[CIRP Note: This 1945 article by David Levy is a landmark article in child psychology. The article is a lengthy one with tables and many case reports. This file contains the summary and conclusions. Persons desiring the full text of the article should be able to find it in the archive of most medical libraries. The term "combat neurosis" is an early name for the disorder that is now known as posttraumatic stress disorder (PTSD).]


A review of the records of 124 children referred for behavior problems who had undergone an operative procedure (tonsillectomy in most instances) revealed that in 25 there were manifest emotional sequelae. The largest percentage of sequelae occurred in the group under the age of 3 years (50 per cent) ; the proportion in those above 3 years averaged about 10 per cent. A study of the percentages obtained in proportion to the number of years that had elapsed between the child’s operative procedure and the date on which the history was derived from the mother revealed that these percentages were reduced as the interval of time increased. Hence the derived percentages were considered to be lower than the actual percentages, and the number of emotional sequelae larger than the number recorded.

In 13 of the 25 children who suffered psychologically from the operation there were no histories of emotional difficulties preceding that event. The increased emotional hazard of the operation for the 1 and 2 year old children was related to their keener response to pain, poorer comprehension of the experience, greater dependence on the mother, less experience in social contacts outside the home and less facility in handling anxiety.

Prolonged night terrors were characteristic responses of the 1 and 2 year old children ; negativistic responses, of those aged 4 years and older. Fears other than night terrors occurred at every age up to 8 years. Dependency reactions, though necessarily arising whenever fears are present, were especially noteworthy in 3 children. Regressive reactions, such as a return to enuresis, feeding problems and the like, were rarely present.

Manifestations of simple anxiety, consistent with dependency and helplessness, occurred in the youngest age group ; manifestations of hostility, consistent with increased aggressiveness, occurred in the oldest age group.

The most frequent fears were of the dark, of physicians and nurses and of strange men. The “total fear reaction” was to strange people, strange places and hurtful objects. There were various modifications of total specific fears. When prolonged, the general fears left, and a specific fear relating to the operative procedure remained. Otherwise, fears of the dark outlasted all others.

When considered in accordance with general psychiatric nosology the emotional sequelae were classified as follows:

1. Conditioned fear.
2. Dependency fears and regressions.
3. Latent fear.
4. Phobias.
5. Anxiety states.
6. Hostility reactions.
7. Obsessions.
8. Hysteria.

The prevention of postoperative fears is thought to consist of the following steps :

  1. Postponement of the operation, if possible to at least the age of 3 years, especially if evidence of anxiety or undue dependency on the mother is evident.
  2. An explanation to the child of what is to take place, to overcome reactions to the strange or surprising event.
  3. Contact with the mother before and after the operation.
  4. Preparatory sedative and anesthetic in the bedroom, to spare the child the experiences of seeing instruments and the operating room and riding through the corridors.

The child has his own method of overcoming anxiety through play of his own devising. In the 2 instances in which suicidal attempts or near attempts were made, the anxiety was unusually severe and was regarded as beyond the child’ “absorptive capacity.”

The child’s postoperative emotional sequelae are analogous to combat neurosis, since the symptoms are of the same type and the principles of prevention the same.

    Presented before the Section on Psychopathology of Childhood at the Fifty-Fifth Annual Meeting of the American Psychiatric Association, May 15, 1944, Philadelphia.
    1. The number and kind of first surgical procedures on these patients were as follows : Tonsillectomy or adenoidectomy or both, 88 ; Paracentesis of the eardrum, 5 ; mastoidectomy, 4 ; appendectomy, 5 ; other abdominal operations, 1 ; circumcision, 3 ; meatotomy, 3 ; incision or excision of glands, cysts or moles, 7 ; treatment of fractures or lacerations, 4 ; operation for strabismus, 2 ; insertion of a cannula into a tear duct, 1 ; injection into buttocks, 1 ; total, 124.

(File revised 27 November 2005)