examined and discharged as well because he made no complaints, for he was anxious to get home. This was his one great desire. At home, with a nice bed to sleep in, good food to eat and the pleasant faces of his own people, his "nerves" would yield, he had no doubt. But he was mistaken; this was not the case. He became no better, and though he tried his old "job," he found that he could not find the energy, enthusiasm or concentration necessary for success. He was then referred to the United States Public Health Service, where I saw him, and he became my patient.
My first problem was to restore the power of sleeping. This I succeeded in doing by means that were entirely "physical." With that accomplished, the man became hopeful of further results, and this enabled one to bring about a desire for food, again by physical means, medicine, in short. The problem of awaking S.'s interest simmered down to that of finding an outlet for his ambition. The Federal Vocational Board granted him the right to take up a business course in a college. Though he found the study hard at first, he was encouraged to keep on and told to expect little of himself at first. This is an important point, for if a man holds himself to a high standard under conditions such as those of S., then failure brings a discouragement that upsets the treatment. At any rate this method of readjustment, with its reliance on medicines to bring sleep and appetite and on training to bring hope and relief from introspection, worked splendidly.
The fact is that no abstruse complicated psychological analysis was necessary here or in most cases. A man is "jarred" from light-hearted health to a grim discouraged state. This discouragement brings with it sleeplessness and loss of appetite, and there gradually develops a series of habits which lower endurance and energy. The habit elements in this condition are not enough recognized, and also the fact that most of the disability is physical in its development though psychological at the start. That is, A. had a severe emotional reaction to a horrible experience; this brought about insomnia and disordered nutrition, and these, by lowering the endurance and ability, brought to being a vicious circle of fatigue and depression, in which fatigue caused depression and depression increased fatigue.
The treatment must be directed at first to the physical factors, and with these conquered the acquired forms of anhedonia usually yield readily.
