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Title: Shell-Shock and Other Neuropsychiatric Problems - Presented in Five Hundred and Eighty-nine Case Histories from the War Literature, 1914-1918
Author: Southard, Elmer Ernest
Language: English
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SHELL-SHOCK AND OTHER NEUROPSYCHIATRY PROBLEMS


      *      *      *      *      *      *

                                  THE
                          CASE HISTORY SERIES

                      CASE HISTORIES IN MEDICINE
                                  BY
                        RICHARD C. CABOT, M.D.
                  Third edition, revised and enlarged

                         DISEASES OF CHILDREN
                                  BY
                        JOHN LOVETT MORSE, M.D.
                  Third edition, revised and enlarged
                Presented in two hundred Case Histories

                     ONE HUNDRED SURGICAL PROBLEMS
                                  BY
                        JAMES G. MUMFORD, M.D.
                            Second Printing

                      CASE HISTORIES IN NEUROLOGY
                                  BY
                          E. W. TAYLOR, M.D.
                            Second Printing

                     CASE HISTORIES IN OBSTETRICS
                                  BY
                      ROBERT L. DENORMANDIE, M.D.
                            Second Edition

                           DISEASES OF WOMEN
                                  BY
                        CHARLES M. GREEN, M.D.
                            Second Edition
       Presented in one hundred and seventy-three Case Histories

                             NEUROSYPHILIS
               MODERN SYSTEMATIC DIAGNOSIS AND TREATMENT
       Presented in one hundred and thirty-seven Case Histories
                                  BY
                      E. E. SOUTHARD, M.D., Sc.D.
                                  AND
                          H. C. SOLOMON, M.D.
     Being Monograph Number Two of the Psychopathic Department of
      the Boston State Hospital, Massachusetts. (Monograph Number
     One was A Point Scale for Measuring Mental Ability by Robert
    M. Yerkes, James W. Bridges and Rose S. Hardwick. Published by
                  Warwick and York. Baltimore 1915.)

            SHELL SHOCK AND OTHER NEUROPSYCHIATRIC PROBLEMS
        Printed in five hundred and eighty-nine Case Histories
                                  BY
                      E. E. SOUTHARD, M.D., Sc.D.
    Being Monograph Number Three of the Psychopathic Department of
               the Boston State Hospital, Massachusetts

      *      *      *      *      *      *


[Illustration: HORSLEY, 1857-1916]

[Illustration: DEJERINE, 1849-1917]

[Illustration: VAN GEHUCHTEN, 1861-1914]

IN MEMORIAM


SHELL-SHOCK AND OTHER NEUROPSYCHIATRY PROBLEMS

Presented in Five Hundred and Eighty-Nine Case Histories
from the War Literature, 1914-1918

by

E. E. SOUTHARD, M.D., Sc.D.

Director (1917-1918), U. S. Army Neuropsychiatric Training
School (Boston Unit); Late Major, Chemical Warfare Service, U.
S. Army; Bullard Professor of Neuropathology, Harvard Medical
School; Director, Massachusetts State Psychiatric Institute
(of the Massachusetts Commission on Mental Diseases); Late
President, American Medico-Psychological Association

With a Bibliography by Norman Fenton, S.B., A.M.

Sergeant Medical Corps, U. S. Army (Assistant in Psychology to
the Medical Director, Base Hospital 117 A. E. F.); late interne
in Psychology, Psychopathic Department, Boston State Hospital;
Assistant in Reconstruction, National Committee for Mental
Hygiene

And an Introduction by Charles K. Mills, M.D., L.L.D.

Emeritus Professor of Neurology, University of Pennsylvania


By Vote of the Trustees of the Boston State Hospital
Monograph Number Three of the Psychopathic Department



Boston
W. M. Leonard, Publisher
1919

Copyright, 1919, by
W. M. Leonard



                                  To
                      THE NATIONAL COMMITTEE FOR
                            MENTAL HYGIENE
                                  AND
                              ITS WORK IN
                             WAR AND PEACE



PREFACE


This compilation was begun in the preparedness atmosphere of the U.
S. Army Neuropsychiatric Training School at Boston, 1917-18. This
particular school had to adapt itself to the clinical material of the
Psychopathic Hospital. Although war cases early began to drift into the
wards (even including some overseas material), it was thought well to
supplement the ordinary “acute, curable, and incipient” mental cases of
the hospital wards and out-patient service with representative cases
from the literature.

As time wore on, this “preparedness” ideal gave place to the ideal of
a collection of cases to serve as a source-book for reconstructionists
dealing with neuroses and psychoses. Shortage of medical staff and
delays incidental to the influenza epidemic held the book back still
further, and, as meantime Brown and Williams had served the immediate
need with their _Neuropsychiatry and the War_, it was determined to
make the compilation the beginning of a case-history book on the
neuropsychiatry of the war, following in part the traditions of various
case-books in law and medicine.

With the conclusion of the armistice, there is by no means an end of
these problems. Peace-practice in neuropsychiatry is bound to undergo
great changes and improvements, if only from the influx into the
peace-community of many more trained neuropsychiatrists than were
ever before available. This is particularly true in the American
community by reason of the many good men specially trained in camp and
hospital neuropsychiatry, both at home and in the A. E. F., through the
enlightened policy of our army in establishing special divisions of the
Surgeon-General’s Office dealing separately with those problems.

Though a book primarily for physicians, some of its material has
interest for _line-officers_, who may see how much “criming” is matter
for medical experts, by running through the boxed headings (especially
of Sections A and B) and reading the simulation cases. As Chavigny
remarks, “shooting madmen neither restrains crime nor sets a good
example.”

But parts of the book look ahead to _Reconstruction_. Surely
occupation-workers, vocationalists, war risk insurance experts, and
in fact all reconstructionists, medical and lay, must find much to
their advantage in the data of Section D (Treatment and Results). Had
time permitted, the whole old story of “Railway Spine”--Shell-shock’s
congener--might have been covered in a series of cases from last
century’s literature, together with others illustrating the effects of
suggestion and psychotherapy; but this must be a post-bellum task.

The compiler, who has personally dictated (and as a rule redictated
and twice condensed) all the cases from the originals (or in a few
instances, _e.g._, Russian, from translations), hopes he has not added
anything new to the accounts. The cases are drawn from the literature
of the belligerents, 1914-1917, English, French, Italian, Russian,
and--so far as available here--German and Austrian.

I would call the collection not so much a posey of other men’s flowers
as a handful of their _seeds_. For I have constantly not so much
transcribed men’s general conclusions as borrowed their specific
fine-print and footnotes. The lure of the 100 per cent has been very
strong in many authors; but the test of fine-print, viz., of the
actual case-protocols, saves us from premature conclusions, and the
plan of the book allows us to confront actualities with actualities.
One gets the impression of a dignified debate from the way in which
case-histories automatically confront each other, say in Section C
(Diagnosis).

Obligations to the books of Babinski and Froment, Eder, Hurst, Mott
(Lettsomian Lectures), Roussy and Lhermitte, Elliot Smith and Pear,
and others are obvious. Yealland’s book came too late for sampling its
miracles, though cases of his in the periodical literature had already
been incorporated in my selection.

Some of the cases in Section A, I, had already been abstracted in
Neurosyphilis: Modern Systematic Diagnosis and Treatment (Southard and
Solomon, 1917).

What we actually have made is a case-history book in the newly
combined fields now collectively termed _neuropsychiatry_. The
more _general_ the good general practitioner of medicine, the more
of a _neuropsychiatrist_! And this is no pious wish or counsel of
perfection. Neuropsychiatry, mental hygiene, psychotherapy and
somatotherapy--all these will flourish intra-bellum and post-bellum,
in days of destruction and in days of reconstruction. And who amongst
us, medical or lay, will not have to deal in reconstruction days with
cases like some here compiled? A minor blessing of the war will be the
incorporation of mental hygiene in general medical practice and in
auxiliary fields of applied sociology, _e.g._, medico-social work.

Subsidies aiding publication are due to the National Committee for
Mental Hygiene; the Permanent Charity Foundation (Boston Safe Deposit
and Trust Company); Mrs. Zoe D. Underhill of New York; Mr. H. T. White
of New York; and Dr. W. N. Bullard of Boston--to all of these the
various military recipients of the book will be under obligations,
as well as others who would otherwise have had to pay the great
_majoration de prix_ due to war times.

Of those great dead contributors to neurology laid (in the Epicrisis)
at the feet of the neo-Attila, perhaps only Sir Victor was in a narrow
sense the Kaiser’s victim: still, but for the war, they might all
remain to us.

By the way, just as I found John Milton had said things that fitted
neurosyphilis, so also Dante is observed in the chosen mottoes to have
had inklings even of Shell-shock. To the _Inferno_ it was natural to
turn for fitting mottoes (Carlyle’s renderings mainly used). The pages
might have been strewn with them. A glint of too great optimism might
seem to shine--in the pre-Epicrisis motto--from the lance of Achilles
with its “sad yet healing gift;” but out of Shell-shock Man may get to
know his own mind a little better, how under stress and strain the mind
lags, blocks, twists, shrinks, and even splits, but on the whole is
afterwards made good again.

                                                        E. E. SOUTHARD.

    WASHINGTON,
      _November, 1918_.



INTRODUCTION


The duties of an introducer, whether of a platform speaker to an
audience, or of a writer to his anticipated readers, are not always
clearly defined. It has been sometimes said that the critic or reviewer
may meet with better success if he has not acquainted himself too
thoroughly with the contents of the book about which he writes, as in
that case he will have a larger opportunity to indulge his imagination,
but a critique thus produced may have the disadvantage of possible
shortcoming or unfairness. In the case of this volume, however, I have
felt it worth while to acquaint myself with its contents, no light task
when one is confronted with a thousand pages.

The great war just closing has done much to enlighten us as to the
causes, nature, outcome, and treatment of injuries and diseases to
which its victims have been subjected. The object of this book is
to present both the data and the principles involved in certain
neuropsychiatry problems of the war. These are presented in a wealth
of detail through an extraordinary series of case records (589 in
all) drawn from current medical literature, during the first three
years of the conflict. Case reporting is here seen at its best, and
the experiences recorded are largely allowed to speak for themselves,
although comments are not wanting and are often illuminating.

Many criticisms have been heard on the use of the term _Shell-shock_
as applied to some of the most important psychiatric and neurological
problems of the recent war; but that the designation has meaning will
be evident if Dr. Southard’s book is not simply skimmed over by the
reader, but is studied in its entirety. The symptoms of a very large
number, if not the majority, of the cases recorded, had for their
initiating influence the psychic and physical horrors of life among
exploding shells. As the author and those from whom he has received
his clinical supply not infrequently point out, in many cases it would
appear that purely psychic influences have played the chief rôle, but
in others physical injuries have not been lacking. Much more than
this is true: in many instances the soil was prepared by previous
defect, disease, or injury, or to use one of Dr. Southard’s favorite
expressions, “weak spots” were present before martial causes became
operative.

While the contributions to the medical and surgical history of the
war have been somewhat numerous in current medical journals and in
monographs, few comprehensive volumes have appeared. The reasons for
this are not far to seek. The conflict has been of such magnitude, and
the demands on the bodily and mental activity of the medical profession
have been so intense and continuous, that time and opportunity for
the careful and complete recording of experiences have not been often
available; but works are beginning to appear in the languages of all
the belligerent countries and these will increase in number and value
during the next lustrum and decade, although it may be that some of the
most important contributions will come after a decade or more is past.
The great work before me is one that will leave its lasting impress,
not only upon military but on civil medicine, for the lessons to be
drawn from its pages are in large part as applicable to the one as to
the other.

Looking backward to our Civil War, one is strongly impressed with the
fact that the present volume, one of the earliest works of its kind
to appear in book form, deals largely with psychiatry and functional
nervous diseases, whereas during and after the American conflict the
most important contributions to neurology related to organic disease,
especially as illustrated by the work of Weir Mitchell and his
collaborators on injuries of nerves. This is the more interesting when
it is remembered that Mitchell not very long after the close of the
Civil War became the most prominent exponent of functional neurology,
from the diagnostic and therapeutic sides. To him the profession the
world over has been indebted for the development of new views as to
the nature of neurasthenia and hysteria and new methods for combating
these disorders. In this fact is to be found matter for thought. Those
who handled best the neuropsychiatric problems of the present war were
in large part qualified not merely by a knowledge of psychology and
psychiatry, but far more by a thorough training in organic neurology.
The problems of psychiatry can be grasped fully only by those who have
a fundamental knowledge of the anatomy, physiology, and diseases of the
nervous system.

Dr. Southard, preëminently a neuropathologist, is well grounded in
organic neurology, and shows at every turn his capabilities for
considering the neuroses, psychoses, and insanities from the standpoint
of the neurologist. Moreover, he clearly shows training and insight
into the problems of non-neurological internal medicine.

The ideal method of training a student for neuropsychiatric work--if
one had the opportunity of directing his course from the time of his
entry into medicine--would be to see to it, after a good grounding in
the fundamental sciences like anatomy, physiology, and chemistry, that
medicine and surgery in their broadest phases first received school and
hospital attention; that the fields of neurology, pure and applied,
were then fully explored; and that psychology and psychiatry received
late but thorough consideration. When after America’s entrance into the
world war the writer assisted in preparing medical reserve officers
for neuropsychiatric service, those men did best both during their
postgraduate work and in base hospitals and in the field, who had built
from the bottom after the manner indicated.

At the outset of Dr. Southard’s book, for more than two hundred and
fifty pages, the author considers under ten subdivisions the acquired
diseases and constitutional defects which may predispose the soldier
to functional and reflex nervous disease. Neurosyphilis, on which Dr.
Southard and Dr. Solomon have already given us a valuable treatise,
the pharmacopsychoses, especially alcoholism, and the somatopsychoses
covering fevers like typhoid and paratyphoid, are considered in
numerous carefully chosen case reports. The reader needs only to look
closely into the case records of the first quarter of the volume to
get a knowledge of the affections chiefly predisposing the soldier or
civilian to functional and reflex nervous diseases. To those familiar
with the medical history of the war it is well known that one of the
reasons for the efficiency of the American Expeditionary Force resided
in the fact that the preliminary examinations of the recruits received
the fullest attention not only from the points of view of acquired and
inherited disease, but also from those of special psychiatric and even
psychological deficiencies. Our country, however, had for its guidance
the experience of nations which were fighting for three years before we
entered the arena and in addition had a large surplus of material from
which to cull out the weaklings.

Among the predispositional affections considered--besides syphilis,
alcohol, and other drug habits, and the somatopsychoses--are the
feeble-mindednesses or hypophrenoses, the epilepsies, the psychoses
due to focal brain lesions, the presenile and senile disorders, the
schizophrenoses including dementia præcox and allied affections, the
cyclothymoses like manic depressive insanity, the psychoneuroses, and
the psychopathoses. The last two subjects indicated, considered in
special chapters, seem to some extent to be receptacles for affections
which cannot well be otherwise placed,--hallucinoses, hysteria,
neurasthenia, and psychasthenia,--and under the psychopathoses,
pathological lying, Bolshevism, delinquencies of various sorts,
homosexuality, suicide and self-mutilation, nosophobia, and even
claustrophobia with its exemplar who preferred exposure to shell-fire
to remaining in a tunnel.

Under the encephalopsychoses are found interesting illustrations of
focal lesions and the general effects of infection and toxemia. Cases
of brain abscess, of spinal focal lesions, and meningeal hemorrhage
are in evidence, aphasias, monoplegias, Jacksonian spasm, and thalamic
disease receiving consideration.

All neurologists know the difficulties in diagnosticating epilepsy
in the absence of opportunities to see attacks and to receive the
carefully analyzed statement of the observers of the patient. All this
and much more is well brought out in the chapter on the epileptoses.
Many epileptics found their way into the armies either through the
carelessness of examiners or by suppression of the facts on the part of
those who desired to serve.

The fact that an imbecile can shoot straight and face fire comes out in
one or two places, but this does not seem to prove that a good rifleman
is necessarily an all-round good soldier.

A book like Dr. Southard’s could be made of much use in teaching
students, especially postgraduates, by having them, when a particular
subject like epilepsy or schizophrenia, for instance, is under
discussion, use as collateral reading the case reports of this work.

Dr. Southard’s book will prove useful to many workers--to the medical
officer whose duty it is to examine recruits for the service or to pass
upon and treat them while in service; almost equally to the medical
officer in time of peace; to authors of textbooks and treatises and to
contributors to neurological and psychiatric journals; to lecturers and
clinical demonstrators; to the examiner for the juvenile courts; and to
members of the psychopathic, psychiatric, and neurological staffs of
our hospitals.

One is not called upon in an introduction to review at length the
contents of the volume, but it may prove of value to the reader to dip
here and there into the pages of the work to which his attention is
being invited.

It will be remembered that fifty years ago and much later, down to
the time of Babinski’s active propaganda in favor of the theories of
suggestion, counter-suggestion, and persuasion in hysteria, various
affections of a vasomotor and thermic type were included in the list
of hysterical phenomena. These and some other phenomena sometimes
classed as hysterical, Babinski and those who accord with him now find
it necessary to sweep entirely from the domain of hysteria, which being
produced by suggestion and cured by counter-suggestion or persuasion
cannot include symptoms which are beyond the control of the will and
intellect of the patient.

According to the new or rather revived pronouncement, these must be due
either to definite organic lesion, or to a disorder of reflex origin,
connoting the occurrence of changes in the nervous centers as long
ago taught by Vulpian and Charcot. In the records of cases and in the
discussions thereon this differentiation receives much consideration.

It is held that the paralysis in the reflex cases is more limited, more
persistent, and assumes special forms not observable in hysteria. The
attitudes in hysterical palsies conform more to the natural positions
of the limbs than do those observed in reflex paralysis. Probably the
presence of marked amyotrophies in the reflex nervous disorders is the
most convincing factor in separating these from pithiatic affections.
These atrophies correspond to the arthritic muscular atrophies of
Vulpian, Charcot, Gowers, and others, and cannot for a moment be
regarded as caused by suggestion or as removable by counter-suggestion
or persuasion. They are influenced, discounting the effect of time
and natural recuperation, only by methods of treatment designed to
improve the peripheral and central nutrition of the patient. Pithiatic
atrophies are slight and probably always to be accounted for by
disuse or the association of some peripheral neural disorder with the
hysteria. Affections of the sudatory and pilatory systems are more
definitely pronounced in reflex cases than in those of a strictly
hysterical character.

Some of the facts brought forward by Babinski and Froment to
demonstrate the differentiation of reflex paralyses from pithiatic
disorders of motion are challenged in the records of this volume by
others, as for instance, by Dejerine, Roussy, Marie, and Guillain.
Babinski tells us that in pithiatism, properly so designated, the
tendon reflexes are not affected. He believes that even in pronounced
anesthesia of the lower extremities the plantar reflexes can always
be elicited and are not abnormal in exhibition. Dejerine, however,
produces cases to illustrate the fact that in marked hysterical
anesthesia of the feet plantar responses cannot be produced. I have
personally studied cases which lend some strength to either contention.
In some of these I was not able to conclude that either the use of the
will or the presence of contractions in extension was sufficient to
exclude the normal responses.

Differences in muscle tonicity, in mechanical irritability of the
muscles, and the presence or absence of fibrotendinous contractions are
indications of a separation between the reflex and purely functional
cases, as apparently demonstrated in some of the case records. True
trophic disorders of the skin, hair, and bones observed in the reflex
cases are also said to have no place in the illustrations of pithiatism.

The delver into the case histories of this volume will find numerous
instructive combinations of hystero-reflex and organo-hysterical
associations which are not to be enumerated in an introduction. The
great importance of what all recognize as pathognomonic signs of
organic disease--Babinski extensor toe response, persistent foot
clonus, reactions of degeneration, marked atrophy, lost tendon
jerks, etc.--is, of course, continuously in evidence. Extraordinary
associations of hysterical, organic, and reflex disorders with other
affections due to direct involvement of bone, muscle, and vessels and
with the secondary effects of cicatrization and immobilization are
brought out on many pages. In quitting this branch of our subject
it might be remarked that considerable changes must be made in
our textbook descriptions of nervous diseases in the light of the
contributions to the neurology of the present war.

One is reminded in the details of some of the cases of the discussions
some decades since on the subject of spinal traumatisms; of the work
of Erichsen which resulted in giving his name and that of “railway
spine” to many of the cases now commonly spoken of as traumatic
hysteria and traumatic neurasthenia; of the rejoinders of Page and his
views regarding spinal traumatisms; and of Oppenheim’s development of
the symptom complex of what he prefers to term the traumatic neurosis.
One who has taken part in much court work cannot but read these case
records with interest, for the neurology of the war as presented in
this volume and in numerous monographs which are now appearing, throws
much light upon many often mooted medicolegal problems. I recall
how many able and honest neurological observers have changed their
points of view since the early days of Erichsen’s “railway spine,” a
pathological suggestion which is said to have cost the corporations of
England an almost fabulous sum during a score of years. I recall also
that a certain Court of Appeals in one of our states even felt itself
called upon to promulgate an opinion intended to exorcise entirely the
plea for damages for alleged injuries if it could be shown that these
were due to fright. The data of this book do not put weapons entirely
into the hands of the attorney and the expert for either the plaintiff
or the defendant.

Some of the French writers on the neurology of the war, as illustrated
in the records collected by Dr. Southard, have brought to our attention
distinctions which they draw between _états commotionnels_ and _états
émotionnels_--happy terms, and yet not sufficient in their invention
or in the explanations which accompany them, fully to satisfy the
requirements of the facts presented. These writers seem to think of
the commotional states as denoting some real disease or condition of
the brain, and yet one which is really curable and reversible. They
explicitly tell us, however, that these commotions fall short of
being _lésionnel_. After all, is this not somewhat obscure? Is it not
something of a return to the period of “railway spine” when one of the
comparisons sometimes made was that the injury suffered by the nervous
tissues produced in them a state comparable to that of a magnet
which had been subjected to a severe blow? At any rate, in commotion
thus discussed the nervous structures are supposed to sustain some
real injury of a physiochemical character, whereas in the emotional
states the neurones are, as Southard puts it, affected somewhat after
the manner of normal emotional functioning, except perhaps that they
are called upon to deliver an excessive stream of impulses. The
latter would be classed among the psychopathic, the former among the
physiopathic affections, and yet the distinction between the two is not
always quite clear.

In not a few instances of Shell-shock--although these are not numerous,
so far as records have been obtained--actual structural lesions have
been recorded even in cases in which no direct external injury of a
material kind was experienced as a result of the explosion of shells.
In others the evidences of external injury were relatively unimportant.
Various lesions, in some cases recognizable even by the naked eye, were
present. Mott, for example, found not only minute hemorrhages, but
in one instance a bulbar extravasation of moderate massiveness, the
patient not showing external signs of injury. Cases are also recorded
of hematomyelia; others with edematous or necrotic areas in the cord;
and still others with lesions of the ependyma or even with splitting of
the spinal canal, reminding one of the classical experiments of Duret
on cerebral and cerebrospinal traumatisms.

It has been argued that too much stress should not be laid on a few
cases of this sort--but are they as few as they seem to be? The fact
is that necropsical opportunities are not often afforded. May not such
scattered lesions often be present without resulting in death or even
in long continued disturbance? There is no essential reason why minute
hemorrhages into the brain and spinal cord, and especially into their
membranes, may not undergo rapid absorption or even remain unchanged
for some time without dire results.

One of the reported cases in which lung splitting occurred from severe
concussion without external injury is not without interest in this
connection, reminding one, as the commentator says, of those cases of
severe concussion in which the interior of a building is injured while
the exterior escapes. In the same connection also the cited experiments
of Mairet and Durante on rabbits are not without instructiveness.
As a result of explosives set off close to these animals, pulmonary
apoplexy, spinal cord and root hemorrhages, and extravasations,
perivascular and ependymal, and into the cortical and bulbar gray were
found. Russca obtained direct and _contrecoup_ brain lesions, etc., in
a similar way.

Here and there throughout the book will be found references to
symptoms and syndromes which will have a particular interest for the
reader--soldier’s heart, trench foot, congealed hand, tics, tremors,
convulsions, sensory areas variously mapped, and forms of local
tetanus, the last being distinctly to be differentiated from pithiatic
contractures and those due to organic lesions of the nervous system.
Cases of an affection described by Souques as camptocormia, from Greek
words meaning to bend the trunk, were shown to the Neurological Society
of Paris in 1914 and later, the main features of this affection being
pronounced incurvation forward of the trunk from the dorsolumbar
region, with extreme abduction and outward rotation of the lower limbs,
pain in the back, and difficult and tremulous walking. In some of these
cases, organic lesions of the trunkal tissues were present, but in
addition psychic elements played a not unimportant part, and the cases
were restored to health by a combination of physical measures with
psychotherapy, enforced by electrical applications.

The part of this book given over to the discussion of treatment will
doubtless to some prove the most interesting section. The presentation
of the subject of therapeutics is in some degree a discussion also of
diagnosis and prognosis; and so it happens in various parts of the
volume that the particular subject under consideration is more or less
a reaffirmation or anticipation of remarks under other headings.

Similar results are brought about by various therapeutic procedures.
Nonne, Myers, and a few others bring hypnosis into the foreground,
although non-hypnotic suggestion plays a larger rôle by far.

Miracle cures are wrought through many pages. Mutism, deafness and
blindness, palsies, contractures, and tics disappear at times as if by
magic under various forms of suggestion. Ether or chloroform narcosis
drives out the malady at the moment when it reveals its true nature.
Verbal suggestion has many adjuvants and collaborators--electricity,
sometimes severely administered, lumbar puncture, injections of
stovaine into the cerebrospinal fluid, injections of saline solution,
colored lights, vibrations, active mechanotherapy, hydrotherapy, hot
air baths and blasts, massage, etc. Painful and punitive measures have
their place--one is inclined to think a less valuable place than is
given them by some of the recorders. In some instances the element of
suggestion, while doubtless present, is overshadowed by the material
methods employed. Persuasion and actual physical improvement are in
these cases highly important. Reëducation is not infrequently in
evidence. The patient in one way or another is taught how to do things
which he had lost the way of doing.

It is interesting to American neurologists to note how frequently
in the reports, especially of French observers, the “Weir Mitchell
treatment” was the method employed, including isolation, the faradic
current, massage, and Swedish movements, hydrotherapy, dietetic
measures, reëducative processes, and powerful suggestion variously
exhibited, especially through the mastery of the physician over
the patient. It is rather striking that few records of Freudian
psychoanalytic therapy are presented.

When all is said, however, counter-suggestion and persuasion, in
whatever guise made use of, were not always sufficient and this not
only in the clearly organic cases, but in those which are ranked under
the head of reflex nervous disorders. In these the long-continued use
of physical agencies was found necessary to supplement the purely
psychic procedures, these facts sometimes giving rise in the Paris
Society of Neurology and elsewhere to animated discussion as to the
real nature of the cases. The pithiatic features of the case at times
disappear, but leave behind much to be explained and more to be
accomplished. The cures wrought are not always permanent and in some
cases post-bellum experiences may be required to prove the real value
of the measures advocated. The reader must study well the detailed
records in order to arrive at just conclusions; nevertheless, the
tremendous efficacy of suggestion and persuasion stands out in many of
the recitals.

Perhaps the author may permit the introducer a little liberty of
comment. His non-English interpellations, especially Latin and French,
may be regarded by some as overdone or perhaps pedantic, but are rather
piquant, giving zest to the text. _Diagnosis per exclusionem in ordine_
is sonorous and has a scholarly flavor, but does not prevent the reader
who lives beyond the faubourgs of Boston from understanding that the
author is speaking of an ancient and well-tried method of differential
diagnosis. _Passim_ may be more impressive or thought-fixing than
its English translation, but this to the reader will simply prove
a matter of individual opinion. _Psychopathia martialis_ is not
only mouth-filling like _Senegambia_ or _Mesopotamia_, but really
has a claim to appreciation through its evident applicability. It
is agreeable to note that the book seems nowhere to indicate that
_psychopathia sexualis_ and _psychopathia martialis_ are convertible
terms.

The bibliography of the volume challenges admiration because of its
magnitude and thoroughness and is largely to be credited, as the author
indicates, to the energy and efficiency of Sergeant Norman Fenton, who
did the work in connection with the Neuropsychiatric Training School
at Boston, resorting first-hand to the Boston Medical Library and the
Library of the New York Academy of Medicine. After Sergeant Fenton
joined the American Expeditionary Force, Dr. Southard greatly increased
the value of the bibliography by his personal efforts.

This bibliography covers not only the 589 case histories of the book,
but it goes beyond this, especially in the presentation of references
for 1917, 1918, and even 1919. Owing to the time when our country
entered the war, American references are, in the main, of later date
than the case histories. They will be found none the less of value to
the student of neuropsychiatric problems.

The references in the bibliography number in all more than two
thousand, distributed so far as nationalities are concerned about
as given below, although some mistakes may have crept into this
enumeration for various reasons, like the publication of the same
articles in the journals of different countries. The list of references
includes French, 895; British (English and Colonial), 396; Italian,
77; Russian, 100; American, 253; Spanish, 5; Dutch, 5; Scandinavian,
5; and Austrian and German, 476. It will be seen, therefore, that the
bibliography covers in number nearly four times the collected case
studies, most of these records being from reports made during the first
three years of the war. The author has wisely made an effort to bring
the bibliographic work up to and partially including 1919.

The manner in which the French neurologists and alienists continued
their work during the strenuous days of the terrible conflict is
worthy of all praise. The labors of the Society of Neurology of Paris
never flagged, its contributions in current medical journals having
become familiar to neurologists who have followed closely the trend of
medical events during the war. Cases and subjects were also frequently
presented and discussed at the neurological centers connected with the
French and allied armies in France.

It may be almost invidious to specify names, the work done by many
was of so much interest and value. Dejerine in the early days of the
war, before his untimely sickness and death, contributed his part.
Marie from the beginning to the end of the conflict continued to
make the neurological world his debtor. The name of Babinski stands
out in striking relief. Other names frequently appearing among the
French contributors are those of Froment, Clovis Vincent, Roussy
and Lhermitte, Léri, Guillain, Souques, Laignel-Lavastine, Courbon,
Grasset, Claude, Barre, Benisty, Foix, Chavigny, Charpentier, Meige,
Thomas, and Sollier.

For a work of this character not only as complete a bibliography as
possible, but a thorough index is absolutely necessary, and this has
been supplied. The author has not made the index too full, but with
enough cross-references to enable those in all lines of medical work
interested to cull out the cases and comments which most concern them.

My prologue finished, I step aside for the play and the player, with
the recommendation to the reader that he give close heed to the
performance--to the recital of the cases, the comments thereon, and the
general discussion of subjects--knowing that such attention will be
fully rewarded, for in this wonderful collection of Dr. Southard is to
be seen an epitome of war neurology not elsewhere to be found.

                                                      CHARLES K. MILLS.

    _Philadelphia_, May, 1919.



TABLE OF CONTENTS


            SECTION A. PSYCHOSES INCIDENTAL IN THE WAR

           I. THE SYPHILITIC GROUP (_Syphilopsychoses_)

  CASE                                                                 PAGE

    1. Desertion of an officer                         _Briand_, 1915     8

    2. Visions of a naval officer  _Carlill_, _Fildes_, _Baker_, 1917     9

    3. Aggravation of neurosyphilis by war           _Weygandt_, 1915    10

    4. Same                                             _Hurst_, 1917    10

    5. Same                                            _Beaton_, 1915    10

    6. Same                                         _Boucherot_, 1915    11

    7. Same                                              _Todd_, 1917    12

    8. Same                                            _Farrar_, 1917    13

    9. Same                    _Marie_, _Chatelin_, _Patrikios_, 1917    14

   10. Root-sciatica                                     _Long_, 1916    15

   11. Disciplinary                                    _Kastan_, 1916    17

   12. Same                                            _Kastan_, 1916    18

   13. Same?                                           _Kastan_, 1916    19

   14. Hysterical chorea _versus_ neurosyphilis
                                      _de Massary_, _du Sonich_, 1917    20

   15. Traumatic general paresis                        _Hurst_, 1917    22

   16. Head trauma; shell-shock; mania; W. R. positive
                                           _Babonneix_, _David_, 1917    23

   17. Head trauma in a syphilitic         _Babonneix_, _David_, 1917    24

   18. Shell wound: general paresis                 _Boucherot_, 1915    25

   19. “Shell-shock” ocular palsy: syphilitic        _Schuster_, 1915    26

   20. Shell-shock: general paresis                    _Donath_, 1915    27

   21. Shell-shock: tabes                               _Logre_, 1917    28

   22. Same                                      _Duco_, _Blum_, 1917    28

   23. Pseudotabes (Shell-shock)           _Pitres_, _Marchand_, 1916    29

   24. Shell-shock neurosyphilis                        _Hurst_, 1917    30

   25. Shell-shock neurosyphilis                        _Hurst_, 1917    31

   26. Pseudoparesis (Shell-shock)         _Pitres_, _Marchand_, 1916    32

   27. War strain and Shell-shock in a syphilitic     _Karplus_, 1915    34

   28. Shell-shock recurrence of syphilitic hemiplegia
                                             _Mairet_, _Piéron_, 1915    36

   29. Shell-shock (functional!) amaurosis in a neurosyphilitic
                                 _Laignel-Lavastine_, _Courbon_, 1916    37

   30. Shell-shock (functional) phenomena in a neurosyphilitic
                                           _Babonneix_, _David_, 1917    39

   31. Vestibular symptoms in a neurosyphilitic
                                            _Guillain_, _Barré_, 1916    40

   32. Syphilophobic suicidal attempts       _Colin_, _Lautier_, 1917    41

   33. Simulated chancre                                 _Pick_, 1916    42

   34. Exaggeration                       _Buscaino_, _Coppola_, 1916    43

             II. THE FEEBLE-MINDED GROUP (_Hypophrenoses_)

   35. A feeble-minded person fit for service         _Pruvost_, 1915    44

   36. An imbecile superbrave                         _Pruvost_, 1915    45

   37. An imbecile fit for barracks work              _Pruvost_, 1915    45

   38. A feeble-minded inventor   _Laignel-Lavastine_, _Ballet_, 1917    47

   39. A feeble-minded simulator                      _Pruvost_, 1915    49

   40. Enlistment for amelioration of character        _Briand_, 1915    49

   41. An imbecile fit for service at the front       _Pruvost_, 1915    50

   42. An imbecile with sudden initiative             _Lautier_, 1915    51

   43. Emotional fugue in subnormal subject            _Briand_, 1915    52

   44. Regimental surgeon _versus_ alienist _re_ feeble-mindedness
                                                       _Kastan_, 1916    53

   45. An imbecile rifleman                            _Kastan_, 1916    55

   46. An imbecile hypomaniacal                         _Haury_, 1915    57

   47. Feeble-minded desire to remain at the front     _Kastan_, 1916    58

   48. An imbecile sent back by Germans               _Lautier_, 1915    60

   49. Unfit for service: feeble-mindedness?           _Kastan_, 1916    61

   50. Oniric delirium in a feeble-minded subject  _Soukhanoff_, 1915    62

   51. Shell-shock and burial: situation not rationalized
                                                       _Duprat_, 1917    63

   52. Shell-shock in weak-minded subject; fear, fugues
                                           _Pactet_, _Bonhomme_, 1917    64

               III. THE EPILEPTIC GROUP (_Epileptoses_)

   53. Epilepsy: neurosyphilis                          _Hewat_, 1917    65

   54. Epilepsy brought out by syphilis            _Bonhoeffer_, 1915    66

   55. Syphilis in a psychopathic subject          _Bonhoeffer_, 1915    67

   56. Epileptic imbecile court-martialed             _Lautier_, 1916    68

   57. Psychogenic seizures in feeble-minded subject
                                                   _Bonhoeffer_, 1915    69

   58. Drunken epileptic: responsibility?           _Juquelier_, 1917    71

   59. Epilepsy: disciplinary case                  _Pellacani_, 1917    74

   60. Same                                         _Pellacani_, 1917    76

   61. Desertion: epileptic fugue                      _Verger_, 1916    78

   62. Specialist in escapes                            _Logre_, 1917    80

   63. Epilepsy and other factors: disciplinary case
                                                    _Consiglio_, 1917    82

   64. Strange conduct and amnesia in epileptic         _Hurst_, 1917    83

   65. Epilepsy after antityphoid inoculation      _Bonhoeffer_, 1915    84

   66. Shell-shock: Jacksonian seizures--decompression
                                                      _Leriche_, 1915    86

   67. Blow on head: hysterical convulsions--cure by neglect
                                                       _Clarke_, 1916    87

   68. Epilepsy with superposed hysteria           _Bonhoeffer_, 1915    88

   69. Musculocutaneous neuritis: Brown-Séquard’s epilepsy
                                             _Mairet_, _Piéron_, 1916    89

   70. Bullet wound: reactive epilepsy?            _Bonhoeffer_, 1915    92

   71. _Epilepsia tarda_                           _Bonhoeffer_, 1915    93

   72. Convulsions by auto-suggestion                   _Hurst_, 1916    95

   73. Epilepsy, emotional                 _Westphal_, _Hübner_, 1915    97

   74. Hysterical convulsions        _Laignel-Lavastine_, _Fay_, 1917    98

   75. Desertion: fugue, probably not epileptic         _Barat_, 1914   100

   76. Epileptic episode                           _Bonhoeffer_, 1915   102

   77. Narcoleptic seizures                         _Friedmann_, 1915   103

   78. Sham fits                                        _Hurst_, 1917   106

   79. Epileptoid attacks controllable by will         _Russel_, 1917   106

   80. Epileptic taint brought out at last by shell-shock
                                                        _Hurst_, 1917   107

   81. Shell-shock _epilepsia larvata_  _Juquelier_, _Quellien_, 1917   108

   82. To illustrate a theory of Shell-shock as epileptic
                                                      _Ballard_, 1915   110

   83. Same                                           _Ballard_, 1917   110

   84. Same                                           _Ballard_, 1917   111

   85. Epileptic equivalents                             _Mott_, 1916   112

        IV. THE ALCOHOL-DRUG-POISON GROUP (_Pharmacopsychoses_)

   86. Pathological intoxication                    _Boucherot_, 1915   113

   87. Same                                             _Loewy_, 1915   116

   88. Desertion in alcoholism: fugue                   _Logre_, 1916   117

   89. Alcoholic amnesia experimentally reproduced     _Kastan_, 1915   118

   90. Desertion and drunkenness                       _Kastan_, 1915   119

   91. Desertion by alcoholic dement                   _Kastan_, 1915   121

   92. Desertion by alcoholic with other factors       _Kastan_, 1915   124

   93. Alcoholism: disciplinary case                   _Kastan_, 1915   126

   94. Atrocity, alcoholism                            _Kastan_, 1915   127

   95. Atrocity, alcoholic                             _Kastan_, 1915   128

   96. Alcoholism and amnesia: disciplinary case       _Kastan_, 1915   129

   97. Post-traumatic intolerance of alcohol           _Kastan_, 1915   130

   98. Adventure with Parisian stranger       _Briand_, _Haury_, 1915   131

   99. Morphinism: tetanus                             _Briand_, 1914   131

  100. Morphinism: medicolegal question                _Briand_, 1914   132

  101.} Two morphinists                                _Briand_, 1914   132
  102.}

        V. THE FOCAL BRAIN LESION GROUP (_Encephalopsychoses_)

  103. Aphasia and left hemiplegia: local and
       _contrecoup_ lesions                        _L’Hermitte_, 1916   133

  104. Gunshot head wound and alcohol: amnesia         _Kastan_, 1916   135

  105. Bullet in brain: cortical blindness and hallucinations
                                        _Lereboullet_, _Mouzon_, 1917   136

  106. Content of existent psychosis changed by
       head trauma               _Laignel-Lavastine_, _Courbon_, 1917   139

  107. Meningococcus meningitis; apparent recovery:
       dementing psychosis                         _Maixandeau_, 1915   141

  108. Meningococcus meningitis           _Eschbach and Lacaze_, 1915   143

  109. Shell-shock: meningitic syndrome   _Pitres and Marchand_, 1916   145

  110. Brain abscess in a syphilitic: matutinal loss of
       knee-jerks            _Dumolard_, _Rebierre_, _Quellien_, 1915   147

  111. Spinal cord lesion: early recovery         _Mendelssohn_, 1916   149

  112. Shell explosion and meningeal hemorrhage:
       pneumococcus meningitis              _Guillain_, _Barré_, 1917   150

  113. _Ante bellum_ cortex lesion: shrapnel wound determines
       athetosis                                       _Batten_, 1916   151

  114. Hysterical _versus_ thalamic hemianesthesia       _Léri_, 1916   152

  115. Shell-shock: multiple sclerosis syndrome
                                           _Pitres_, _Marchand_, 1916   154

  116. Mine explosion: hysterical and organic symptoms  _Smyly_, 1917   156

  117. Same                                             _Smyly_, 1917   156

             VI. THE SYMPTOMATIC GROUP (_Somatopsychoses_)

  118. Rabies: neuropsychiatric phenomena
                     _Grenier de Cardenal_, _Legrand_, _Benoit_, 1917   162

  119. Tetanus, psychotic                   _Lumière_, _Astier_, 1917   164

  120. Tetanus _fruste_ _versus_ hysteria
                                         _Claude_, _L’Hermitte_, 1915   165

  121. British officer’s letter concerning local tetanus
                                                      _Turrell_, 1917   166

  122. Dysentery: psychosis                             _Loewy_, 1915   168

  123. Typhoid fever: hysteria                          _Sterz_, 1914   169

  124. Dementia praecox _versus_ posttyphoid encephalitis
                                                     _Nordmann_, 1916   170

  125. Paratyphoid fever: psychosis outlasting fever  _Merklen_, 1915   171

  126. Paratyphoid fever: psychopathic taint brought out
                                                      _Merklen_, 1915   172

  127. Diphtheria: post diphtheritic symptoms        _Marchand_, 1916   173

  128. Diphtheria: hysterical paraparesis            _Marchand_, 1915   174

  129. Malaria: amnesia                               _De Brun_, 1917   175

  130. Malaria: Korsakow’s syndrome                   _Carlill_, 1917   176

  131. Malaria: ventral horn symptoms                    _Blin_, 1916   178

  132. Trench foot; acroparesthesia                    _Cottet_, 1917   180

  133. Bullet injury of spine; bronchopneumonia:
       _état criblé_ of spinal cord                    _Roussy_, 1916   181

  134. Shell-shock (shell not seen); sensory and motor
       symptoms: decubitus; recovery                    _Heitz_, 1915   183

  135. Shell-shock; later typhoid fever: neuritis
       (_ante bellum_ hysteria)                        _Roussy_, 1915   185

  136. Bullet wound of pleura: hemiplegia and ulnar syndrome
                                            _Phocas_, _Gutmann_, 1915   186

  137. Tachypnoea, hysterical                        _Gaillard_, 1915   188

  138. Soldiers’ heart                              _Parkinson_, 1916   190

  139. Soldiers’ heart?                             _Parkinson_, 1916   191

  140. War strain and shell wound: diabetes mellitus  _Karplus_, 1915   192

  141. Dercum’s disease                  _Hollande_, _Marchand_, 1917   193

  142. Hyperthyroidism                              _Tombleson_, 1917   195

  143. Hyperthyroidism?, neurasthenia     _Dejerine_, _Gascuel_, 1914   196

  144. Hyperthyroidism                              _Rothacker_, 1916   197

  145. Graves’ disease, _forme fruste_     _Babonneix_, _Célos_, 1917   198

  146. Shell-shock hysteria: surgical complications _Oppenheim_, 1915   199

   VII. THE PRESENILE AND SENILE GROUP (_Geriopsychoses_)--No cases.

         VIII. THE DEMENTIA PRAECOX GROUP (_Schizophrenoses_)

  147. Hatred of Prussia: diagnosis, dementia praecox
                                                   _Bonhoeffer_, 1916   200

  148. Dementia praecox: arrest as spy                 _Kastan_, 1915   201

  149. Fugue, catatonic                             _Boucherot_, 1915   203

  150. Desertion: schizophrenic?                    _Consiglio_, 1916   204

  151. Schizophrenia; alcoholism: disciplinary case    _Kastan_, 1915   206

  152. Schizophrenia aggravated by service        _de la Motte_, 1915   208

  153. Shot himself in hand: delusions                  _Rouge_, 1915   209

  154. Dementia praecox volunteer                       _Haury_, 1915   210

  155. Hysteria _versus_ catatonia                 _Bonhoeffer_, 1916   211

  156. “Hysteria” actually dementia praecox             _Hoven_, 1915   213

  157. Hallucinatory and delusional contents influenced
       by war experiences                              _Gerver_, 1915   214

  158. Iron cross winner, hebephrenic              _Bonhoeffer_, 1915   215

  159. Occipital trauma; visual hallucinations
                                         _Claude_, _L’Hermitte_, 1915   217

  160. Shell-shock: Dementia praecox                 _Weygandt_, 1915   219

  161. Same                                            _Dupuoy_, 1915   220

  162. Shell-shock; fatigue; fugue; delusions           _Rouge_, 1915   221

           IX. THE MANIC-DEPRESSIVE GROUP (_Cyclothymoses_)

  163. A maniacal volunteer                         _Boucherot_, 1915   222

  164. Fugue, melancholic                               _Logre_, 1917   223

  165. Apples in No-man’s-land                       _Weygandt_, 1914   224

  166. Trench life: depression; hallucinations;
       arteriosclerosis; age, 38                       _Gerver_, 1915   225

  167. War stress: manic depressive psychosis        _Dumesnil_, 1915   226

  168. Predisposition; war stress: melancholia       _Dumesnil_, 1915   227

  169. Depression; low blood pressure; pituitrin        _Green_, 1916   228

            X. THE PSYCHONEUROTIC GROUP (_Psychoneuroses_)

  170. Three phases in a psychopath
                                 _Laignel-Lavastine_, _Courbon_, 1917   229

  171. Fugue, probably hysterical                      _Milian_, 1915   232

  172. Hysterical Adventist                       _de la Motte_, 1915   234

  173. Fugue, psychoneurotic                            _Logre_, ----   235

  174. Shell-shy; war bride pregnant: fugue with amnesia
       and mutism                                       _Myers_, 1916   236

  175. A neurasthenic volunteer                      _E. Smith_, 1916   237

  176. War stress: neurasthenia in subject without
       heredity or soil                                 _Jolly_, 1916   238

  177. Arterial hypotension in psychasthenia          _Crouzon_, 1915   239

  178. War stress: psychasthenia                         _Eder_, 1916   240

  179. _Ante bellum_ attacks: neurasthenia         _Binswanger_, 1915   241

  180. Antityphoid inoculation: neurasthenia        _Consiglio_, 1917   244

  181. Neurasthenia (one symptom: sympathy with the enemy)
                                                      _Steiner_, 1915   245

             XI. THE PSYCHOPATHIC GROUP (_Psychopathoses_)

  182. Claustrophobia: shells preferred to tunnel     _Steiner_, 1915   246

  183. Pathological liar                            _Henderson_, 1917   247

  184. Psychopath almost Bolshevik                      _Hoven_, 1917   249

  185. Hysterical mutism: persistent delusional psychosis
                                                     _Dumesnil_, 1915   250

  186. Psychopathic inferiority brought out by the war
                                                      _Bennati_, 1916   251

  187. Psychopathic episodes                        _Pellacani_, 1917   252

  188. Maniacal and hysterical delinquent _Buscaino_, _Coppola_, 1916   253

  189. Psychopathic delinquent            _Buscaino_, _Coppola_, 1916   254

  190. Psychopathic excitement            _Buscaino_, _Coppola_, 1916   255

  191. Desertion: dromomania                        _Consiglio_, 1917   256

  192. Suppressed homosexuality                   _R. P. Smith_, 1916   257

  193. Psychopathic: at first suicidal, then self-mutilative
                                                     _MacCurdy_, 1917   258

  194. Bombardment: psychasthenia
                                 _Laignel-Lavastine_, _Courbon_, 1917   259

  195. Nosophobia                            _Colin_, _Lautier_, 1917   261

  196. Psychopath: Attacks of disgust and terror
                                              _Lattes_, _Goria_, 1915   262

               SECTION B. SHELL-SHOCK: NATURE AND CAUSES

  197. Shell explosion: Autopsy--hemorrhages;
       vagoaccessorius chromatolysis                     _Mott_, 1917   265

  198. Mine explosion: Autopsy--hemorrhages          _Chavigny_, 1916   270

  199. Mine explosion: Autopsy--hemorrhages
                                           _Roussy_, _Boisseau_, 1916   271

  200. Shell fragment in back: Autopsy--softenings in
       spinal cord                       _Claude_, _L’Hermitte_, 1915   272

  201. Shell explosion: Autopsy--lungs burst!         _Sencert_, 1915   274

  202. Shell explosion: Hemorrhage in spinal canal and bladder
                                                       _Ravaut_, 1915   276

  203. Shell explosion: Hemorrhage and pleocytosis of
       spinal fluid                                   _Froment_, 1915   277

  204. Shell explosion: Pleocytosis of spinal fluid  _Guillain_, 1915   279

  205. Shell explosion: Pleocytosis of spinal fluid
       as late as a month after explosion   _Souques_, _Donnet_, 1915   280

  206. Burial: Thecal hemorrhage                      _Leriche_, 1915   282

  207. Shell explosion: Hypertensive spinal fluid     _Leriche_, 1915   283

  208. Bullet wound: Hematomyelia; partial recovery
                                                  _Mendelssohn_, 1916   284

  209. Shell explosion, subject prone: Hematomyelia  _Babinski_, 1915   286

  210. Struck by missile: Hysterical paraplegia? Herpes;
       segmentary symptoms                             _Elliot_, 1914   288

  211. Mine explosion: Head bruises, labyrinth lesions,
       canities unilateral                              _Lebar_, 1915   291

  212. Shrapnel wounds: Focal canities; hysterical symptoms
                                                    _Arinstein_, 1915   292

  213. Burial: Organic (?) hemiplegia           _Marie_, _Lévy_, 1917   293

  214. Shell explosion; no wound: Organic and functional symptoms
                                         _Claude_, _L’Hermitte_, 1915   294

  215. Gassing: Organic symptoms                      _Neiding_, 1917   296

  216. Gassing: Mutism, battle dreams               _Wiltshire_, 1916   297

  217. Shell explosion: Organic deafness; hysterical
       speech disorder                             _Binswanger_, 1915   298

  218. Distant shell explosion not seen or heard: Tympanic
       rupture, cerebellar symptoms        _Pitres_, _Marchand_, 1916   300

  219. Mine explosion: Organic and functional symptoms  _Smyly_, 1917   302

  220. Shrapnel skull wound: Differential recovery from
       functional symptoms                         _Binswanger_, 1917   303

  221. Shell explosion shrapnel wound: Battle memories,
       scar hyperesthetic                             _Bennati_, 1916   305

  222. Shrapnel wounds, operation: Hysterical facial spasm
                                                       _Batten_, 1917   306

  223. Shell explosion: Tremors and emotional crises    _Myers_, 1916   307

  224. Shell explosion, comrades killed: Tremors, crises
                                                        _Meige_, 1916   308

  225. Under fire: Tremophobia: French artist’s description
                                                        _Meige_, 1916   310

  226. Shell explosion: German soldier’s account of
       Shell-shock symptoms                             _Gaupp_, 1915   312

  227. A British soldier’s account of shell-shock      _Batten_, 1916   315

  228. Blown up by shell: Crural monoplegia; hysterical
       four days later                                   _Léri_, 1915   317

  229. Shell explosion nearby: Description of treatment to
       demonstrate hysterical nature of characteristic
       symptoms                                    _Binswanger_, 1915   318

  230. Leg wound: Pseudocoxalgic monoplegia and anesthesia
                                         _Roussy_, _L’Hermitte_, 1917   323

  231. Leg contusion: Crural monoplegia, hysterical;
       later crutch paralysis, organic               _Babinski_, 1917   324

  232. War strain: Arthritis; crural monoplegia and
       anesthesia; hysterical “conversion hysteria”  _MacCurdy_, 1917   325

  233. Lance thrust in back; Crural monoplegia     _Binswanger_, 1915   326

  234. Shell explosion: After six days, crural monoplegia
       (“metatraumatic” suggesting persisting hypersensitive
       phase after shell-shock)                      _Schuster_, 1916   329

  235. Wound of foot: Acrocontracture, seven months’
       duration; psycho-electric cure at one sitting
                                         _Roussy_, _L’Hermitte_, 1917   330

  236. Shell explosion: Trauma; emotion; hysterical
       paraplegia                                    _Abrahams_, 1915   332

  237. Shell explosion: Burial; paraplegia             _Elliot_, 1914   334

  238. Shell explosion: Paraplegia and sensory symptoms,
       organic?                                         _Hurst_, 1915   335

  239. War strain and rheumatism; no emotional factors:
       Paraplegia, later brachial tremor           _Binswanger_, 1915   336

  240. Emotion in fever patient from watching barrage
       creep up: Paraplegia                              _Mann_, 1915   338

  241. Incentives, domestic and medical, to paraplegia _Russel_, 1917   338

  242. Bullet in back: Hysterical bent back; “camptocormia”
                                                      _Souques_, 1915   339

  243. Shell explosion: Camptocormia     _Roussy_, _L’Hermitte_, 1917   340

  244. Shell explosion; burial: camptocormia
                                         _Roussy_, _L’Hermitte_, 1917   342

  245. Shell explosion; burial; Paraplegia, later camptocormia
                                                     _Joltrain_, 1917   344

  246. Bullet in thigh: Astasia-abasia. Wound of neck:
       Again astasia-abasia              _Roussy_, _L’Hermitte_, 1917   346

  247. Shell explosion: Wound of thorax; astasia-abasia
                                         _Roussy_, _L’Hermitte_, 1917   346

  248. War strain and fall in trench without trauma: Dysbasia
                                                        _Nonne_, 1915   347

  249. Shell explosion: Partial burial; hysterical
       symptoms in parts buried                     _Arinstein_, 1916   349

  250. Wound of hand: Acroparalysis      _Roussy_, _L’Hermitte_, 1917   350

  251. Wound of arm: Hysterical paralysis            _Chartier_, 1915   351

  252. Wound in brachial plexus region: Supinator
       longus contracture                       _Léri_, _Roger_, 1915   353

  253. Contusion of muscle with “stupefactive” paralysis
       of biceps (supinator longus still functioning)   _Tinel_, 1917   355

  254. Wound of arm: Blockage of impulses to hand movements
                                                        _Tubby_, 1915   356

  255. Shell explosion: Bilateral symmetrical phenomena
                                                       _Gerver_, 1915   357

  256. Shell explosion: Paralytic symptoms on side exposed:
       Contralateral irritative symptoms            _Oppenheim_, 1915   359

  257. Shell explosion: Bilateral asymmetrical symptoms
                                                       _Gerver_, 1915   360

  258. Shell explosion: Sensory disorder on side exposed
                                                       _Gerver_, 1915   362

  259. Shell explosion: Hysterical deafness and other
       symptoms; relapse                                _Gaupp_, 1915   363

  260. Shell explosion: Deafness                     _Marriage_, 1917   365

  261. Mine explosion: Deafmutism; recovery on epistaxis
       and fever                                     _Liébault_, 1916   366

  262. Shell explosion: Deafmutism      _Mott_, 1916   367

  263. Shell explosion: Deafmutism and convulsions      _Myers_, 1916   368

  264. Gunfire: Aphonia                               _Blässig_, 1915   370

  265. Shell-shock mutism: (_a_), observed, (_b_) dreamed
       of, (_c_), developed by victim of shell explosion _Mann_, 1915   370

  266. Mortar explosion: Deafness             _Lattes_, _Goria_, 1917   371

  267. Shell-explosion: onomatopœic noises             _Ballet_, 1914   371

  268. Shell explosion: Gravel in eyes; eye and face symptoms
                                                    _Ginestous_, 1916   372

  269. Shell explosion; burial; blow on occiput; Blindness
                                                    _Greenlees_, 1916   373

  270. Shell-shock amblyopia: Composite data          _Parsons_, 1915   374

  271. Factors in shell-shock amblyopia: Excitement,
       blinding flashes, fear, disgust, fatigue     _Pemberton_, 1915   375

  272. Shell explosion amblyopia                        _Myers_, 1915   376

  273. Shell windage without explosion: Cranial nerve disorder
                                                   _Pachantoni_, 1917   378

  274. Initial case in Babinski’s series to show chloroform
       elective exaggeration of reflexes  _Babinski_, _Froment_, 1917   380

  275. Wound of ankle: Contracture, chloroform effect
                                          _Babinski_, _Froment_, 1917   383

  276. “Reflex” disorder of right leg: Chloroform effect
                                          _Babinski_, _Froment_, 1917   384

  277. Bullet in calf: Hysterical lameness cured--reflex disorder
       associated therewith _not_ cured               _Vincent_, 1916   385

  278. Trauma of foot: Hysterical dysbasia and reflex
       disorders; differential disappearance of
       hysterical symptoms                            _Vincent_, 1917   386

  279. Shell-shock and paraplegia: Vasomotor and secretory
       disorder twenty months later                    _Roussy_, 1917   387

  280. Tetanus clinically cured: Phenomena reproduced under
       chloroform anesthesia                    _Monier-Vinard_, 1917   388

  281. Example of a “reflex” disorder after shell
       explosion at great distance                    _Ferrand_, 1917   390

  282. Shell fire: Shell-shock symptoms delayed      _McWalter_, 1916   391

  283. Shell-shock symptoms early and late              _Smyly_, 1917   392

  284. Wounds: Gassing; burial; collapse on home leave
                                                 _Elliot Smith_, 1916   393

  285. Late sympathetic nerve effect after bullet wound of neck
                                                        _Tubby_, 1915   394

  286. Hysterical crural monoplegia after fall from
       horse under fire (reminiscence of similar
       _ante bellum_ accident)                        _Forsyth_, 1915   395

  287. Shell explosion, cave-in: Right leg symptoms
      (_ante bellum_ experiences)                       _Myers_, 1916   396

  288. Shell explosion, wound of back: Paraparesis (subject
       always weak in legs)                          _Dejerine_, 1915   397

  289. Wound near heart: Fear; paraparesis (subject always
       weak in legs)                                 _Dejerine_, 1915   399

  290. Wounds: Tic on walking and recovery except frontalis tic
       (emphasis of _ante bellum_ habit)   _Westphal_, _Hübner_, 1915   401

  291. Fatigue and emotion: Hysterical hemiplegia (similar
       hemiplegia _ante bellum_)         _Roussy_, _L’Hermitte_, 1917   402

  292. War strain: Hemiplegia (similar hemiplegia _ante bellum_,
       subject’s father hemiplegic)            _Duprés_, _Rist_, 1914   403

  293. Shell explosion and burial: Deafmutism (speech
       difficulty _ante bellum_)                     _MacCurdy_, 1917   405

  294. War strain: Shell-shock and psychotic symptoms
       determined to parts _ante bellum_               _Zanger_, 1915   406

  295. Mine explosion: Emotion; delirium (previous head
       trauma without unconsciousness)        _Lattes_, _Goria_, 1917   407

  296. Sniper stricken blind in shooting eye             _Eder_, 1916   408

  297. Anticipation of warfare: Fall while mounting sentry;
       hysterical blindness                           _Forsyth_, 1915   408

  298. Spasmodic neurosis from bareback riding (similar
       episode _ante bellum_)                        _Schuster_, 1914   409

  299. _Ante bellum_ spasm of hands                     _Hewat_, 1917   409

  300. Quarrel: Hysterical chorea, reminiscent of former
       attack and itself reminiscent of organic chorea
       in subject’s mother                             _Dupuoy_, 1915   411

  301. Hallucinations and delusions of _ante bellum_ origin:
       Treatment by explanation                          _Rows_, 1916   412

  302. Tremors and convulsive crises in a poor risk
                                             _Rogues de Fursac_, 1915   413

  303. Emotionality and tachycardia in a martial misfit
                                                      _Bennati_, 1916   415

  304. Hereditary instability                        _Wolfsohn_, 1918   416

  305. Genealogical tree of a shoemaker              _Wolfsohn_, 1918   417

  306. Traumatic hysteria without hereditary or acquired
       psychopathic tendency                           _Donath_, 1915   418

  307. Mine explosion, burial: Neurosis in perfectly
       normal soldier                                _MacCurdy_, 1917   419

  308. Shell explosion: Tremophobia                     _Meige_, 1916   421

  309. Frozen in bog: Glossolabial hemispasm       _Binswanger_, 1915   424

  310. Bruise by horse: Invincible pain--subject cured
       by performing heroic feat                        _Loewy_, 1915   426

  311. Kick by horse: Hysterical symptoms including
       monocular diplopia                           _Oppenheim_, 1915   427

  312. Windage from non-exploding shell: Emotion;
       homonymous hemianopsia                         _Steiner_, 1915   428

  313. Shell-shock psoriasis                 _Gaucher_, _Klein_, 1916   429

  314. _Croix de guerre_ and Shell-shock got simultaneously:
       Hallucinatory bell-ringing reminiscent of civilian
       work                      _Laignel-Lavastine_, _Courbon_, 1916   430

  315. Waked by shell explosion: Nystagmiform tremor
       (occupational reminiscence in cinema worker) and
       tachycardia                                      _Tinel_, 1915   432

  316. Synesthesialgia: Foot pain on rubbing dry hands
                                       _Lortat-Jacob_, _Sézary_, 1915   433

  317. Shell-shock and burial: Clonic spasms, later stupor
                                                        _Gaupp_, 1915   435

  318. War stress (liquid fire) and shell-shock: Puerilism
                                        _Charon_, _Halberstadt_, 1916   437

  319. Bombed from aeroplane: Battle dreams; dizziness; fugue
                                              _Lattes_, _Goria_, 1917   439

  320. Hyperthyroidism after box drops from aeroplane _Bennati_, 1916   440

  321. Shell dropped without bursting: Stupor and delirium
                                              _Lattes_, _Goria_, 1917   441

  322. Subject carrying explosives is jostled: Unconsciousness,
       deafmutism, later camptocormia         _Lattes_, _Goria_, 1917   443

  323. Grazed by sliding cannon: Stupor and amnesia
                                              _Lattes_, _Goria_, 1917   444

  324. Shell explosions nearby: Emotion and insomnia
                                                    _Wiltshire_, 1916   445

  325. Shell explosion: symptoms after hearing artillery
       twelve days later                            _Wiltshire_, 1916   446

  326. Exhaustion (heat?): Hyperthyroidism, hemiplegia
                                                    _Oppenheim_, 1915   447

  327. War strain and rheumatism: tremors          _Binswanger_, 1915   448

  328. Shell explosion; emotion: Fear and dreams         _Mott_, 1916   451

  329. Under fire; barbed wire work: tremors and sensory symptoms
                                                        _Myers_, 1916   452

  330. Shell explosion: Emotional crises; twice recurrent mutism
                                _Mairet_, _Piéron_, _Bouzansky_, 1915   453

  331. Shell explosion: Emotional crises (fright at a frog)
                                    _Claude_, _Dide_, _Lejonne_, 1916   455

  332. War strain; wound; burials; shell-shock: neurosis
       with anxiety and dreams: Relapse              _MacCurdy_, 1917   457

  333. Bombed by airplane: Suicidal thoughts; oniric delirium;
       “moving picture in the head”                     _Hoven_, 1917   460

  334. Shell explosion; emotion at death of best friend:
       Stupor and amnesia                               _Gaupp_, 1915   462

  335. Emotional shock from shooting comrade: Horror,
       sweat, stammer, nightmare                         _Rows_, 1916   463

  336. Emotion at death of comrade: Phobias           _Bennati_, 1916   464

  337. Shell explosion: Fright; delayed loss of consciousness
                                                    _Wiltshire_, 1916   465

  338. Shell explosion; burial work: amnesia; unpleasant ideas
       reflexly conditioned by shell whistling      _Wiltshire_, 1916   467

  339. Comrade’s death witnessed: Suicidal depression _Steiner_, 1915   468

  340. Marching and battles: Neurasthenia?         _Bonhoeffer_, 1915   469

  341. English schoolmaster’s account of dreams          _Mott_, 1918   470

  342. War dreams shifting to sex dreams                 _Rows_, 1916   472

  343. Shock at death of comrade: War and peace dreams   _Rows_, 1916   474

  344. War dreams including hunger and thirst            _Mott_, 1918   475

  345. Burial work: Olfactory dreams and vomiting   _Wiltshire_, 1916   476

  346. War dreams: Phobia conditioned on postoniric suggestion
                                                       _Duprat_, 1917   477

  347. Service in rear: War dreams not based on actual experiences
                                                       _Gerver_, 1915   478

  348. Hysterical astasia-abasia: Heterosuggestive “big belly”
                                 _Roussy_, _Boisseau_, _Cornil_, 1917   479

  349. Collapse going over the top: Neurasthenia        _Jolly_, 1916   481

  350. Battles: Mania and confusion                    _Gerver_, 1915   483

  351. Machine-gun battle: Mania and hallucinations    _Gerver_, 1915   484

  352. Attacks and counter-attacks: Incoherence and quick
       development of scenic war hallucinations        _Gerver_, 1915   485

  353. Hysterical stupor under shell fire after 2 days
       in the trenches                                  _Gaupp_, 1915   486

  354. Monosymptomatic amnesia                         _Mallet_, 1917   488

  355. Aviator shot down: Mental symptoms, organic   _MacCurdy_, 1917   489

  356. Shell fire and corpse work: Daze with relapse; mutism
                                                         _Mann_, 1915   491

  357. Mine explosion: Confusion                    _Wiltshire_, 1916   492

  358. Shell explosion: Alternation of personality      _Gaupp_, 1915   493

  359. “A Horse in the Unconscious”                      _Eder_, 1916   497

  360. Shell explosion, gassing, fatigue: Anesthesia    _Myers_, 1916   498

  361. Shell explosion and burial: Somnambulism;
       dissolution of amnesia under hypnosis            _Myers_, 1915   499

  362. Shell explosion with injuries: Somnambulism     _Donath_, 1915   502

  363. Shock: Stupor as if dead                         _Régis_, 1915   503

  364. Emotions over battle scenes: Twenty-four days’ somnambulism
                                                       _Milian_, 1915   504

  365. Putative loss of brother in battle: Somnambulism
       and mutism twenty-seven days                    _Milian_, 1915   506

  366. Shell explosion: Trauma, windage: Somnambulism four days
                                                       _Milian_, 1915   508

  367. Burial, head trauma; gassing: Tremors, convulsions,
       confusion, fugue                             _Consiglio_, 1916   509

  368. Shell explosion: Hysterical symptoms and
       tendency to fugue                           _Binswanger_, 1915   510

  369. Burial: Dissociation of personality            _Feiling_, 1915   512

  370. Ear Complications and hysteria     _Buscaino_, _Coppola_, 1916   516

                   SECTION C. SHELL-SHOCK DIAGNOSIS

  371. Value of lumbar puncture             _Souques_, _Donnet_, 1915   524

  372. Meningeal and intraspinal hemorrhage: Lumbar puncture
                                                     _Guillain_, 1915   525

  373. Burial: Slight hyperalbuminosis                 _Ravaut_, 1915   526

  374. Paraplegia, organic: Lumbar puncture           _Joubert_, 1915   527

  375. Gunshot of spine: Spinal concussion, quadriplegia,
       cerebellospasmodic disorder       _Claude_, _L’Hermitte_, 1917   528

  376. Trauma of spine: Anesthesia and contracture,
       homolateral, with trauma                     _Oppenheim_, 1915   529

  377. Mine explosion combining hysterical and lesional effects
                                                       _Dupouy_, 1915   530

  378. Shell explosion: Hysterical and organic symptoms _Hurst_, 1917   532

  379. Gunshot: Cauda equina symptoms, combined with
       functional paraplegia                        _Oppenheim_, 1915   533

  380. Intraspinal lesion: Persistent anesthesia      _Buzzard_, 1916   534

  381. Functional shell-shock: Erroneous diagnosis    _Buzzard_, 1916   534

  382. Retention of urine after shell-shock _Guillain_, _Barré_, 1917   535

  383. Same                                 _Guillain_, _Barré_, 1917   536

  384. Incontinence of urine after shell-shock and burial
                                            _Guillain_, _Barré_, 1917   536

  385. Struck by missile: Crural monoplegia; plantar
       reflex absent                                  _Paulian_, 1915   537

  386. Shell explosion: Crural monoplegia; sciatica (neuritis?)
                                                      _Souques_, 1915   538

  387. Functional paraplegia and internal popliteal neuritis
                                                       _Roussy_, 1915   540

  388. Bullet in hip: Local “stupor” of leg          _Sebileau_, 1914   542

  389. Localized catalepsy: Hysterotraumatic          _Sollier_, 1917   544

  390. Contracture: Hysterotraumatic                  _Sollier_, 1917   545

  391. Crural monoplegia, tetanic: Recovery           _Routier_, 1915   546

  392. Spasms, contracture, crises--tetanic            _Mériel_, 1916   548

  393. Shell explosion, windage, flaccid paraplegia,
       _not_ “spinal contusion”                          _Léri_, 1915   550

  394. Scalp wound: Quadriparesis; paraplegia, cataleptic
       rigidity of anesthetic legs                     _Clarke_, 1916   551

  395. Shell explosion: Spasmodic contractions of sartorii,
       persistent in sleep                              _Myers_, 1916   553

  396. Shell explosion: Brown-Séquard’s syndrome, hematomyelic?
                                                       _Ballet_, 1915   555

  397. Question of structural injury of spinal cord     _Smyly_, 1917   557

  398. Dysbasia, psychogenic round an organic nucleus (cerebellar?)
                                                     _Cassirer_, 1916   557

  399. Shell explosion: Dysbasia, in part hysterical,
       in part organic?                                 _Hurst_, 1915   558

  400. Peculiar walking tic                          _Chavigny_, 1917   559

  401. Mine explosion: Camptocormia. Hospital rounder
       twenty months--cure by electrotherapy, 1 hour
             _Marie_, _Meige_, _Béhagne_, _Souques_, _Megevand_, 1917   561

  402. Astasia-abasia                       _Guillain_, _Barré_, 1916   563

  403. Shell wounds: Abdominothoracic contracture, tetanic,
       four months after injury                         _Marie_, 1916   564

  404. Shoulder dislocation: Hysterical paralysis of arm
                                                      _Walther_, 1914   566

  405. Gunshot: Paralysis of arm increasing in degree
                                                    _Oppenheim_, 1915   567

  406. Wound of wrist: Differential glove anesthesias  _Römner_, 1915   568

  407. Hysterical contracture combined with edema and
       vasomotor disorder                              _Ballet_, 1915   569

  408. Hemiparesis with syringomyelic dissociation
       of sensations: Hematomyelia?                    _Ravaut_, 1915   570

  409. Brachial monoplegia: Tetanic                   _Routier_, 1915   571

  410. Paralysis of right leg: Hysterical? Organic? “Microörganic”?
                                                    _Von Sarbo_, 1915   572

  411. Shell explosion: Burial: Paralysis on third day
                                     _Léri_, _Froment_, _Mahar_, 1915   573

  412. Shell explosion: Hemiplegia. Plantar areflexia
                                                     _Dejerine_, 1915   575

  413. Shell explosion: Tic _versus_ spasm              _Meige_, 1916   577

  414. Shell explosion: Tremors, anæsthesias             _Mott_, 1916   580

  415. Hysteria, appendix to trauma                  _MacCurdy_, 1917   582

  416. Peripheral nerve injury: Neurasthenic hyperalgesia
                                                     _Weygandt_, 1915   583

  417. Soldier lead worker: Peripheral neuritis _Shufflebotham_, 1915   584

  418. “Peripheral neuritis” cured by faradism        _Cargill_, 1916   585

  419. Late tetanus                                   _Bouquet_, 1916   586

  420. Spasmodic neurosis and neurasthenia          _Oppenheim_, 1915   588

  421. Hysterical and reflex (“physiopathic”) disorders
                                                     _Babinski_, 1916   590

  422. Bullet wound: Paralysis non-“organic,”
       non-hysterical, _i.e._ reflex      _Babinski_, _Froment_, 1917   592

  423. Asymmetry of reflexes under chloroform
                                          _Babinski_, _Froment_, 1917   594

  424. Reflexes under chloroform          _Babinski_, _Froment_, 1915   595

  425. Same                               _Babinski_, _Froment_, 1915   596

  426. Shrapnel wound: Monoplegia, hysterical and organic
                                          _Babinski_, _Froment_, 1917   597

  427. Gunshot, later Erb’s palsy: “reflex”?        _Oppenheim_, 1915   598

  428. Paralysis hysterical? Organic? _Gougerot_, _Charpentier_, 1916   600

  429. Same                           _Gougerot_, _Charpentier_, 1916   602

  430. Same                           _Gougerot_, _Charpentier_, 1916   604

  431.} Reflex “paralysis”                            _Delherm_, 1916   606
  432.}

  433. Shell explosion: Functional blindness, monosymptomatic
                                                      _Crouzon_, 1915   609

  434. Retrobulbar neuritis (nitrophenol)  _Sollier_, _Jousset_, 1917   611

  435. Eye symptoms, hysterical                      _Westphal_, 1915   613

  436. Sandbag on head: Eye symptoms: Lenses          _Harwood_, 1916   615

  437. Hemianopsia, organic or functional?            _Steiner_, 1915   616

  438. Hysterical pseudoptosis    _Laignel-Lavastine_, _Ballet_, 1916   617

  439. Shell explosion: Rombergism                       _Beck_, 1915   620

  440. Case for otologists _and_ neurologists
                                           _Roussy_, _Boisseau_, 1917   622

  441. Jacksonian syndrome: Hysterical      _Jeanselme_, _Huet_, 1915   625

  442. Leg tic: Phobia against crabs                   _Duprat_, 1917   627

  443. Convulsions reminiscent of fright               _Duprat_, 1917   628

  444. Fatigue, delusions, fugue                       _Mallet_, 1917   629

  445. Obsessions and fugue                            _Mallet_, 1917   631

  446. Aprosexia and birdlike movements              _Chavigny_, 1915   632

  447. Shell explosion: Unconsciousness (45 days): Mutism
                                                     _Liébault_, 1916   633

  448. Shell explosion: Recurrent amnesia    _Mairet_, _Piéron_, 1917   634

  449. Shell explosion: Comrade killed: Amnesia         _Gaupp_, 1915   635

  450. Shell explosion: Recurrent amnesia    _Mairet_, _Piéron_, 1915   636

  451. Soldiers’ heart, neurotic and organic         _MacCurdy_, 1917   639

  452. Soldiers’ heart, neurotic                     _MacCurdy_, 1917   640

  453. Shell explosion: Hysteria: Malingering (?)       _Myers_, 1916   642

  454. Officer who could not kick                       _Mills_, 1917   644

  455. “Simulation”: Diagnosis incorrect                 _Voss_, 1916   645

  456. Wound: Hysterical edema?                         _Lebar_, 1915   646

  457. Head trauma: simulation? Hysteria? Surgical?      _Voss_, 1916   648

  458. Disease and disorder to avoid service           _Collie_, 1916   649

  459. Yes-No test in anesthesia                        _Mills_, 1917   651

  460. Guardhouse test                                 _Roussy_, 1915   651

  461. Light in a dark room                    _Briand_, _Kalt_, 1917   652

  462. Mutism simulated                                _Sicard_, 1915   654

  463. Deafmutism simulated                             _Myers_, 1916   655

  464. Same: Explained by patient                       _Myers_, 1916   657

  465. Deafmutism: Appearance of malingering        _Gradenigo_, 1917   658

  466. A lame rascal                                   _Gilles_, 1917   659

  467. Picric acid jaundice                   _Briand_, _Haury_, 1916   660

  468. Swelling of hand and arm, 7 months       _Léri_, _Roger_, 1915   663

  469. Shell-shy German                                 _Gaupp_, 1915   664

  470. Germany sends back a simulator                   _Marie_, 1915   664

  471. Simulation of Quincke’s disease                _Lewitus_, 1915   665

  472. “Pensionitis”                                   _Collie_, 1915   666

             SECTION D. SHELL-SHOCK TREATMENT AND RESULTS

  473. Deafmutism: Spontaneous cure                      _Mott_, 1916   672

  474. Two returns to the front                        _Gilles_, 1916   675

  475. Vicissitudes in 15 months                       _Purser_, 1917   676

  476. Deafmutism: Spontaneous cure                     _Jones_, 1915   678

  477. Course of an oniric delirium       _Buscaino_, _Coppola_, 1916   679

  478. Same                               _Buscaino_, _Coppola_, 1916   681

  479. Paraplegia: Cure by Iron Cross                   _Nonne_, 1915   682

  480. Mutism cured by getting drunk                  _Proctor_, 1915   682

  481. Mutism cured by working in vineyard               _Anon_, 1916   683

  482. Deafmutism: Spontaneous recovery of speech.
       Recovery of hearing by isolation                _Zanger_, 1915   684

  483. Excess of sympathy on furlough              _Binswanger_, 1915   685

  484. Hysterical seizures treated by hydrotherapy _Hirschfeld_, 1915   688

  485. Low blood pressure treated by pituitrin          _Green_, 1917   690

  486. Manual contracture: Various treatments        _Duvernay_, 1915   691

  487. Massage and mechanotherapy                     _Sollier_, 1916   692

  488. Mine explosion; headache: Lumbar puncture       _Ravaut_, 1915   693

  489. Hysterical clenched fist: Treatment by fatigue of flexors
                                                        _Reeve_, 1917   694

  490. Hysterical adduction of arm: Treatment by induced fatigue
                                                        _Reeve_, 1917   695

  491. Hysterical cross-legs: Treatment by induced fatigue
                                                        _Reeve_, 1917   696

  492. Hysterical torticollis: Treatment by induced fatigue
                                                        _Reeve_, 1917   697

  493. Claw foot (2 years): Cure by induced fatigue     _Reeve_, 1917   698

  494. Traumatic and post-traumatic effects: Surgical treatment
                                                   _Binswanger_, 1917   699

  495. Vomiting: Cure by restoration of self-confidence
                                                     _McDowell_, 1917   701

  496. Self-accusatory delusions: Treatment by “autognosis”
                                                        _Brown_, 1916   702

  497.} Deafmutism in three men shell-shocked at one time
  498.}                                                _Roussy_, 1915   703
  499.}

  500. Vomiting; incontinence, abasia: Cure by persuasion
                                                   _McDowell_, 1916 705-706

  501. Hysterical convulsions cured by an explanation   _Hurst_, 1917   706

  502. Course of a case with crises of trembling       _Roussy_, 1915   706

  503.} Two cases of lameness cured by persuasion      _Russel_, 1917   707
  504.}

  505. Head trauma: Treatments by bandage, isolation,
       open air and to-and-fro transfers           _Binswanger_, 1915   708

  506. Rationalization of war memories                 _Rivers_, 1918   712

  507. Same                                            _Rivers_, 1918   713

  508. Same                                            _Rivers_, 1918   714

  509. Same                                            _Rivers_, 1918   715

  510. Same, without redeeming feature as nucleus of
       rationalization                                 _Rivers_, 1918   716

  511. Paraplegia cured by removal of crutches          _Veale_, 1917   717

  512. Same                                             _Veale_, 1917   718

  513. Paraplegia: Chocolates _versus_ isolation      _Buzzard_, 1916   719

  514. Blindness, mutism, deafness. Immediate spontaneous
       recovery from the first; gradual recovery from
       second; deafness cured by “small operation”      _Hurst_, 1917   720

  515. Deafness: Treatment by stimulating vestibular apparatus
                                                     _O’Malley_, 1916   721

  516. Mutism: Treatment by operative manipulation   _Morestin_, 1915   722

  517. Visual impairment: Treatment by suggestion,
       faradism injections                              _Mills_, 1915   724

  518. Aphonia: Treatment by manipulation in larynx  _O’Malley_, 1916   725

  519. Same                                            _Vlasto_, 1917   727

  520. Mutism, amnesia: Treatment by faradism;
       climatic cure in dream                           _Smyly_, 1917   728

  521. Blindness: Cure by injections in temple          _Bruce_, 1916   729

  522. Deafness cured by suggestion in writing       _Buscaino_, 1916   730

  523. Reproduction of Shell-shock story in hypnosis: Recovery
                                                        _Myers_, 1916   732

  524. Same                                             _Myers_, 1916   733

  525. Automatism, amnesia, deafmutism: Recovery by hypnosis
                                                        _Myers_, 1916   734

  526. Mutism: Recovery by hypnosis                     _Hurst_, 1917   736

  527. Stammering: Cure by hypnosis                     _Hurst_, 1917   737

  528. Mutism and amnesia: Cure by hypnosis             _Myers_, 1916   739

  529. Victoria Cross winner: Bayonet clutch contracture
       revealed by hypnosis                              _Eder_, 1916   741

  530. Contracture: Hypnotic cure “indecently quick”    _Nonne_, 1915   742

  531. “Doll’s head” anesthesia: Mutism: Cure by hypnosis
                                                        _Nonne_, 1915   744

  532. Mine explosion: Tremors (also _ante bellum_ tremors):
       Cure by hypnosis                              _Grünbaum_, 1916   745

  533. Astasia-abasia: Cure by hypnosis                 _Nonne_, 1915   747

  534. Crural monoplegia: Cure by hypnosis              _Hurst_, 1917   748

  535. Tremors and sensory disorders: Cure by hypnosis  _Nonne_, 1915   749

  536. Paraplegia of gradual development: Cure by repeated hypnosis
                                                        _Nonne_, 1915   751

  537. Visual impairment and dysbasia: Cure by hypnosis
                                                       _Ormond_, 1915   752

  538. Blindness cured by hypnosis                      _Hurst_, 1916   753

  539. Postoperative retention of urine: Relief by hypnosis
                                                  _Podiapolsky_, 1917   754

  540. Postoperative pains: Relief by hypnosis    _Podiapolsky_, 1917   755

  541. Stereotyped war dream and _ante bellum_ headache:
       Cure by hypnosis                               _Riggall_, 1917   756

  542. Amnesia and _ante bellum_ headache: Cure by hypnosis
                                                    _Burmiston_, 1917   757

  543. Convulsions cured by hypnosis                    _Hurst_, 1917   759

  544. Two attacks of mutism: Spontaneous recovery from
       one in 18 months, from the other by hypnosis      _Eder_, 1916   759

  545. Neurasthenic symptoms cured by repeated hypnosis
                                                    _Tombleson_, 1917   760

  546. Neurasthenic symptoms: Improvement under repeated hypnosis
                                                    _Tombleson_, 1917   761

  547. Convulsions “Jacksonian” and dysbasia: Cure by hypnosis
                                                    _Tombleson_, 1917   762

  548. Agoraphobia: Cure by hypnosis                    _Hurst_, 1917   763

  549. Manual tremors: Treatment by forcing and isolation
                                                   _Binswanger_, 1915   764

  550. Mutism: Psychoelectric cure                     _Scholz_, 1915   766

  551. Hemiplegia and deafmutism; (also convulsions by
       heterosuggestion): Improvement by faradism;
       full recovery by suggestion                  _Arinstein_, 1915   767

  552. Deafmutism, cures, relapses and eventual cure by anesthesia
                                                       _Dawson_, 1916   768

  553. Deafness: Cure by suggestion on emerging from ether
                                                        _Bruce_, 1916   770

  554. Aphasia, hemiplegia, hemianesthesia, and (by medical suggestion)
       trismus: Cure by anesthesia and suggestion   _Arinstein_, 1915   771

  555. Triplegia, mutism, jumping-jack reactions: Cure by
       anesthesia, verbal suggestion, faradism      _Arinstein_, 1915   773

  556. Mutism and musical alexia: Cure by anesthesia  _Proctor_, 1915   775

  557. Deafmutism: Deafness cured by anesthesia     _Gradenigo_, 1917   776

  558.} Interaction of two cases (deafmute and mute)
  559.} under treatment                                 _Smyly_, 1917   777

  560. Dysbasia: Cure by stovaine anesthesia           _Claude_, 1917   778

  561. Same                                            _Claude_, 1917   779

  562. Deafmutism                            _Bellin_, _Vernet_, 1917   780

  563. Monoplegia: Cure by electricity administered with a
       bored and authoritative look        _Adrian_, _Yealland_, 1917   782

  564. Monoplegia after sling: Technique of electrical suggestion
       and “rapid” reëducation             _Adrian_, _Yealland_, 1917   783

  565. Hysterical “sciatica”: Treatment by faradism and
       verbal suggestion                               _Harris_, 1915   785

  566. Prognosis of intensive reëducation in reflex
       (physiopathic) disorder                        _Vincent_, 1916   786

  567. Hysterical contracture (with physiopathic features)
       brutally conquered                             _Ferrand_, 1917   788

  568. Paraparesis: Cure by exercises electrically provoked
                                                      _Turrell_, 1915   790

  569. Astasia-abasia: (“Lourdes-like” cure)             _Voss_, 1916   791

  570. Abasia: Rapid cure                            _Schultze_, 1916   792

  571. Heterosuggestive brachial paresis: Electric suggestion
       and recovery in five days                        _Hewat_, 1917   794

  572. Contracture of right index finger and thumb:
       Psychoelectric cure               _Roussy_, _L’Hermitte_, 1917   795

  573. Brachial monoplegic able to descend ladder with arms only
                                                       _Claude_, 1916   795

  574. Brachial monoparesis: Vicissitudes of treatment
                                                      _Vincent_, 1917   796

  575. Paresis and sensory disorder: Reëducation   _Binswanger_, 1915   798

  576. Seizures (of _ante bellum_ origin), astasia-abasia,
       anesthesias: Reëducation                    _Binswanger_, 1915   800

  577. Progress in case of paresis of foot and spasticity of hip
                                                   _Binswanger_, 1915   805

  578. Mutism (Reëducation)                _Briand_, _Philippe_, 1916   808

  579. Stammering: Isolation and reëducation       _Binswanger_, 1915   810

  580. Deafmutism: Phonetic reëducation              _Liébault_, 1916   814

  581. Aphonia: Pressure on sternum and respiratory gymnastics
                                                        _Garel_, 1916   816

  582. Stammering: Reëducation                       _MacMahon_, 1917   817

  583. Speech disorder: Reëducation                  _MacMahon_, 1917   818

  584. Camptocormia: Psycho-electric cure: lameness cured by
       reëducation                       _Roussy_, _L’Hermitte_, 1917   819

  585. Deafmutism: Speech recovery by suggestion and reëducation:
       Hearing by reëducation                        _Liébault_, 1916   822

  586. Mutism; stammering; Reëducation; hypnosis     _MacCurdy_, 1917   823

  587. Anesthesias: Spontaneous gradual recovery: “Paralysis”
       cured by reëducation                        _Binswanger_, 1915   824

  588. Deafmutism; head movements, anesthesia: Cure by
       faradism, massage and reëducation            _Arinstein_, 1916   827

  589. Amnesia and paralysis: Reëducation              _Batten_, 1916   828

                         SECTION E. EPICRISIS

                                                                  PARAGRAPH
  TERMINOLOGY                                                           1-8

  DIAGNOSTIC DELIMITATION PROBLEM                                      9-39

  THE NATURE OF WAR NEUROSES                                          40-74

  DIAGNOSTIC DIFFERENTIATION PROBLEM                                  75-99

  GENERAL NATURE OF SHELL-SHOCK                                      89-102

  TREATMENT: GENERAL OBSERVATIONS                                   103-114



A. PSYCHOSES INCIDENTAL IN THE WAR

    La divina giustizia di qua punge
      quell’ Attila che fu flagello in terra.

    Divine justice here torments that Attila, who
      was a scourge on earth.

                      Inferno, Canto xii, 133-134.


The data from all the belligerent countries, collected in this book, go
far to prove that, whatever at last you elect to term Shell-shock, you
must pause to consider whether your putative case is not actually:

A matter of spirochetes?

The response of a subnormal soldier?

An equivalent of epilepsy?

An alcoholic situation?

A result of neurones actually _hors de combat_?

A state of bodily weakness (perhaps of _faiblesse irritable_)?

A bit of dementia praecox?

One of the ups and downs of the emotional (affective, cyclothymic)
psychoses?

An odd psychopathic reaction in which the response is abnormal not so
much by reason of excessive stimulus as by reason of defective power of
response?

On a simpler basis, is not our Shell-shocker just a banal example of
hysteria, neurasthenia, psychasthenia; and is not this psychoneurotic
more peculiar in his capacity to be shocked than are the conditions
that purvey the shocks?

Put more concretely in the terms of available tests and criteria,
open to the psychiatrist, does not every putative Shell-shock soldier
deserve at some stage a blood test for syphilis? Should we not be
reasonably sure we are not facing a man inadequate to start with, so
far as mental tests avail? Should we not verify (even at considerable
expense of time and money by so-called “social service” methods) the
facts of epilepsy and epileptic taint? Of alcoholism? And so on? There
can be no two answers to these questions.

Upon the following page is a practical grouping of mental diseases,
devised in the first place, not for war psychoses, but for the
initial sifting of psychopathic hospital cases. Now the psychopathic
hospital group of cases constitutes in peace practice the closest
analogue of the mental cases met in active military practice, because
the “incipient, acute, and curable”[1] cases, for which psychopathic
hospitals are built and which flock to or are sent to the wards and
outdoor departments of such hospitals, are precisely the cases that
early come forward in active military practice. They are precisely the
cases in which that pathological event--whatever it is--we know as
Shell-shock may be expected to develop. It is precisely the “incipient,
acute, and curable” instances of mental disease which we hope to
exclude from our American army by cis-Atlantic winnowing-out at the
hands of neuropsychiatric experts--the best preventive we hope both of
Shell-shock and of other worse mental conditions, if such there be.
Military mental practice plainly deals, not so much with frank and
committable insanity, as with mental diseases of a medically milder but
a militarily far more insidious nature.

    [1] Official phrase for the scope of the Psychopathic Hospital,
    Boston, Massachusetts.

A further inspection of this grouping of mental diseases shows not
only that it contains many conditions not usually termed “insanity”
(such as, e.g., feeblemindedness, epilepsy, alcoholism, sundry somatic
diseases, psychoneuroses), but that these conditions are presented for
practical purposes in a certain seemingly arbitrary order. Without
attempting to justify this selection of scope (not too wide for modern
psychiatry, most would readily acknowledge), I shall draw out a little
further what I consider to be the virtues of the order selected. In
the first place, all will concede, _some_ order of consideration of
collected data is a prime necessity to the tyro. Without an order of
consideration the diagnostic tyro is but too apt to find in the best
textbooks of psychiatry (even more easily the better the textbook)
all he needs to prove that the case in hand is--almost anything he
selects to make his case conform to! And how much more dangerous this
debating-society method of diagnosis (by choice of a side and matching
a textbook type) may become in the fluid and elastic conditions
of psychopathic hospital practice, can readily be observed by one
who contemplates the _formes frustes_ and entity-sketches that the
“incipient, acute, and curable” group of cases presents.

                                CHART 1

                 PRACTICAL GROUPING OF MENTAL DISEASES

    The order adopted for these groups (which roughly correspond
    to botanical or zoological orders) is a pragmatic order for
    successive exclusion on the basis of available tests, criteria,
    or information: the actual diagnosis is a product of still
    further differentiation within the several groups.

    The case-histories of this book will show that

    (_a_) most shell-shock is in group X, Psychoneuroses,

    (_b_) the diagnostic delimitation problem is chiefly against I.
    Syphilopsychoses, III. Epileptoses, VI. Somatopsychoses,

    (_c_) the finer differentiation problem is between X.
    Psychoneuroses and V. Encephalopsychoses. (See Epicrisis,
    propositions 9-12, 40-43, 72-73.)

       I. Syphilitic Psychoses             SYPHILOPSYCHOSES

      II. Feeblemindedness                 HYPOPHRENOSES

     III. Epilepsy                         EPILEPTOSES

      IV. Alcoholic, Drug, and Poison
          Psychoses                        PHARMACOPSYCHOSES

       V. Focal Brain Lesion Psychoses     ENCEPHALOPSYCHOSES

      VI. Symptomatic (Somatic) Psychoses  SOMATOPSYCHOSES

     VII. Presenile-Senile Psychoses       GERIOPSYCHOSES

    VIII. Dementia Praecox and Allied
          Psychoses                        SCHIZOPHRENOSES

      IX. Manic-Depressive and Allied
          Psychoses                        CYCLOTHYMOSES

       X. Psychoneuroses                   PSYCHONEUROSES

      XI. Other Forms of Psychopathia      PSYCHOPATHOSES

No conclusions are intended to be drawn in these introductory pages.
Such conclusions as are risked are placed in the Epicrisis (see
Section E). But so much can be said: If we are ever to surround the
problem of Shell-shock (_intra bellum_ or _post bellum_), we must
approach it with no artificial and _à priori_ limitations of its scope.
We must not even agree beforehand that Shell-shock is nothing but
psychoneurosis: that would be a deductive decision unworthy of modern
science. In the collection of these cases, I have tried to place the
topic upon the broadest clinical base. Samples of virtually every sort
of mental disease and of several sorts of nervous disease have been
laid down, some obviously not instances of Shell-shock, some mixed with
clinical phenomena of Shell-shock, others hard to tell offhand from
Shell-shock--the whole on the basis that we shall earliest learn what
Shell-shock, the pathological event, is by studying what it is not. As
the sequel may show, we are perhaps not entitled to regard Shell-shock,
the pathological event, as always associated with shell-shock, the
physical event. We shall, therefore, find in Section A (see tables on
pages 6 and 7).

(1) Cases without either physical shell-shock, or pathological
Shell-shock--psychoses of various kinds incidental in the war (--+).

(2) Cases with physical shell-shock but without pathological
Shell-shock--psychoses of various kinds seemingly liberated by,
aggravated by, or accelerated by the physical factor of shell-shock
(+-+).

(3) Cases without physical shell-shock but with both symptoms of
pathological Shell-shock as well as of other psychosis (-++).

(4) Cases with physical shell-shock, with clinical phenomena of
Shell-shock, as well as of other psychosis (+++).

At the end of Section A, accordingly, we shall be left with two more
formulae for discussion in Sections B, C, and D, viz:

(5) Cases without physical shell-shock but with symptoms of
pathological Shell-shock (-+-).

(6) Cases with physical shell-shock and pathological Shell-shock (++-).

The data of Section A will solidly prove that Shell-shock, however
picturesque the term for laymen or in the _argot_ of the clinic, is
medically most intriguing. As we cannot get rid of the term (even by
suppressing it in parentheses or by condemning it to the limbo of the
_so-called_), we must make the best of it by calling Shell-shock just
the ore in the clinical mine. To say the least, the _term_ is harmless:
it merely stimulates the lay hearer to questions. These questions he
must ask of the expert. But every time that the expert suavely states
that Shell-shock is nothing but psychoneurosis, that expert runs the
risk of hurting some patient who may or not have a psychoneurosis but
has been _called_ psychoneurotic. All the while, of course, the suave
expert is perfectly right--_statistically_. In fine, the man you have
called a victim of Shell-shock is probably a victim of psychoneurosis,
_but only probably_!

Section A shows how he may--not probably, but possibly--be a victim of
say ten other things. But it is not that he has an even chance of being
one of these ten other things. As the reader watches the procession
of cases in Section A, he will perceive that, amongst the ten major
groups there studied, some have far greater diagnostic likelihood than
others. Thus, syphilis, epilepsy, and somatic diseases will in the
sequel prove more dangerous to our success as diagnosticians than, e.
g., feeblemindedness or even perhaps alcoholism. But now let us look at
these cases systematically, just as if we dealt with so many cases of
Railway-spine or any other “incipient, acute, and curable” cases.

                                CHART 2

                        PSYCHOPATHIA MARTIALIS

              ⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫
                                               ⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫
    SHELL-SHOCK              SHELL-SHOCK          PSYCHOSIS
    (THE PHYSICAL FACTOR)  (NEUROTIC SYMPTOMS)  (SYMPTOMS NON-NEUROTIC)

    ABSENT                     ABSENT             INCIDENTAL

    PRESENT                    ABSENT             LIBERATED,
                                                  AGGRAVATED,
                                                  ACCELERATED
                                                  PSYCHOSES

    ABSENT                COMBINED NEUROSES
                            AND PSYCHOSES
                          [2](FORMULA -++)

    PRESENT               COMBINED NEUROSES
                            AND PSYCHOSES
                            (FORMULA +++)

    ABSENT                   NEUROSES              ABSENT
                         (QUASI SHELL-SHOCK)

    PRESENT                  NEUROSES              ABSENT
                         (TRUE SHELL-SHOCK)

    [2] For formulae see Chart 3 on opposite page.

                                CHART 3

                        PSYCHOPATHIA MARTIALIS

                               FORMULAE

                           ⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫
                                                          ⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫
    S, N, P[3] = SHELL-SHOCK       SHELL-SHOCK              PSYCHOSIS
               (THE PHYSICAL[4]   (NEUROTIC SYMPTOMS)    (NON-NEUROTIC
               FACTOR) PRESENT      PRESENT             SYMPTOMS) PRESENT

      P =             -                 -                       +

     SP =             +                 -                       +

     NP =             -                 +                       +

    SNP =             +                 +                       +

      N =             -                 +                       -

     SN =             +                 +                       -

    [3] In the literal formulae, S = Shell-shock, N = Neurosis, P =
    Psychosis.

    [4] These plus-or-minus formulae are not intended to imply
    that the physical factor, where present (+), must have worked
    a physical effect upon the nervous system: the effects of the
    physical factor might be wholly emotional or otherwise psychic.



I. SYPHILOPSYCHOSES (SYPHILITIC GROUP)


An officer of high rank deserts his command in a crisis: alienists’
report.

=Case 1.= (BRIAND, February, 1915.)

M. X. was an officer ranking high in the French army, having military
duties of a critical nature and of great importance (social reasons
forbid Briand’s giving informatory details). Suffice it to say that he
was brought before court-martial for abandoning his post at the very
moment when his presence was most urgently required. He turned tail,
without taking the most elementary military precautions.

M. X. was passed up to alienists. He was not a case of Shell-shock
unless of the anticipatory sort. He was somatically run-down and of
lowered morale and now 65 years of age. The campaign had been fatiguing.

The alienists decided that the officer had not been responsible for
his non-military acts. He had been, they found, in a state of mental
confusion at the time of desertion, such that amnesia for his duties
and heedlessness of consequences had allowed him to leave the front
without looking behind him or securing substitution. This state of
mental confusion had been preceded by overwork and several nights of
insomnia.

Moreover he was palpably arteriosclerotic. Blood pressure was high. The
history was one of slight shocks and a mild hemiplegia. The confusion
at the front was only the most recent of a series of transitory attacks
of confusion. At the time of examination this high officer was actually
in a state of mild dementia.

M. X. was an old colonial man, malarial, and had been a victim of
syphilis.


A naval officer sees hundreds of submarines: General paresis.

=Case 2.= (CARLILL, FILDES, and BAKER, July, 1917.)

A naval officer, 36, during August, 1916, asserted that he could see
hundreds of submarines. At one time he imagined that he was receiving
trunk calls in the middle of the ocean. He was admitted to Haslar, and
the Wassermann reaction of the serum was found strongly positive. The
spinal fluid was not at this time examined. The officer recovered to
some extent, was given no special treatment, and was sent on leave.

He came under observation again in October, 1916, having become very
strange in his manner, on one occasion passing water into the coal box,
and talked about impending electrocution. His ankle-jerks were found
sluggish and there was a patch of blunting to pin pricks. The diagnosis
of general paresis was made. The spinal fluid was afterward examined
and found to be negative to the Wassermann reaction but contained 15
lymphocytes per cubic mm.

Three full doses of Kharsivan freed him from delusions and left him
apparently absolutely sane. It was recommended that he should be kept
at Haslar to continue treatment. However, he had been certified insane
and was therefore sent to Yarmouth, from which he was discharged in
February, 1917, having been in good mental health throughout his stay
there.

_Re_ syphilis and general paresis of military officers, as in Cases 1
and 2, Russo-Japanese experience was already at hand. Autokratow saw
paretic Russian officers sent to the front in early but still obvious
phases of disease. These paretics and various arteriosclerotics,
Autokratow saw back in Russia in the course of a few months.

_Re_ naval cases, see also Case 5 (Beaton). Beaton thinks that
monotonous ship duty, alternating with critical stress of service,
bears on morale and liberates mental disorder.


Neurosyphilis may be aggravated or accelerated under war conditions.

=Case 3.= (WEYGANDT, May, 1915.)

A German, long alcoholic and thought to be weakminded, volunteered, but
shortly had to be released from service. He began to be forgetful and
obstinate, cried, and even appeared to be subject to hallucinations.
The pupils were unequal and sluggish. The uvula hung to the right.
The left knee-jerk was lively, right weak. Fine tremors of hands.
Hypalgesia of backs of hands. Stumbling speech. Attention poor.

It appeared that he had been infected with syphilis in 1881 and in 1903
had had an ulcer of the left leg.

The military commission denied that his service had brought about the
disease.


=Case 4.= (HURST, April, 1917.)

An English colonel thought himself perfectly fit when he went out with
the original Expeditionary Force. He had had leg pains, regarded as
due to rheumatism or neuritis. He was invalided home after exhaustion
on the great retreat. He was now found to be suffering from a severe
tabes. He improved greatly under rest and antisyphilitic treatment. He
has now returned to duty.


=Case 5.= (BEATON, May, 1915.)

An apparently healthy man, serving on an English battle-ship, severed
a tendon in a finger. The injury was regarded as minor. The tendon was
sutured and the wound healed. During the man’s convalescence he was
accidentally discovered to have an Argyll-Robertson pupil and some
excess reflexes. Neurosyphilis had probably antedated the accident. But
from the moment of this trivial injury, the disease advanced rapidly.


Overwork in service; several months exacting work well performed:
General paresis.

=Case 6.= (BOUCHEROT, 1915.)

A lieutenant of Territorials, aged 41 (heredity good, anal fistula at
30, with ulceration of penis of an unknown nature at the same period).
In 1907 when off service and married, his wife gave birth to a child;
no miscarriages. Had been a good soldier in service before the war. The
lieutenant was called to the colors August 2, 1914, and was detached
for special duty, for the performance of which he was much praised by
the commanding officers. The work, however, was too much for him and
on April 1 he had to be evacuated to the hospital with a ticket saying
“Nervous depression following overwork in service.” On April 14 he
seemed well enough for a convalescent camp, but, apparently through
red tape, was sent to a hospital at Orléans. On June 23 he had to be
evacuated to the Fleury annex. His eyes were dull and features flaccid;
his whole manner suggested fatigue. His pupils were myotic, tongue
tremulous, speech slow and stumbling. Knee-jerks were exaggerated and
gait difficult, the right leg dragging. Headaches. He could not perform
the slightest intellectual work and was the victim of retrograde and
anterograde amnesia. He was aware of the decline of his mental power
and was fain to struggle against it, becoming restless and sad. The
gaps in his memory grew deeper, he became more and more impulsive,
even violent, and had spells of excitement. Dizziness and palpitation
developed. Sometimes there were auditory and visual hallucinations of
such intense character that he tried feebly to commit suicide with a
penknife. He fell into semicoma, and then had a number of apoplectiform
attacks. W. R. +

Apparently the moral and physical situation of the lieutenant was
absolutely normal when the campaign began and, as he fulfilled detail
duties with absolute correctness for a number of months, Boucherot
argues that here is an instance of general paresis _declanché_ by
overwork.


Syphilis contracted before enlistment. Neurosyphilis aggravated by
service.

=Case 7.= (TODD, personal communication, 1917.)

A laboring man, 42, who always strenuously denied syphilitic infection,
proceeded to France eight months after enlistment. He had not been
in France three weeks when he dropped unconscious. He regained
consciousness, but remained stupid, dull in expression, and with memory
impaired. His speech was also impaired. There was dizziness and a
right-sided hemiplegia.

He was confined to bed four months and was then “boarded” for discharge.

Physically, his heart was slightly enlarged both right and left; sounds
irregular; extra systoles; aortic systolic murmur transmitted to neck;
blood pressure 140:40. Precordial pain, dyspnoea.

Neurologically, there was a partial spastic paralysis of the right
thigh which could be abducted, could be flexed to 120°, and showed
some power in the quadriceps. There was also a spastic paralysis of
the right arm, but the shoulder girdle movements were not impaired.
There was a slight weakness on the right side of the face. There was no
anesthesia anywhere.

The deep reflexes were increased on the right side, Babinski on right,
flexor contractures of right hand, extensor contractures of right
leg, abdominal and epigastric reflexes absent, pupils active, tongue
protruded in straight line.

Fluid: slight increase in protein. W. R. + + +

The Board of Pension Commissioners ruled that the condition had been
aggravated _by_ service (not “_on_ service”).

_Re_ general paresis, Fearnsides suggested at the Section of Neurology
in the Royal Society of Medicine early in 1916, that in all cases of
suspected Shell-shock the Wassermann reaction of the serum should be
determined, and went on to say that cases of so-called Shell-shock with
positive W. R. often improve rapidly with antisyphilitic remedies.


Duration of neurosyphilitic process important _re_ compensation.

=Case 8.= (FARRAR, personal communication, 1917.)

A Canadian of 36 enlisted in 1915, served in England, and was returned
to Canada in February, 1917, clearly suffering from some form of
neurosyphilis (W. R. positive in serum and fluid, globulin, pleocytosis
108).

There is no record of any disability or symptom of nervous or mental
disease at enlistment. The first symptoms were noted by the patient in
May, 1916, six months or more after enlistment. The case was reviewed
at a Canadian Special Hospital, October 11, 1916, by a board which
reported:

“The condition could only come from syphilitic infection of three
years’ standing” (a decision bearing on compensation); but the general
diagnosis remained:

“Cerebrospinal lues, =aggravated by service=.”

The picture which the medical board regarded as of at least three
years’ standing was as follows:

History of incontinence, shooting pains, attacks of syncope, general
weakness, facial tremor, exaggerated knee-jerks, pupils react with
small excursion. Speech and writing disorder, perception dull, lapses
of attention, memory defect, defective insight into nature of disorder,
emotional apathy.

    1. Was the conclusion “aggravated by service” sound? On
    humanitarian grounds the victim is naturally conceded the
    benefit of the doubt. But it is questionable how scientifically
    sound the conclusion really was.

    2. Could the condition come only from syphilitic infection of
    at least three years’ standing? Hardly any single symptom in
    this case need be of so long a standing; yet the combination
    of symptoms seems by very weight of numbers to justify the
    conclusion of the medical board.

Farrar’s case and thirteen others of “Neurosyphilis and the War” were
included in a general work on Neurosyphilis (Case History Series,
1917, Southard and Solomon). For military syphilis in general, see
Thibierge’s _Syphilis dans l’Armée_ (also in translation).


General paresis lighted up by the stress of military service without
injury or disease?

=Case 9.= (MARIE, CHATELIN, PATRIKIOS, January, 1917.)

In apparently good health a French soldier repaired to the colors, in
August, 1914, being then 23 years old.

Two years later, August, 1916, symptoms appeared: speech disorder
with stammering, change of character (had become easily excitable),
stumbling gait. He became more and more preoccupied with his own
affairs, grew worse, and was sent to hospital in October, 1916.

He was then foolish and overhappy, especially when interviewed.
There was marked rapid tremor of face and tongue. Speech hesitant,
monotonous, and stammering to the point of unintelligibility. His
memory, at first preserved, became impaired so that half of a test
phrase was forgotten. Simple addition was impossible and fantastic sums
would be given instead of right answers. Handwriting tremulous, letters
often missed, others irregular, unequal, and misshapen.

Excitable from onset, the patient now became at times suddenly violent,
striking his wife without provocation. After visit at home, he would
forget to return to hospital. Often he would leave hospital without
permission (of course the more surprising in a disciplined soldier). No
delusions.

Serum and fluid W. R. positive; albumin; lymphocytosis.

Neurological examination: Unequal pupils, slight right-side mydriasis,
pupils stiff to light, weakly responsive in accommodation, reflexes
lively, fingers tremulous on extension of arms.

The patient had, December 5, 1916, an epileptiform attack with head
rotation, limb-contractions and clonic movements. Should this soldier
recover for disability obtained in service? Marie was inclined to
think military service in part responsible for the development of
the paresis. Laignel-Lavastine thought so also, but that the amount
assigned should be 5%-10% of the maximum assignable.


SYPHILITIC ROOT-SCIATICA (lumbosacral radiculitis) in a fireworks man
with a French artillery regiment.

=Case 10.= (LONG (DEJERINE’S clinic), February, 1916.)

No direct relation of this example of root-sciatica to the war is
claimed nor was there a question of financial reparation.

There was no prior injury. At the end of March, 1915, the workman was
taken with acute pains in lumbar region and thighs, and with urgent but
retarded micturition.

Unfit for work, he remained, however, five months with the regiment,
and was then retired for two months to a hospital behind the lines.
He reached the Salpêtrière October 12, 1915, with “double sciatica,
intractable.”

There was no demonstrable paralysis but the legs seemed to have “melted
away,” _fondu_, as the patient said. Pains were spontaneously felt in
the lumbar plexus and sciatic nerve regions, not passing, however,
beyond the thighs. These pains were more intense with movements of
legs; but coughing did not intensify the pains. Neuralgic points could
be demonstrated by the finger in lumbar and gluteal regions and above
and below the iliac crests (corresponding with rami of first lumbar
nerves). The inguinal region was involved and the painful zone reached
the sciatic notch and the upper part of the posterior surface of the
thigh.

The sensory disorder had another distribution, objectively tested. The
sacral and perineal regions were free. Anesthesia of inner surfaces of
thighs, hypesthesia of the anterior surfaces of thighs and lower legs.
The anesthesia grew more and more marked lower down and was maximal in
the feet, which were practically insensible to all tests, including
those for bone sensation. There was a longitudinal strip of skin of
lower leg which retained sensation.

Position sense of toes, except great toes, was poor. There was a
slight ataxia attributable to the sensory disorder--reflexes of upper
extremities, abdominal, and cremasteric preserved, knee-jerks, Achilles
and plantar reactions absent.

The vesical sphincter shortly regained its function, though its
disorder had been an initial symptom. Pupils normal.

The “sciatica” here affects the lumbosacral plexus.

As to the syphilitic nature of this affection, there had been at
eighteen (22 years before) a colorless small induration of the penis,
lasting about three weeks. There was now evident a small oval pigmented
scar. The patient had married at 20 and had had three healthy children.

The lumbar puncture fluid yielded pleocytosis (120 per cmm.). Mercurial
treatment was instituted.

The treatment has not reduced the pains. Long thinks it was undertaken
too long (six months) after onset. The warning for early diagnosis is
manifest. There was somehow a delay under the medical conditions of the
army.

_Re_ syphilis in munition-workers Thibierge has much to say of French
conditions. Throughout his work on syphilis in the army, he stresses
the large number of venereal cases in men mobilized for munition-work.
Medical inspections ought, according to Thibierge, imperatively to be
made in the munition-works and upon all mobilized workmen, whether
French or belonging to the Colonial contingents. These men are under
military control in France, but they have more opportunities than the
soldiers for contracting and disseminating syphilis. They are, in point
of fact, very often infected and in a higher proportion than are the
soldiers at the front. The munition-workers should also be obliged to
report their infections to the physician, whether or no they are under
treatment by military or by private physicians.

Thibierge devotes a chapter to syphilis as a national danger. Not
only do available statistics prove that there is more syphilis in
the population since the outbreak of war, but the number of married
women going to special hospitals for syphilis is abnormally high and
entirely out of proportion to the number of married women resorting
to these clinics in peace times. A certain number are contaminated
by their husbands on leave. Thibierge calls attention to the fact of
the extraordinary frequency of syphilis in young men (two or three,
sixteen to eighteen years of age, at Saint-Louis Hospital at each
consultation).


A disciplinary case: Syphilitic?

=Case 11.= (KASTAN, January, 1916.)

Reports varied about a certain German soldier who came up for
discipline. Inferiors thought he was harsh and tricky. A lieutenant
declared that the man always wanted to have proper respect paid to him,
and that he was unduly excited by trifles. The man had become latterly
very nervous on account of battle strain and protracted shelling.

July 28, 1915, the man, who had been drinking with comrades the night
before, was excitedly talking to an officer concerning relief of a
guard. The soldier stated, “As a sergeant on duty with a service record
of 15 years, I think it is my affair.” The lieutenant replied, “So
far as I am concerned, the matter is settled.” The sergeant yelled,
“As far as I am concerned, it is settled also. By the way, my name
is _Mr._ Vice Sergeant …,” and with that the sergeant wrote down the
lieutenant’s words and refused to obey the lieutenant’s order to
“Stop writing.” The lieutenant drew his sword and said, “Take your
hands down.” The sergeant replied, “Surely I am permitted to write.”
Lieutenant: “Subordination; don’t forget yourself, Vice Sergeant.…”
The sergeant jeered, “You forgot yourself anyhow;” whereupon the
lieutenant: “Well, such a thing never happened to me before.” The
sergeant, jeeringly, “Nor to me either. If I were not in undress I
should know what to do.” The lieutenant: “Vice Sergeant …, remain here.
This matter will be settled at once.” The sergeant: “It is _Mr._ Vice
Sergeant …,” whereupon he gave his notebook to a hornblower and said,
“Write.” The lieutenant: “Stay.” The sergeant: “What, stay here. No,
I’ll not stay,” and made off. The lieutenant called after him, “Put
on your service dress and see the captain.” He made ready but said,
“This half-idiot gives an order like that to a sergeant with 15 years’
record.”

The examination showed that the man had a hypalgesia. He complained of
violent headaches. He said that he had had syphilis 10 years before;
there were no bodily stigmata.


Regulations broken: General paresis.

=Case 12.= (KASTAN, January, 1916.)

A German 1st-lieutenant, on active service before the war, had left
the service because there was not enough for him to do in peace times.
During his war service, he became drunk and had two soldiers bound to
a doorpost, with coats unbuttoned and without their caps--a process
quite _verboten_. While in Königsberg, he reported himself ill, and
failed to go to a designated hospital. He was accordingly treated as
a deserter. He ran up bills with landlady and servant girls, saying
that he was going to receive money from his wife. Under hospital
examination, he said he was only a Baden man with a lively temperament.
He got angry at the phrase _test feeding_, refused food, got excited
when asked to help in the care of other patients, and wrote a letter
saying, “If it is the idea to make me nervous by removing the air from
me, by prescribing rest in bed--a punishment only suitable for a boy
who cannot keep himself neat--and such chicaneries, these philanthropic
attempts are bound to fail on my robust peasant nerves. Of course I
know that money considerations make the stay of every paying patient
desirable, but I am really too good for that. [The expenses were being
borne by the state.] I have openly stated what is being here done with
me is foolery, and I stick to that phrase. The food, already poor
enough, is no better, when the meat of a half-rotten cow comes twice to
the table.” This patient was, according to Kastan, a victim of general
paresis.

_Re_ general paresis and delinquency, Gilles de la Tourette long ago
maintained that there was a medicolegal period in paresis. Lépine in
his work on _Troubles Mentales de la Guerre_ speaks of the unexpected
frequency of general paresis in the army, and calls attention at the
outset to the medicolegal period. The danger of overt delinquency
is, in fact, greater under military than under civilian conditions
on account of the closer surveillance of the soldier. Desertion and
thievery are the main forms.


Unfit for service: General paresis.

=Case 13.= (KASTAN, January, 1916.)

Kastan describes a non-commissioned officer, who came voluntarily
into the clinic. It seems that he had absented himself (?) from the
army in the suburbs of Königsberg, September 3, 1914. He was arrested
October 7th. Once before he had been brought to Kastan’s clinic on the
suspicion of general paresis, but had been dismissed as non-paretic.
Brought in again in a condition of marked fear, he declared that he had
to fall behind his company while he was on the march on account of a
feeling of weakness. He had been taken to a hospital and then carried
to the suburbs of Königsberg, examined, and found unfit for service.

He had in his 20th year become infected with syphilis, and had recently
become forgetful, subject to fears, and easily excitable. He had been
very unhappily married with a woman who was hysterical and threatened
to shoot and poison him. He lived in a condition of continual quarrels
with her. The symptoms that he felt on the march were numbness of the
legs and a rush of blood to the head. In the clinic, he was subject
to much dreaming and raving about the war. There was excessive
perspiration.

    1. As to the proper interpretation of this case, details
    are lacking as to the physical and laboratory side. In
    fact, it would appear that the suspicion of paresis at his
    first reception in a clinic was dismissed without resort to
    laboratory findings.

    There are no neurological symptoms in the case clearly
    suggestive of neurosyphilis, except perhaps the numbness of
    the legs. The remainder of the picture appears to be entirely
    psychic. Sensory and intellectual symptoms are missing unless
    we count the war dreams and mania as intellectual. It appears
    wiser to count these as emotional in the sense that they were
    roused by emotion-laden memories. The fear, perspiration, and
    feelings of head flush are perhaps to be best interpreted as
    satellites about an emotional nucleus.


Hysterical chorea versus neurosyphilis.

=Case 14.= (DE MASSARY and DU SONICH, April, 1917.)

There were various complications in the case of a lieutenant (nervous
tic in childhood; travel 23 to 30), who was at Antwerp during the
period of mobilization. He was taken there by the Germans; was a
prisoner in their hands for 55 days; and succeeded under great strain
in escaping.

He then entered his regiment, and, passing the examinations, was
made an adjutant, and went to the front, March, 1915. He stayed ten
months in the Verdun region, under heavy bombardment, and in June was
bowled over and buried by a 210. He seemed to be fearless, getting no
sensation from shell-bursts except a griping sensation in the bowels.

However, his character had altered in the direction of irritability;
and by the end of January, 1916, he had to be evacuated for the
first time from the front, for general weakness, with the diagnoses:
neurasthenia, neuralgia, dyspeptic troubles, great general fatigue,
marked depression. In fact, at Narbonne he was asked no questions
for several days on account of his obvious depression. He was given
ice-bags for violent headaches, complete rest in bed, cacodylate and
sodium nucleinate. In two weeks he was up and about.

At this time appeared choreiform movements, which reached their maximum
in two or three days, whereupon he was sent, March 4, 1916, to the
neurological centre at Montpellier. Here W. R. positive! Neosalvarsan
on the second injection (0.45 and 0.60) yielded a strong reaction, with
fever, delirium, vomiting, and then jaundice.

About a month later, he was given twenty more intravenous injections,
whereupon the choreic movements now decreased, and July 15 he was given
convalescence for three months. October 15 he went back to his dépôt
cured; and October 20, on request, went to the front. He was potted
and under machine-gun fire at times during the next three months, but
the choreic movements did not reappear. January 1 he left the trenches
as the division went into billets. January 8, suddenly, without
any emotional cause, he began to “dance” again. Accordingly, he was
evacuated for the second time, January 10, 1917, with the diagnosis:
choreic movements, especially on left; evacuate to special centre.

At Royallieu, a lumbar puncture showed a slight lymphocytosis.
The headache improved. He was evacuated January 24, 1917, to
Val-de-Grâce, with a diagnosis: Recurrent chorea; first attack followed
commotio cerebri, nervous depression, inequality of pupils, various
pains, contracted in the army. Another W. R. was positive. Twelve
intramuscular injections of oxygen cyanide were given, besides baths.
He was then sent to Issy-les-Moulineaux with a diagnosis of tic. He
showed choreiform movements affecting the legs alone. When sitting,
legs extended and flexed, the knees would abduct, then adduct;
the thighs flexed. When standing, flexor movements were produced
alternately on the left and the right, the knee being raised high,
sometimes striking the patient’s hand. In walking, the thigh and lower
leg flexion was always out of proportion to the required step. There
was thus a sort of saltatory chorea limited to the legs. The reflexes
so far as they could be tested were normal save that the left pupil
was fixed to light and accommodation; the right pupil was sluggish to
light but accommodated normally. Leucoplakia of the cheeks; nocturnal
headaches; and pains resembling lightning pains in arms and legs.
Lumbar puncture, March 26, showed blood-stained fluid, and the puncture
was followed by headache, vomiting, and slow pulse. The fluid showed a
slight lymphocytosis; W. R. negative.

It is clear that a diagnosis limiting itself to the leg trouble would
probably content itself with “hysterical chorea.” The lieutenant said
that when he saw people “dance” he did have a tendency to imitate
them; and when he was cured of that, he did not want to go to Lamalou
because he would see the ataxic patients there and might fall back
into his “dancing.” However, in view of the pupillary inequality, the
lymphocytosis, the leucoplakia, the W. R., and the initial neurasthenia
and depression found in the very first hospital in which he was
examined, we probably should be entitled to consider that general
paresis played a part in the chorea.


Shrapnel fragment driven through skull: General paresis.

=Case 15.= (HURST, April, 1917.)

A private, 31, was wounded December 7, 1916, by a shrapnel fragment
which entered the skull above the left ear and lodged in the brain,
an inch above and 2½ inches below the middle of the right orbital
margin. At Netley, December 30, he proved to show a complete internal
and external left sided ophthalmoplegia, with the exception of the
external rectus. On the right side, there was a complete paralysis of
the superior rectus and a partial paralysis of the inferior rectus and
levator palpebrae superioris. There was a paresis of the left side of
the face. The right plantar reflex was said to have been extensor at
the clearing station, but at Netley it and the other reflexes proved
to be normal, as were the optic. The patient was stuporous and had
incontinence of urine and feces for two days. Shortly after admission,
slurring of speech with a long latent period occurred. It was clear
that the shrapnel fragment must have passed far above the crus, and
it was not plain how isolated lesions of the third and seventh nerve
nuclei could have been brought about without injury of the long tracts
of the crus.

The Wassermann reaction of the serum was negative, but that of the
spinal fluid was positive. Iodide and mercury secured considerable
improvement in the mental condition and some diminution in the
paralysis. The patient is now extremely pleased with himself and has a
speech suggestive of paresis.


Head trauma: Shell-shock effects, over in a few months.
Manic-depressive (?) attack more than two years later. X-ray evidence
suggesting brain lesion. Serum Wassermann reaction positive.

=Case 16.= (BABONNEIX and DAVID, June, 1917.)

A bullet glancing from his gun barrel November 28, 1914, wounded a
man in the head, whereupon he lost consciousness and was carried to a
hospital and trephined. On coming to, he found that he could not hear
and felt pains; but the latter disappeared in a few months. He was
given sedentary employment and did his work properly until February,
1917, when he suddenly became sad, wept, slept poorly, stopped eating,
had an absent air, and began to complain of his head. He passed whole
days without moving, in a sort of stupor, which was then followed by a
hypomaniacal agitation in which he walked furiously up and down in the
room and threw objects about.

He was found subject to a generalized tremor and he was distinctly
weaker on the right side. The tendon reflexes were excessive. The
bony sensibility, as well as the pain and temperature sense, and
the position and stereognostic senses were completely abolished on
the right side. The scar lay on the left side. It was deep and very
sensitive to pressure, so that if it was touched ever so slightly
the patient began to weep. X-ray indicated loss of substance in the
posterior part of the left parietal region. Remains of the projectile
were found subcutaneously in the right supraorbital region. The W. R.
of the serum was positive. There was no lymphocytosis in the spinal
fluid.

Interpretation of this case is manifestly difficult. Four possibilities
exist: Syphilis, manic depressive psychosis, traumatic brain disease,
and functional shock effects. More than two years had passed between
the trauma and the change of character.


Skull trauma in a syphilitic.

=Case 17.= (BABONNEIX and DAVID, June, 1917.)

A soldier, 31, sustained fracture of the occiput from shell-burst,
and thereafter showed confusion and total loss of memory. Operation
November 11 withdrew bony fragments and clots, whereupon the man
returned practically to normal. He developed, however, a few seizures,
in which he struggled, fell, and lost consciousness, afterward
suffering from headache. The tendon reflexes were increased. The
occipital cicatrix was a little depressed and slightly painful on
pressure.

Lumbar puncture showed a very slight lymphocytosis (5 to 6 cells),
practically negative globulin reaction, and a low albumin titer. There
were no signs of syphilis in the eyes. The W. R. in the serum was
strongly positive. Very possibly the traumatic phenomena in this case
can be safely disengaged from the syphilitic phenomena.

_Re_ the mechanism by which trauma evokes or accelerates the course of
neurosyphilis, it is probable that most neuropathologists believe that
the _commotio cerebri_ causes sundry chemical or physical effects in
the nerve tissues such that spirochetes are moved into new and more
dangerous places, or such that more appropriate food is supplied to the
organisms, which then begin to multiply. Whether the organisms live in
a kind of symbiosis in the tissues under ordinary circumstances in the
pre-paretic period of the development of neurosyphilis, is unknown.
Possibly fat embolism should be added to the list of possible causes
of the hastening of the neurosyphilitic process. Fat embolism in the
brain has been shown by various authors to be accompanied by minute
hemorrhages, in the midst of which by proper stains the fat embolism
can be made out.


Shell-wound in battle: General paresis.

=Case 18.= (BOUCHEROT, 1915.)

A soldier in the Territorial Infantry, 42, a gardener who went to
taverns, as he said, “like everybody else,” a widower with two
children, a good worker though irascible, had had syphilis as a youth.
He was called to the colors at the outbreak of the war and got on well
despite tremendous strain. March 9, 1915, he was in a bayonet charge
with his regiment and was bowled over by a shell of which a fragment
wounded him above the knee and several fragments in the thorax. All
these fragments were extracted at a temporary hospital, March 11.
The man now became strange, refused to obey orders and did a number
of peculiar things so that he was sent to Orléans temporary hospital
whence he was evacuated to Fleury Asylum, March 19. He refused to give
up his things because he was the master. He did not want to go to bed
and wanted to keep on walking constantly. He was without sense of
shame, satisfied with himself, grandiose as to his millions in bank and
the thirty-six decorations he believed had been awarded him. He mistook
the identity of the landscape and of the people about him.

Tongue tremulous; pupils unequal; knee-jerks exaggerated; dysarthria;
gaps in memory. In May occurred a number of violent reactions.

In June, however, there was a remission; the ideas of grandeur
disappeared first, then the tremors and reflex disorder and finally the
speech disorder. There was a slight seizure at this point and the man
said he had had another such just before he came to the army. July 20
he was invalided out much improved.

In this case of general paresis there is, besides the syphilis, also
alcoholism to consider, so that it is not entirely plain that the
exertions of campaign liberated the paresis.

_Re_ wounds and paresis, see also Case 5 (Beaton), in which
neurosyphilis advanced rapidly from the time of a trivial injury.


Shell-explosion: Syphilitic ocular palsy.

=Case 19.= (SCHUSTER, November, 1915.)

Schuster notes briefly a curious result of the explosion of a shell,
which caused the patient in question to lose consciousness. Shortly
after the explosion, the patient came to his senses again, but a
surprising paresis of the eye muscles had developed. This paresis
looked precisely like a syphilitic paresis clinically.

Examination of the blood serum yielded a strongly positive Wassermann
reaction.

According to Schuster, the explosion of the shell had brought about
hemorrhage in vessels supplying the region of the eye muscle nerves or
nuclei. The reason for the selection of these vessels for rupture due
to shell explosion is, according to Schuster, that the vessels were
probably already syphilitically diseased.

_Re_ hemorrhages in the neighborhood of the oculomotor nuclei, the
phenomena of polioencephalitis may be recalled. In that disease, the
predisposition to hemorrhage is presumed to be alcoholic, as the cases
of ophthalmoplegia of this group almost always appear in alcoholics.
However, the first case of hemorrhagic superior polioencephalitis was a
non-alcoholic one of Gayet (1875), in which the symptoms followed three
days after a boiler explosion.


A tabetic lieutenant “shell-shocked” into paresis?

=Case 20.= (DONATH, July, 1915.)

An apparently competent German professor in an intermediate school,
a lieutenant of infantry reserves, 33 years old, on the 17th August,
1914, was stunned for a while by the shock of a cannon-firing 25 feet
away. Urination became difficult. Headaches and limb pains ensued, with
paralysis of fingers, gastric troubles, forgetfulness, especially for
names, insomnia, and general scattering of mental faculties.

Neurologically, the pupils were irregular, left larger than right;
Argyll-Robertson reaction. Right knee-jerk livelier than left. Achilles
reactions absent. Slow and dissociated pain reactions in feet, lower
thighs and lower quarter of upper thighs, with hypalgesia or analgesia.
Station good; gait steady. Mentally depressed, slow of thought. Speech
poor and of indistinct construction (mild dementia). Calculation
ability poor. No pleasure in work.

Wassermann reaction of serum weakly positive.

It seems that for a year the patient had been subject to spells of
anger. He was irritated by his wife who had been nervous since an
earthquake.

_On the occasion of the earthquake_, 1911, the patient himself had had
a spell of _difficulty with urination_. The spell had lasted two or
three months. The patient had had a chancre in 1902, “cured” in four or
five weeks with xeroform. In 1908, when about to marry, he had had six
mercurial inunctions.

_Re_ tabes, Lépine shows that tabetics are numerous. They are numerous
among officers and also in the auxiliary service, in which latter
tabetics are maintained on desk duty. Perhaps they had been admitted
to such work as unable to march or fight, on the basis of having had
so-called “rheumatism.”


Shell-explosion may precipitate neurosyphilis in the form of tabes
dorsalis.

=Case 21.= (LOGRE, March, 1917.)

An artilleryman, 38, had a large calibre shell explode very near
him and afterward could not hear the whistle of a shell without
falling down in a generalized tremor, sweating profusely, urinating
involuntarily, in a mental state approaching stupidity. Here was a case
that might be regarded as one of morbid cowardice in a psychopath,
following violent emotion.

The artilleryman proved to be a victim of tabes and of general paresis.
The incontinence of urine under the influence of emotion was nothing
but an effect of tabetic sphincter disorder. The crisis of cowardice
proved nothing but an initial symptom of general paresis.


Shell-explosion; burial: Tabes dorsalis incipiens.

=Case 22.= (DUCO and BLUM, 1917.)

A French soldier was buried by effects of shell explosion September 8,
1914. He sustained no wound or fracture.

Incontinence of urine developed. Anesthesia of penis and scrotum.
Reflexes absent; pupils sluggish. Wassermann reactions suspicious.

The diagnosis =tabes dorsalis incipiens= was made (hematomyelia of
conus terminalis eliminated).

The patient was estimated to be “40% incapacitated,” according to the
French “_échelle de gravité_” of conditions. A full pension would not
be justified in the opinion of the French authors.


SHELL-SHOCK PSEUDOTABES (non-syphilitic, serum W. R. positive).
Improvement.

=Case 23.= (PITRES and MARCHAND, November, 1916.)

Innkeeper B., 36, a shell-shock and burial victim June 20, 1915, was
looked on by a number of physicians as a case of genuine tabes.

Even eight months after the episode, he still showed (when observed
by Pitres and Marchand, February 3, 1916) absence of knee-jerks and
Achilles jerks, a slight swaying in the Romberg position, pupils
sluggish to light, incoördination, delayed sensations. There was also
a history of pains in the legs, compared by the patient to those of
sciatica. These pains came in crises, the longest of which had lasted
30 hours.

It seems that this soldier’s troubles began the day after his shock
with a feeling of swollen feet and of cotton wool under them. He stayed
on service, however, walking with increasing difficulty.

At the time of his evacuation, July 10, he could walk with great
difficulty. “Strips of lead were between his legs.” He could hardly
control movements in the dark, or descend stairs. Often his legs would
bend under him. Vesical function sluggish.

After a few months the patient could walk better. In February, 1916,
he walked thrusting his legs forward trembling, and dragging toes a
little. He could not support himself on either leg. Jerkiness and
incoördination in extension or flexion of leg on thigh.

The muscular weakness was decidedly against tabes or at all events
a pure tabes. The incoördination proved to be due, not to loss
of position sense (which was intact) but to unsteady muscular
contractions. Deep sensibility was intact.

There were no mental symptoms. There was a slight hesitation in speech
and doubling of syllables, but nothing demonstrable with test phrases.

The serum W. R. was positive.


Shell explosion; unconsciousness: Neurosyphilis.

=Case 24.= (HURST, April, 1917.)

A private, 31, was in the retreat from Mons, was blown up by a shell
and buried in May, 1915, went back to the front after two months leave,
was knocked unconscious by a shell December, 1916. He came to himself
two days later in the hospital, but remained confused and lethargic.
In England, December 21, his legs were still weak and walking was
unsteady. The right pupil reacted neither to light nor to accommodation
and was irregular, eccentric, and dilated. The left pupil showed the
Argyll-Robertson reaction. There was early primary optic atrophy.
The right knee-jerk was slightly exaggerated. The vibration sense
was reduced over sacrum and malleoli. At this time the man’s mental
condition was practically normal.

The Wassermann reaction of the serum and spinal fluid proved positive.
Improvement followed rest, iodide, mercury, and seven injections of
salvarsan. By the middle of February he was able to walk well. The
right pupil regained its power to react to accommodation, but remained
inactive to light. Meanwhile, the left pupil had regained a slight
power to react to light.

_Re_ treatment of syphilis, both Thibierge and Lépine give warning
of some bad results with arsenobenzol treatment, though Thibierge
states that the number of serious accidents and especially of deaths
has diminished more and more now that no arsenobenzol (drug No.
914) is given. Encephalitis is the gravest of the untoward results
of injection, sometimes appearing in young and vigorous subjects.
Hemorrhagic encephalitis appears to occur more frequently after the
second injection than after the first, and according to Thibierge may
be especially suspected in subjects who after the first injection
present much fever, congestion of face, and cutaneous eruptions.
Treatment in these cases should be suspended or given in moderate
doses.


Shell-explosion: Neurosyphilis. Fit for light duty.

=Case 25.= (HURST, April, 1917.)

A corporal, 26, blown up by a shell December 7, 1916, was admitted
to the hospital on the 13th, dazed and with symptoms of a left-sided
hemiplegia of organic origin. The right pupil was larger than the left.
There was a bruise of the scalp in the right parietal region. The
man had had syphilis at 16. The Wassermann reaction of the serum was
strongly positive. Rest, salvarsan, mercury, and iodides were given,
and the general symptoms and hemiplegia gradually disappeared, until
on December 12 there was only a moderate weakness of the left side,
with knee-jerks in excess, abdominal reflexes absent, and the Babinski
reaction.

The Wassermann reaction was still strongly positive. Salvarsan,
mercury, and iodide were continued. January 6, 1917, the plantar reflex
had become flexor. The abdominal reflex returned. Babinski’s second
sign (combined flexion of thigh and pelvis) was now the only evidence
of organic disease. Further antisyphilitic treatment removed this sign
also. February 28, the man was discharged fit for light duty, with
unequal pupils and positive Wassermann reaction, and a complete amnesia
for the four weeks following his blowing up in the trenches.

_Re_ fitness for light duty, see remarks on Case 20 concerning desk
duty for certain tabetics.

_Re_ the premature or unexpectedly early appearance of neurosyphilis
under war conditions, the early claims of some authors have not been
maintained. In the above instance, the infection was at 16 and the
shell explosion occurred at 26, namely, at about the right interval for
the development of neurosyphilitic signs. Gerver states that military
service brings out the lesions of paresis earlier than they would
otherwise come. Bonhoeffer has been unable to show that cerebrospinal
syphilis is favored in its development by the exhaustion factor.


SHELL-SHOCK PSEUDOPARESIS (non-syphilitic). Recovery.

=Case 26.= (PITRES and MARCHAND, November, 1916.)

June 19, 1915, a shell exploded some distance from Lieutenant R. He
remembers the gaseous smell, the bursting of several shells nearby
and a sensation of being lifted into the air. When he recovered
consciousness, he was in hospital at Paris-Plage, covered with bruises
and scratches. They told him he had been delirious and had vomited and
spat blood.

June 24, his wife came to see him, but this visit he could not
remember. Nor could his wife at first recognize him, he was so thin. He
roused a few moments and recognized his wife, but relapsed into torpor
again. Speech was difficult and ideas confused.

A few days later he was able to rise; but his mental status grew worse,
especially as to speech and writing, the latter quite illegible. There
was insomnia, or, if he slept, war dreams.

August 7, he began a period of five months’ convalescence passed with
his family, depressed, given to spells of weeping, confined to bed or
couch, unable to “find words,” conscious of his state and troubled
about it, speaking of nothing but the war, and afraid to go out for
fear of ambuscade. There was at first a slight lameness of the right
leg. Although he could walk, he felt pain in the knee on flexing the
right leg on the thigh. He walked holding this leg in extension.

On going back to the colors, he was immediately evacuated to the
_Centre Neurologique_ at Bordeaux, January 20, 1916.

Examination found a bored, impatient, irritated man, vexed that a man
who was not sick should be sent up “_comme fou_.”

Omitting negative details, neurological examination showed slight
lameness as above, body stiff and movements jerky, difficult, unsteady
gait. The lieutenant could stand for some time on either leg. Tongue
and face tremulous during speech. Limbs moderately tremulous,
especially in the performance of test movements.

Knee-jerks and Achilles jerks absent. Other reflexes, including
pupillary, normal. Segmentary hypalgesia of right leg, especially
about knee. Tremulous speech and writing. Patient would stop short in
speaking for lack of words.

Malnutrition. Appetite good, but a bursting feeling after meals.

Skin dry, scaly on legs, fissured on fingers.

Serum W. R. negative. Fluid not examined.

=Mental examination.= Conscious and complaining of his troubles,
Lieutenant R. claimed persistently that he was not sick. Memory for
recent events was in general poor. Errands easily forgotten. Lost in
the street. Complaint of corpse odors round him. Everybody is looking
at him and making fun of him. He was apt to insult bystanders. He was
afraid of German spies. Things in shops angered him as they seemed to
him to be of German manufacture.

There were frequent periods of depression, with pallor and no
spontaneous speech for some hours to a half-day. Headaches coming on
and stopping suddenly.

As to diagnosis, the first impression, say Pitres and Marchand, was
that of general paresis. The progress of symptoms after the shock was
consistent with this diagnosis. The mental state and the physical
findings seemed consistent, although the pupils were normal. His
partial insight into his symptoms was not inconsistent with the
diagnosis. He had a characteristic self-confidence. There had been four
stillbirths (two twins); two children are alive, 11 and 13. Typhoid
fever at 30. Syphilis denied. No mental disease in the family.

The patient had never done military duty, having been invalided for
“right apex.” But he had volunteered and been accepted in September,
1914.

    How was Lieutenant R. cured? Apparently by rest in the _Centre
    Neurologique_. Pitres and Marchand do not speak of the subtle
    relation between mental state and the idea of non-return
    to military service. This motive might still work even if
    Lieutenant R. kept protesting sincerely that he wanted to go
    back into military service.


War strain; shell explosion; unconsciousness. Sensory and motor
disorders. Subject an old syphilitic.

=Case 27.= (KARPLUS, February, 1915.)

A captain, 34, was under much stress and strain in the field and gave
himself over to excesses of alcohol and tobacco. August 25, 1914, at
the Krasnik battle he suddenly saw at his right a gleam of fire and was
afterward able to remember very distinctly the words of a lieutenant
standing near by, “The man is dead.” Three or four hours later he came
to himself at a relief post, vomited and bled a good deal from nose and
mouth. He heard later that he had been thrown on his back.

Manual tremors and general pains developed in the next few days. Two
weeks after the accident a slight nystagmus on looking to the left
appeared, but there was otherwise no disorder of head or extremities.
He was able to sit up, supported by his arms, and he was able to
contract his abdominal muscles normally. As for his legs, active
movements were limited and weak. He could not lift his legs. The
paralysis was more marked distally. He could walk with the support of
two persons, but was unable to lift his feet from the ground. The right
upper abdominal reflex was elicited, and both patellar reflexes were
tolerably active. Cremasteric and plantar reflexes were absent. Neither
of the Achilles jerks could be produced. There was hypesthesia and
hypalgesia of the lower extremities, and of the back up to a horizontal
line corresponding with the ninth dorsal segment; thermo-hyperesthesia
and disorder of vibration sense in the lower legs. Both the motor and
the sensory disorders were more marked on the right than the left.
Insomnia and battle dreams.

The gait disorder and paresis gradually improved. There was no
alimentary glycosuria and adrenalin produced no mydriasis. In the
course of several weeks the patient gained seven kilograms, began to
sleep well and showed gradual improvement in his gait and in the
execution of various movements with his feet. The abdominal reflexes
were now both present, but there were no plantar reflexes and the
Achilles were still both absent. The sensory disorder remained
unchanged, so far as the skin was concerned, but the deep sensibility
improved. Both legs from the knee down were somewhat cold.

This man had had syphilis at twenty-two, had gone through an inunction
cure, and repeated W. R.’s came through negative. He had suffered from
vomiting spells and anxiety feelings for a number of years which had
been diagnosed by physicians as cardiac neurosis. Yet for a year before
going into the war he had felt absolutely well.


Shell-explosion: Amnesia; syphilitic hemiplegia. Recovery except for
amnesia as to brief period and loss of occupational skill.

=Case 28.= (MAIRET and PIÉRON, July, 1915.)

A man of 40 underwent shell shock June 15, 1915, and had no remembrance
of what happened up to July, 1915, when in hospital at Tunis he felt
“born again.”

Examined in January, 1916, it was found that he had a left hemiplegia
(in fact, he had a syphilitic hemiplegia on that side, several years
before, which had disappeared under antisyphilitic treatment). This
hemiplegia passed, but he then had crises of depression due to his
despair at not being able to know who he was and what he was doing.
He could speak French and Spanish, and knew from the hospital ticket
that he was born in Spain; but he had no idea what had happened to
his relatives or what he was doing in France. He had, however, a very
correct idea of what happened during six months after July, 1915.

One morning in April, 1916, his old memories came back all of a sudden
on waking. The gap was filled up to the moment of the shock. There was
no gap left except for a period of about 25 days following the shock.
He now found that he knew a little English but that he had lost his
stenography as well as his professional skill at typewriting.

_Re_ French statistics for the occurrence of general paresis, Lautier
found 27 cases in 426. Early in the war, Boucherot at Fleury received
four cases of paresis among 107 cases; the majority of these, however,
had not left the interior. Consiglio in Italy received two cases out of
270.

_Re_ hemiplegia in this case, it may be inquired whether the hemiplegia
which developed after the shell explosion on the same side of the body
on which the patient had a true syphilitic hemiplegia, was really
syphilitic or not. Was it not, perhaps, in some sense psychogenic? A
similar question may be raised concerning cases in which the _locus
minoris resistentiae_ becomes the site of symptoms. See Cases 409-414.


Shell-shock: Hysterical blindness. Signs of cerebrospinal syphilis:
Nevertheless, amaurosis functional.

=Case 29.= (LAIGNEL-LAVASTINE and COURBON, March, 1916.)

A soldier of the class of 1906 underwent shell-shock August 13, 1914,
regaining consciousness 20 days later, but blind. The light of the
shellburst, he said, was the last thing he had seen.

For sixteen months, he was transferred from hospital to hospital,
looked on sometimes as blinded; sometimes as feigning. Finally, on the
isolation service of Maison-Blanche, December 15, 1915, he received
an ophthalmologist’s diagnosis namely, hysterical amaurosis. At this
time there were found: stereotyped winking, with slight lachrymation,
a slight left external strabismus, limitation in movement of all
the extrinsic muscles of both eyes, especially to the right and in
convergence and elevation; pupils slightly smaller than normal--and
the general impression of a genuinely blinded or amblyopic subject. He
seemed to be able to distinguish faint whitish spots, without contour
or color, in objects brought to a distance of at least 40 cm.

He also complained of bad feelings inside his head on the left side,
and he proved to have a left-sided hemianesthesia of hysterical nature.
There were no other sensory disorders and no reflex disorders.

The nasolabial fold on the left side was flattened out, and there
was also on the same side a slight diminution in the lower abdominal
skin reflexes, and no response to plantar stimulation. Examination
of the mouth showed leucoplakia, and the history showed that the
man’s fifth child was born before term and died at two months. Lumbar
puncture yielded lymphocytosis (55 cells) and an excess of albumin. The
fundus examination showed a slight papillary disorder, suggesting a
retrobulbar affection of the optic nerves.

However, the preservation of the pupil reflexes seemed to indicate
that nine-tenths, at least, of the amaurosis was functional. After
mercurial treatment the headache grew less and the man was able to see
somewhat better with his right eye.

Laignel-Lavastine and Courbon suggest that there was a dynamic disorder
in this case, bearing the same relation to vision as mental confusion
bears to the process of ideation. Analogous phenomena have been found
in the sense of hearing, in such wise that the victims can, as it were,
passively hear but do not listen.

_Re_ functional eye cases, see below, especially Cases 432-437.


Shell shock (functional) phenomena in a syphilitic.

=Case 30.= (BABONNEIX and DAVID, June, 1917.)

A marine, 26, on land service March, 1916, was buried by the explosion
of a large calibre shell which killed most of his comrades. He remained
for a time in a sort of lethargy. Coming to, he found himself victim
of a right hemiplegia and deafmutism, which phenomena vanished under
electricity.

In July, however, he had to be sent to a hospital on account of his
sufferings, which received the diagnoses _commotio cerebri_, disorder
of consciousness, disorientation, delirium, amnesia, over-emotionality.
He was sent back to the front in December, 1916, but promptly reported
sick, with headaches and insomnia.

Examination showed nonorganic nervous disorders, consisting in
a variable and patchy anesthesia of the legs, anesthesia of the
conjunctiva and pharynx, and over-reaction, with sighing, during the
course of the examination. The organic signs were: exaggeration of
tendon reflexes, equilibration disorder, and incapacity to stand on
one foot or execute a half turn or to stand still with eyes closed,
and disorder of position sense. The lumbar puncture showed no cells,
a slight globulin reaction, and an albumin titer within the normal.
There was a leucoplakia and a positive W. R. The man was emaciated,
febrile, and showed signs, with the X-ray, of bronchial lymph node
disease. According to Babonneix and David, the normality of the fluid
indicates that the phenomena here were Shell-shock phenomena, despite
the indisputable syphilis of the blood serum.

_Re_ occurrence of functional phenomena in syphilitics, Freud’s remark
may be recalled to the effect that a large proportion of his hysterics
and other psychoneurotics are the offspring of syphilitics.

Consider in this connection also Case 28: an old syphilitic hemiplegia
was followed by a probably psychogenic or hysterical hemiplegia on the
same side.


Vestibular symptoms in a neurosyphilitic.

=Case 31.= (GUILLAIN and BARRÉ, April, 1916.)

A soldier, Colonial, 29, was twice in the 6th Army neurological
centre. The first time, February, 1916, he was under observation for
astasia-abasia, having been invalided twice for this disease,--once
in 1915. This man had had syphilis at 21, and was then taken care of
at Saint-Louis Hospital and at Cochin. A volunteer for the duration
of war, September, 1914, he had intermittent disorders of station and
walking, which caused his invaliding January, 1915. As the trouble
stopped, he asked to go back to the front in September, but the same
difficulty reappeared with fatigue, and he was sent to the army
neurological centre. When standing, there was a ceaseless trembling of
the whole body but especially of the legs, with tendency to propulsion.
In walking also, there was a trepidant abasia, sometimes dizziness, and
even a sudden fall. Standing on one foot he trembled and fell.

Examined on his back, muscular strength was found intact in all limbs,
and there was no trembling or incoördination or intention tremor in
the performance of any movements, though there was a slight trembling
of the raised fingers and hand. Reflexes were normal. The right pupil
was dilated; the left pupil reacted sluggishly. There were lateral
nystagmiform movements to the left. Caloric nystagmus appeared from
the right ear in 15 seconds, from the left in 30. Rotatory nystagmus
appeared in 35 seconds on both sides. Lumbar puncture yielded a fluid
with a slight lymphocytosis; albumin, .3 grams; chloride, 7.30; sugar
normal.

Rest in bed improved the astasia-abasia, and the man was sent back to
his corps, February 20, 1916. He came back March 16, having had a dizzy
spell, with suffocation feeling and a fall, whereupon the trepidant
astasia-abasia had reappeared. There were none of the so-called
defensive reflexes. The neuromuscular excitability of gastrocnemii was
less on the right than on the left. A von Graefe sign was sometimes
found; no diplopia save on looking far to right.


Lay reflections on syphilis: Suicidal attempts.

=Case 32.= (COLIN and LAUTIER, July, 1917.)

A man was called to the auxiliaries at the outbreak of the war, and
served as stretcher-bearer at the Marne. He then became an attendant at
the Grand-Palais. Acquiring gonorrhoea, he was cared for but he grew
depressed. The blood was examined and the W. R. found positive. The
physician immediately made known the result without circumlocution,
and knowing vaguely that the W. R. meant syphilis, the patient felt an
irresistible impulse to suicide, and cut his throat. It seems that he
had often before said that if he got syphilis he would kill himself.
Recovering from his wound, he was invalided to Villejuif, Sept. 19,
1916, breathing through a cannula and responding to questions in
writing. He had always been a nervous and emotional man, a farmer in
Auvergne; he was married and the father of several children.

Examination showed that the recurrent nerves had been cut and that the
man must needs always breathe through the cannula. In point of fact,
the W. R., only partially positive at the outset, did not indicate
syphilis, and the gonorrhoea was now cured. But though the patient
knew these facts, his hypochondria persisted, basing itself upon the
suicidal wound. He said that his larynx had been stolen and he wondered
why. He said that he had violent crises of suffocation, though there
was, as a matter of fact, no difficulty with his breathing. Verdigris,
he said, was forming on his cannula. Self-accusations about the suicide
developed. On being transferred to his department asylum, he made a
suicidal attempt on the trip.

Of course the gonorrhoea may have served as a partial factor in the
genesis of the case, and his own mental attitude toward the contraction
of syphilis may have been another factor.


The imitation of chancre.

=Case 33.= (PICK, July, 1916.)

A married German farmer, 32, was in Prague hospital in 1908 during his
period of military service and was then treated by inunction for a
local chancre. He was given mercurial injections a year later for rash.

In 1912, he had signs of syphilis in the mouth.

He was sent home from service in 1913, with ulcers of hand.

At the beginning of the war he was found to have ulcers on the knee,
legs, and mouth, and was sent home for six months.

Again called up in 1915, the ulcers were still in evidence; he got
inunctions in a military hospital four months.

He was sent to his corps in July and had no relapse until July, 1916,
when he was detailed for active service. Thereupon, ulcers began on the
left hand and right leg. He reported sick, but was sent nevertheless
to the front. In hospital he was found to have several scars about
one inch across on each leg, on the dorsum of the left hand, at the
right of the left index finger, and elsewhere. These scars were deeply
pigmented. _One of them was square!_ There were other recent ulcers
that closely resembled tertiary ulcers. The most recent of these ulcers
was angular, intensely red, and showed remains of a collapsed vesicle.
There was a deep dark scab on the mucous membrane of the left cheek.

There is no doubt that these ulcers were produced by some caustic, the
nature of which remains unknown. The patient had, however, been able to
evade military obligation during peace time and for two years during
war time.

_Re_ simulation, according to Pick, some 5 to 7 per cent venereal
diseases in the German army have been simulations. Gonorrhoea is
simulated by soap, balanitis by cantharides, soft chancre by soap
and mercuric or mercurous chloride mixed, hard chancre by a fluid or
powder containing NaOH, Na_{2}CO, and NaCl. Secondary syphilitic signs
are imitated by cantharides or garlic, producing scrotal dermatitis.
Tertiaries are imitated with caustics.


Ramón to Rosina: a soldier’s letter to his fiancée.

=Case 34.= (BUSCAINO and COPPOLA, January, 1916.)

    “I am here to stay a month. Believe me, it is better here than
    in the army. There is a rule that we may eat as much as we can
    and everything is of the very best. The servants treat us like
    brothers. Do not think it is a nuisance to be inside four walls
    with a wee bit of a garden. No, indeed! But I have got to act
    the fool and from the very first day I began to play and act
    crazy with a kitten, so that if you had seen me you would say:
    “Ramón is really crazy.” Rosina, dear, to avoid paying taxes
    you have got to be a smuggler. And now that I am at the ball I
    have got to dance. I want to see if after all the suffering I
    cannot get something better. I am better off here than at the
    regiment. I sleep in a fine warm bed, and they have only cold
    straw; I have good food and drink and plenty of milk, and they
    have poor food and drink and so little.

    “I expect to go home in about three weeks. I would have been
    there before if some fool of a spy at our place had held his
    tongue and minded his own business. At the same time, Rosina,
    dear, remember what I told you at Leghorn: that they had some
    officers sent there to get information and instead of going
    home they asked somebody else and were told that I had never
    been sick and had never had neurasthenia. When this information
    was got from the officers I was called to the office and they
    read to me that all that I had said and done was not true. I
    kept on acting the fool, and as they were still doubtful they
    sent me here, where there is a professor who passes me every
    morning in the garden and says: “How are you?” I always say:
    “I am the same,” acting like a crazy man. Let me tell you,
    Rosina dear, not to say anything contrary to this in your
    letters because they open and read everything in order to find
    out everything that happens and everything that is said. Now
    what you must do is to ask me how I am feeling, and whether my
    headaches are gone, and whether I have them all the time as
    formerly, and any other trifle that will help me.”

Rosina’s fiancé had a strongly positive W. R. in the serum. It was
negative in the fluid. He was returned to the front.



II. HYPOPHRENOSES

(THE FEEBLE-MINDED GROUP)


Moron of use at front (alienist’s report).

=Case 35.= (PRUVOST, 1915.)

Vigouroux reports concerning a tanner of 19 who could not read, write
or calculate (3 plus 8 equals 14) and had been of the 1916 class in an
infantry regiment at Brest, on the occasion of his asking to be sent to
the front more speedily:

Mental weakness, with insufficient school and theoretical knowledge but
with the ability to assimilate practical ideas, though not knowing how
to read, write or calculate; seems to have earned his living in several
lines. “As a soldier, he does not know the insignia of the different
ranks but understands how to obey a superior officer. Understands a gun
and can tell a _chargeur_ from a _Le Bel_ gun. Moreover he seems to be
perfectly stable, fixed in his wishes, persistently and intelligently
wants to go to the front and kill Boches. He appears to be well
disciplined and educable. Although feebleminded, he appears to us able
to be useful at the front, though he should not be employed in any
undertaking requiring initiative or foresight.”


An imbecile, superbrave.

=Case 36.= (PRUVOST, 1915.)

A loquacious, active fellow, 22, with very slight school knowledge and
no idea of military ranks (treated his superiors like his comrades),
was often punished in the barracks. He did not get on well with his
instructors. His activities were never interrupted by any obstacles or
by derision. He kept singing and talking enthusiastically during the
mobilization. He was the butt of his section.

At Dinant he did very well; though his section was losing a good many
men he remained calm. He was careless of danger and remained at his
post firing ceaselessly at the enemy and giving a magnificent example
to the few comrades who remained with him. In fact, he remained so long
in his shelter that he was surrounded and taken prisoner. He escaped,
swam the Meuse and got back to his regiment.


An imbecile of service in barracks work.

=Case 37.= (PRUVOST, 1915.)

A farmer, 36 (father alcoholic, mother always sick, two brothers at the
front; patient had typhoid at an unknown age; had gone to school at
13 but “learned nothing”; worked in fields with his brother who gave
him some pennies on Sunday), was put into the auxiliary service by the
Council at 20. Patient said he was not strong enough for this service.
In 1914 the Council reconsidered the case and put him into a regiment
of infantry. He could not be given military instruction or execute the
most simple drilling manual. He said that 4 plus 2 equalled 7; 4 plus
3 equalled 5. He was of an excellent character, very docile and easily
directed. He did all his comrades’ barracks work and was very proud
because, as he said, “I do everything they tell me to do.” He was happy
in working, everybody was good to him, but he had no comrades. He had
no general knowledge and knew nothing about the war but that they were
fighting the Boche.

_Re_ imbeciles, Colin, Lautier and Magnac found amongst 1000 soldiers
entering Villejuif, 53 imbeciles. Twenty-four of them had been either
exempt or retired at the outset of the war, when military surgeons had
reviewed them and considered them fit for service. Several of the 29
others also had shown previous evidence of imbecility.

Of course, French military surgeons may have felt that a number of
these men would be of just such service in barracks and otherwise as
Case 37 (Pruvost). But for one or two cases like Cases 37 and 41 of
Pruvost, there are great numbers of other imbeciles who prove quite
useless in the army. Two of the Villejuif cases had been volunteers:
one volunteer declared that, if he had been intelligent, he never would
have enlisted! Ten cases proved unable to use a gun; one turned his gun
upon his mates. One regularly forgot the password. One (see Case 42
of Lautier) thought the war too long and tried to take command of the
company in order to finish the war one way or the other. Three of the
imbeciles had to be evacuated for desertion (unmotivated fugues); two
of them cursed their officers. Some of the imbeciles had an emotional
diarrhoea throughout their service.

Colin suggests that line officers and military surgeons ought to agree
that these men are not fit for service, and that the civil authorities
of the home towns should advise the review boards about known imbeciles
and criminals. In point of fact, previous knowledge of imbecility could
have been obtained quite readily in 27 of the 53 cases observed by
Colin.


A feeble-minded inventor.

=Case 38.= (LAIGNEL-LAVASTINE and BALLET, 1917.)

A jockey of Nîmes, 31, entered the service May 15, 1917. He
retired before the war. He was in the auxiliaries at the moment of
mobilization. Nothing is known as to any pathological episodes in his
past. He said he had been a poor scholar, had left the primary school
at eleven hardly knowing how to write or spell, but he had a lively
imagination and was a happy-go-lucky youth, playing many tricks on
the trades people. He tried a variety of ideas in the industrial or
commercial world with very varying success. He had a mechanical taste.
The Colonial Exposition at Marseilles caused him to float a variety of
projects, from that of having the visitors photographed on a camel to
the sale of lemonade. He said he had been a jockey and then a trainer
and had finally become a valet de jockey at Maisons Laffitte. He was a
gambler and invented a “system.” He made various inventions in relation
to horses. At the end of 1914 he had plans for a bomb thrower and
placed his discovery at the service of the War Minister. He was not
discouraged by the lack of success of the bomb thrower. He now made an
aerial torpedo carrier. He had the idea of the tanks. However, he found
the secret of his torpedo carrier printed in a magazine. There was a
slight difference between the German apparatus and his own.

From this time he began to be mistrustful, and now he jealously avoided
entering into any details about his inventions and he did not let
his officers see his plans. The Commandant offered to give a place
in the safe to his documents, but he could not embrace the offer. He
now invented a counter-torpedo machine. He went on leave to Paris,
asked an audience of the Minister of Marine, who put him in relation
to the Committee on Inventions, who put him off, desiring that he
should forward all his plans. He emerged from one of his interviews so
excited that there was a scandal on the public street and the police
commissary evacuated him to Val-de-Grâce, but the patient says he does
not remember this incident. He came on service of Laignel-Lavastine
May 15. He shortly wrote again to the Minister, who again referred
him to the Committee on Inventions. He protested to the President of
the Republic and wrote directly to the King of England, who referred
him to the Military Administration. He is now occupied in creating a
machine to destroy the first line trenches and continues to write to
the Ministry. He has documents buried underground in a secret place. He
still talks with great vivacity of his discoveries.

According to Laignel-Lavastine, we deal with a feeble-minded person who
has for many years had a _délire raisonnant_ of the inventing group.

_Re_ feeblemindedness in the British Army, Shuttleworth found 70 who
had joined from special schools for the feeble-minded in London, and
100 from Birmingham in the year 1915. The institutional “children” were
in general good at drilling and obeying. One of them, given to lying
and stealing, got into constant trouble in Flanders.

Sir George Savage stated that he had sometimes run the risk of allowing
enlistment of men who had shown earlier in life a weakness for lying
and pilfering, and remarked that such men might make good soldiers.
A case like the above (38) would run counter to this view. On this
matter, see below Case 183 (Henderson), one of pathological lying.


An imbecile who walked lame.

=Case 39.= (PRUVOST, 1915.)

A soldier, 20, eight days after being called to the colors, complained
of pain in the knee and hip. He was observed for 18 days in hospital
and then sent back to his company; but he continued to complain of the
pains, and the regimental surgeon sent him to a neurological center
where the joints were found to be normal and where no sensory, motor or
reflex disorders were in evidence. The man continued to walk lame and
insisted he could not get about without a cane. He also complained of
his mouth and his belly and, though he was very ruddy, said he was _á
bout de forces_.

It was a question of simulation. The man, however, was a feebleminded
person who could not read, write or calculate. He was invalided as such.


Enlistment to improve character.

=Case 40.= (BRIAND, February, 1915.)

A village boy had passed for simple ever since typhoid fever at 8.
He had learned to read and write, but had always been impulsive
and subject to fugues, running to see his grandmother, or off as a
truant. It was decided that he, at 19, should enlist to improve his
character. But one fine day, even before the war, he deserted. He said,
in explanation, that he had lost his way, and he was being examined
mentally when mobilization began.

He looked ape-like, with spread ears; had a low forehead, a head
flattened behind, an asymmetrical face, prognathous jaws, an arched
palate, and defective teeth. He talked freely of homosexual relations,
and said he wandered off because it occurred to him to do so. He was
determined to be unfit for service.


An imbecile who may be sent to the front.

=Case 41.= (PRUVOST, 1915.)

A Parisian sandwichman, 25, of unknown parentage and a state ward,
placed out with a farmer at 12, escaping with a friend to Bordeaux at
14, thence leading a wild, improvident life at Lyons, Marseilles and
Paris, sleeping in fields and hedges, earning 22 sous a day but in no
case mixing with the police, was examined for physical inefficiency
at 20 years. He wanted to enlist but was refused. He insisted and was
very proud of the fact that he got in as the Major said to them, “Let
him go in.” He could hardly read, write or calculate but was by reason
of his adventurous life full of practical resources. He was irascible
and frequently _crimed_, whereupon he would cry under the Captain’s
window, “Robber band, idiots, I shall write to the Minister.” He was
passionately fond of military life, though he had but the vaguest
notions about the commands, the names of generals and the like. He
wanted to drill. His comrades played practical jokes upon him asking
him to look for a trajectory, for the squad’s umbrella and the key
to the drill ground. They also told him he had been proposed to be
corporal, whereupon he was greatly overjoyed and immediately sewed
stripes on his sleeve and began to give commands. He said if they put
him among the auxiliaries he would throw the adjutant in the water. He
sang and swung his gun with joy when he went to the front. He thought
there were stripes hanging to the barbed wire and wanted to pick as
many as possible. Such a man may be safely sent to the front although
he will bear watching. At the date of report this man had been at the
front two months doing very well.

_Re_ the comparative success of the Germans in the matter of excluding
imbeciles, Meyer found that 8 per cent of the mental cases in the army
were cases of mental defect.


Imbecile with sudden initiative.

=Case 42.= (LAUTIER, 1915.)

A soldier, 41, a farmer, from the Department of the Marne, married,
childless, was called to the colors August 31, 1914. He was on guard
duty until May, 1915, watched prisoners until October and was finally
sent to the front, February, 1916, where he fell sick.

“He was tired in his head.” “His commanding officer made him drill
without rhyme or reason; he would have been able himself to have
commanded with greater intelligence.” He once attempted to put himself
at the head of the company to lead them against the Boche; this idea
arrived to him all of a sudden in a phase of perfect confidence and
_sang froid_. He thought his comrades would follow him and that the
officers would do likewise. He hoped thus to be able to end the war
one way or the other. He was getting tired of the war and regretted
his family life and kept saying that this was no existence for family
men. “We ought to attack or ask for peace.” No one followed him and his
comrades said he was _un peu fou_ but he did not share this opinion.

In point of fact he hardly knew how to read or write and at home lived
with his relatives, submitting himself entirely to their guidance. He
was much afraid of being punished and often feared that he had done
badly as he had _trop de conscience_. He was non-alcoholic and without
hereditary or acquired neuropathic taint. He had no pronounced stigmata
of degeneration. He was rather reticent about certain mystical ideas of
a political tinge. At Villejuif, whither he was brought February 17,
1916, he received a diagnosis of imbecility.


Emotional fugue in a subnormal subject.

=Case 43.= (BRIAND, February, 1915.)

A soldier in the Territorial Army, 40, appeared before the examining
board in a depressed, dejected-looking state, speaking slowly but
collectedly and lucidly. Mobilized the second day, this man was much
afraid that he could not get through the marches, and asked for a
special examination to determine whether his feet did not make him
unsuitable for fatigue. Two physicians thought he was unsuitable for
marching, and another thought he put it on. A trial march was not
executed well. He was kept in barracks but jumped the wall, put on
civilian clothes, and made off for Paris. But a relative, warned by his
wife, finally got him to go to the authorities. He was told that he
ought to return in the afternoon, when suddenly he was arrested.

It seems that the man relied on the opinion of the two physicians
and discounted that of the third. He thought himself the victim of
an injustice, and not knowing how to get on, it occurred to him that
he would abandon the regiment and get out of the difficulty. It was
without resistance, however, that he gave himself up as a prisoner.
This fugue was neither unconscious nor amnestic, nor was it due to
an irresistible impulse; nor can we say that it was due to a genuine
intellectual disorder. It was an emotional fugue, and partly due to
the man’s long-standing depression. It seems that he had inherited
this character from his father. He was below normal intelligence,
had a very poor education, lost his wife, and grew more and more
sombre. He married again, but this time a neuropath. He began to be
preoccupied with his health and he had even some ideas of suicide. At
the time of his leaving the regiment, he had passed through a phase of
depression of about 6 months’ duration, and at this time had a number
of hypochondriacal ideas with poor appetite and loss of weight.


Diagnostic dispute between regimental surgeon and alienist.

=Case 44.= (KASTAN, January, 1916.)

Julius Q. was sent on guard April 14, 1915, with orders to remain
there. While on guard he made a noise and made a movement as if to take
a knife from his pocket. Ordered to empty his pockets, he attacked the
other guards. The witnesses said that he was drunk.

Upon examination, it appeared that he had recognized and called by name
those present in the guardhouse, despite his supposed intoxication.
There were red spots on the skin and a certain amount of analgesia. His
powers of computation and reasoning were poor. He was unable to explain
the meaning of a picture shown him. He maintained that he had an
indomitable desire for drink. A diagnostic draught of alcohol yielded
no reaction. Upon dismissal, he got drunk at once again, and had again
to be imprisoned in a state of excitement. What the outcome in this
case was is not stated by Kastan.

The previous history seems important. Julius Q. had been a state ward.
He had escaped several times from the institution but had always to be
brought back again because he could not be trained at home. He had once
attacked a supervisor in the state institution with a knife. It seems
that he had at this time been drunk, having been brought back drunk to
the institution.

Two years before the war he had been taken to the Breslau Hospital
for the Insane on account of fits of insanity. In 1913 he had been a
patient in Wuhlgarten on similar grounds. The diagnosis there had been
epileptoid degeneration, psychopathic constitution, imbecility, or
epilepsy(?). He had been convicted of crimes a number of times and put
to labor. He had been given to cruelty in childhood.

Despite this, he was _declared perfectly healthy in mind and body by
the regimental surgeon_.

In 1914, Q. fell suddenly ill in prison (he was presumably in prison
for a military offence), and smeared the cell with feces, saying that
he was able to do that as he could pay for anything. He stared at
the floor and failed to answer questions. He remarked, however, that
he had frequently been convicted for breach of the peace and assault
and battery, and he said his father had been a drunkard, and he
acknowledged hallucinations to the extent of saying that he heard his
name called when he was alone.

The story of this case warrants our inquiring why such a patient was
kept in the army. He was kept there clearly on account of the report of
the regimental surgeon, who could not have taken seriously the previous
history of the case, or else thought the patient perfectly good cannon
fodder.

The hypothesis of syphilis apparently need not be entertained. That of
feeblemindedness is possibly the fundamental diagnosis, yet epilepsy
was considered by the German diagnosticians, doubtless on account of
the sudden violent attacks and breaches of peace on the part of the
patient. There is clearly something behind mere alcoholism in the
entire story of this state ward. On the whole, the periodicity of the
attacks is equally consistent with the picture presented by numerous
feeble-minded persons, and the institutions that had to deal with Q.
regarded him rather as epileptoid. There seems to be evidence of actual
intellectual defect. Accordingly it seems wiser to consider the case
of Julius Q. one of feeblemindedness, possibly of the moron group. We
should then consider the epileptoid features as part and parcel of the
feeblemindedness. We should consider the intellectual defect a part
of the process; and the uncontrollable impulse to drink, the sudden
violent attacks, and the cruelty in childhood would then be regarded
as merely symptomatic of the feeblemindedness. It seems clear that
either mental tests by the regimental surgeon or an examination of the
patient’s previous history would tend to exclude such a patient from
the army.


How can a rifleman be an imbecile?

=Case 45.= (KASTAN, January, 1916.)

Anton K. was down in the list as “missing.” He was found at home. He
said his feet had become sore from the marching. He had lain down and
become unconscious. Coming to his senses, he was possessed only of
trousers and a shirt but he got a civilian suit in a village. He had
gone home part way by train, part way on foot. It seems that he did not
tell his father any details about his coming back although he expressly
denied deserting.

It seems no mental weakness had been noticed in the army. It had been
observed, however, that after seeing the first corpses he was deeply
impressed and did not want to see any more. On examination in the
hospital he gave the impression of indifference and low spirits. He had
to be urged to eat and work. No great amount of intelligence defect
could be determined, though his knowledge and capacity were below the
average. The physician examining him thought his depression was either
caused by or increased by his imprisonment; but this examiner thought
that the protection of Section 51 did not extend to the patient at the
time of his desertion. The examiner thought that an examination by a
psychiatrist was not necessary, though both judge and prosecutor urged
it.

When examined in the clinic, he seemed to be disoriented for time. He
claimed to have been able to stand the shooting and the sight of the
corpses. After becoming unconscious, he had wakened and eaten cucumbers
and carrots in the fields, wandering on for a period of three or four
weeks, until he came to a place where he had formerly worked. The
reason he had thrown away his uniform was because Russians had been
about. He had not known that it was his duty to report to the army
again.

It was found that the patient’s father was poorly developed as to mind,
that his brother was subject to periodic mental disturbance so that he
had to be watched. It was found also that K. himself had had a similar
mental disturbance, lasting a week, two years before. Moreover he was
not considered mentally right in his home town. In fact, no one there
wondered really at his desertion because he was so stupid. His school
work had been poor and limited.

He himself said that his people were of sound mind; that during school
days he had felt bad in his head, once running into the woods after
being told something. He was able to give the names of his former
superiors. His calculations were only partly correct. He was poor at
reasoning and at simple distinctions; for example, asked the difference
between a bird and a butterfly, he replied that a butterfly was a bird
too. He did not know the difference between a river and a lake. He
thought Russia, England, and Austria were the enemies of Germany.

He sat about or lay on the floor, motionless and indifferent, with
a newspaper stuffed into his trousers, unoccupied although saying
that he wanted to work, and even allowing his fingers to be burned by
cigarettes he was smoking.

He was tried once more and the first medical expert still adhered to
his former opinion, pointing out that K. was a rifleman and that _only
an intelligent man could be a rifleman_. The court, however, accepted
Kastan’s opinion and granted K. the protection of Section 51.

In comment upon this case, it seems clear that ever so slight a
knowledge of K’s home town reputation would have naturally excluded him
from the army. However, what is to be said “when doctors disagree,”
as noted by Kastan in this very case? It seems impossible, also, that
his comrades should not have noticed something odd about him (over
and above the deep impression on seeing the first dead) which might
have given occasion to the regimental surgeon for a special mental
examination. However, to the military mind, mayhap the man seemed to be
sufficiently “effective.”

_Re_ imbecility in a rifleman, the compiler has studied somewhat
elaborately the brain of a feeble-minded murderer with some North
American Indian blood in him. This man was a crack shot despite his
subnormality. It would seem that the German regimental surgeons
castigated by Kastan as above were very properly so castigated.


Hypomania in an imbecile.

=Case 46.= (HAURY, August, 1915.)

A brusque little man, of a somewhat bold and talkative disposition,
though giving a good first impression, was evidently a bit
feebleminded, though (as Haury says) of the active group. He had a
sister like himself, whose children were taken care of by the State,
and at home he had had a number of fugues, about which details were
lacking. It was soon evident what sort of soldier he would make, and
he was put in one of the Territorial regiments, but it was not noted
that he had a genuine mental disorder, as he was thought to be just a
peculiar person.

His new relations caused him to do a number of eccentric things.
He shortly proved to be in a sort of rudimentary maniacal state;
talkative, restless, scheming rather feebly to go back to his village.
He said that he couldn’t walk on account of corns, and that these corns
required a certain drug, which he wanted to get from home. He said that
he had been struck by lightning twice; that he had fires in his body,
etc. He wanted only to be retired on a pension of one or two hundred
francs so he could take care of his farm, his hay and his fields. There
was no need of trying to get land by means of bullets, he said, since
he had enough.

The mental disorder of this man was much deeper than appeared, and in
fact, he did a number of dangerous things compromising the security of
the entire regiment.

_Re_ the dangerous tendencies of Case 46, see the remarks above drawn
from Colin, under Case 37.


Insubordinate desire to remain at the front.

=Case 47.= (KASTAN, January, 1916.)

Friedrich L., on March 4, 1915, was ordered to go back to the
baggage-train. He did not obey. He said to the non-commissioned officer
who then came to him, “I am not going; you have nothing to say anyhow,
you ox-tender!” He stood with his hands in his pockets, and, when the
officer seized him angrily by the collar, L. struck the officer’s face.

He stated at his hearing that no one had the right to send him back.
At that time even he conveyed the impression of being not quite normal
and was let off with his arrest only. Later he refused again to go on
guard duty, saying, “You have nothing to say at all. Perhaps you will
find out that we shall meet each other again in hell tomorrow morning.”
He was taken before the physician, who considered him mentally inferior
and not entirely appreciative of the nature of his acts. He was told
that the death penalty would meet such behavior, whereupon he remarked,
“I am not afraid of the death penalty,” staring excitedly at the
officer and trembling throughout his body. It seems that he had already
made an impression of mental inferiority in the troop, and had once
before said to an officer who wanted to send him to the front, that he
would not go; this had been regarded as almost a breach of discipline.
He had been in the habit of not reacting to the calls of his superiors,
and had smiled at their reproaches. He seemed to hold the opinion
that not even a company commander had power to order him to go back.
Examined in the clinic he held to the same opinion, that there was no
need of his going back; that they took volunteers; and that he wanted
to remain at the front. On the day of the deed, he had drunk a rye
whiskey. He had shaken off the non-commissioned officer because the
leader had seized him by the throat. In the clinic he often smiled and
wrinkled his forehead. He gave evasive and inadequate answers. Asked
about oaths and perjury, he remarked, “I prefer to remain silent.”

He said that one of his sisters was a little stupid. Study of his
previous history indicates that Friedrich L. had formerly been a quiet
and steady man, although he often had attacks of rage, breaking out
upon sudden excitements. As to his capacity in school, nothing could be
learned, since the Russians had taken the school registers away.

The analysis of this case seems to reduce to the question of
feeblemindedness and schizophrenia, unless some form of inborn
qualitative inferiority of mind be preferred as the diagnosis. On the
whole, possibly, the diagnosis of feeblemindedness seems preferable.
The entire symptom picture seems to relate to the patient’s one mental
attitude about sticking at the front, _ruat coelum_.


A French soldier who admired Germans.

=Case 48.= (LAUTIER, 1915.)

A man with the extraordinary first name of _Agapithe_ (Laurent insists
on the frequency of strange first names in degenerate families) came
from Val-de-Grâce to Villejuif June 5, 1916, with the diagnosis
of mental weakness, interpretative ideas of persecution, mental
excitement, recrimination, logorrhoea, and a tendency to revengeful
reactions.

On arrival the patient said he must be in an insane asylum because he
heard _spiritiques_ talking together. He, however, was “not insane”
and began expounding his plans for revenge with the words “Kill,”
“Cut-throat.”

This man had been placed in the auxiliary service by the Council,
called to the colors December 13, 1914, and finally sent to the front
in May, 1915. In July he was made prisoner in a brush. He said, “I
cried out, ‘Comrades, what difference does it make to me whether I am
German or French? My officers are imbeciles that drink the blood of us
unlucky ones!’” He was interned in some camp whose name he could not
exactly give and reported that the Germans were very gentle with him,
that his real enemies were the French, for the French were against
him night and day. “As a matter of fact, among Germans the French are
nothing but _cochons malades_. The Germans are fine types.”

He was repatriated in May, 1916. He kept making verbose and neologistic
eulogia of the Germans. He had been a farm boy in Brittany, where he
had had headaches. He had been at Quimper Asylum in 1910. In fact, he
said his parents had tried to poison him and to have him assassinated;
they had charged him with setting fire to their house. His mother was
an imbecile, he said, who believed she was the Queen of France. His
recriminations did not stop short of himself. He had been accused of
kissing a girl and stealing apples; as a matter of fact he knew what to
do with girls.

He had a coarse face and a number of stigmata besides his name
_Agapithe_. He was kept at Villejuif as an imbecile.


Unfit for service: Question of feeblemindedness.

=Case 49.= (KASTAN, January, 1916.)

Walter N. was declared unfit for military service in 1912, on the
ground of mental incapacity. He had shown this clearly during his
period of training. He committed a number of slight offences secretly,
but not so secretly but that they were immediately discovered and
punishment meted out therefor. He could do nothing without aid. It
appears that his mental weakness had not been noticed in school, but
that his employers had thought him both feebleminded and irresponsible.
Nevertheless he always executed orders properly. While in hospital in
1912, he had occupied himself very little, sitting indifferently, quiet
and dreaming. At that time, he had shown poor calculating ability and
decreased power of perception. It also appears that he did not grasp
the nature of simple orders, the requisite associations being disturbed.

Despite this history, on September 11, 1914, he found himself being
transported. He claimed to be very tired. Upon reaching the city,
he picked up a large stone and raised his arm as if to strike the
transport leader. While N. was being bound by the transport leader in
consequence, he kicked at his leader’s shins.

In the clinic he resisted examination, moving his legs without
speaking, staring at the floor, moaning frequently, sitting motionless
with head hanging, answering monotonously repeated questions, but
turning his head at a loud noise. He felt ill. It appeared that he
was oriented and that his knowledge was well preserved although his
calculation ability was poor.

It would seem that psychiatric examination, possibly with the aid of
psychological work, would have excluded Walter N. from the army.


Oniric delirium (Régis) in a somewhat feebleminded Esthonian.

=Case 50.= (SOUKHANOFF, November, 1915.)

An Esthonian, 21, a soldier in a reserve regiment, came to a
psychiatric section towards the close of 1914. He was negativistic,
mumbling, restless, fugacious; later more tranquil. One day he entered
the physician’s office, walking up and down, mute, looking at articles
and attempting to take them away.

February 21, 1915, he was evacuated to the Notre Dame Hospital for the
insane at Petrograd,--a tall, healthy, agitated-looking youth with a
rapid pulse. He explained in poor Russian how he was now among Germans
and feared that they were going to hurt him. At first in the hospital
he was seclusive and morose. March 9 he became excited, and tried
to break through the door. He was placed in the bath, agitated and
yelling. An Esthonian interpreter did not quiet him. The Germans were
going to make a martyr of him. After an hour of this he grew quieter,
and next day complained only of head weakness and malaise, was in good
humour, smiling, and reading an Esthonian paper, and well behaved in
church, though tired and pale.

He now got better, began to work and wrote letters. It seemed as if he
had waked up from a painful dream. He explained how he thought he had
been in captivity; that he was going to be hanged. He had thought that
the Germans could talk Russian. He had had hard work in his regiment,
as he did not understand Russian and had never before left his little
village in Livonia. His mental disorder had started in the autumn,
but all that was now like a dream. He said that he had had a mental
disorder of short duration following some bodily disease, at the age of
thirteen. According to Soukhanoff, this is a case of Meynert’s amentia,
in a somewhat feebleminded person. The twilight state might well
receive (according to Soukhanoff) the term “oniric delirium” invented
by Régis.


Shell-shock; burial: Incapacity to rationalize the situation.

=Case 51.= (DUPRAT, October, 1917.)

A soldier, 39, a herdsman, was shell-shocked at Hill 304 May 23, 1916,
buried twice, slightly wounded in right eye, and carried unconscious
to Bar-le-Duc. He was then forty days in a semi-confusional state with
headaches and dreams of the Boches wanting to behead him. Some of these
dreams came in the waking state, in which state he could recognize them
as imaginary. In April, 1917, he said he had always been afraid, even
in daytime, that he would be hurt and had been especially troubled by
the fear of shells. He was also bothered by nocturnal enuresis which
might become an incurable disease and bring impairment of memory and
attention. Although not feebleminded the man was of but moderate
intelligence, and his emotions, according to Duprat, were such as to
defeat any complete resolution of his plight by the intellect.

An affective complex, passing from the surprise of the shell-shock over
to a fright based on clear though wrong ideas of what might happen to
him, had left him without sufficient power of _autocritique_.


Weakling, twice buried by shell explosions in one day: Change of
character; fear; three fugues (“It is stronger than I am”).

=Case 52.= (PACTET and BONHOMME, July, 1917.)

An infantryman, Class of 1913, at the front from September, 1914, had a
somewhat infantile build physically but was intellectually of average
powers, having been a type-setter (three years in a job). However, the
confined life had borne hard upon him and his father put him on a farm.
He passed through his military service successfully, though he was
given two weeks in the guardhouse for overstaying Easter leave. He was
suggestible enough at this time to think that he would not be punished
very severely, since there were other men whose leaves did not expire
at the same time as his own.

He was buried twice in the same morning, March, 1915, at Bois Le
Prêtre, spent four or five days in hospital, and went back to his
battalion. But now there was a change in his character. Formerly
indifferent to danger, he was now apprehensive every time he went to
the line and felt an almost irresistible impulse to make for the rear.
He was condemned to five years in prison, June, 1915, but was finally
sent back to the front.

However, in July he left his company a second time as it was going into
the trenches, and this time the captain simply asked him to do better.
A third fugue, a few weeks later, sent him back to court-martial, and
thence to be examined by alienists. He was perfectly conscious at the
time of the fugues and understood his duties and possible punishments.
All he would say was, “_It is stronger than I am._” Fear outweighed
every consideration after the episode of the shell burials.

The man may be regarded as a hypobulic, somewhat feebleminded person,
able to get on in civil life but thrown out of gear by war. Of course,
the concept of fear as a disease can easily be overdone; however,
here was a case in which three desertions occurred; the third after
severe punishment. In the differential diagnosis, epilepsy, alcoholism,
impulsive poriomania, must be considered, as well as feeblemindedness.



III. EPILEPTOSES

(THE EPILEPTIC GROUP)


Diagnosis “epilepsy” revised to neurosyphilis.

=Case 53.= (HEWAT, March, 1917.)

A Scotch soldier, in the Royal Navy, 43, was admitted to the Royal
Victoria Hospital at Netley, as major epilepsy. He had been 12 years
a stoker, and 16 years before admission had suffered from syphilis, a
chancre locally treated with black wash, without secondary rash.

After leaving the Navy, he had worked in a fire-brigade and as dock
laborer. He had been very alcoholic when funds permitted, although
never “primed.” His first convulsive seizures came at 40, while working
at the docks, following a night on which he had drunk a bottle of
whiskey. He thought he had been about half an hour in the fit.

He joined the A. S. C., January, 1915; served in France; later at
Salonica. He had eight convulsive seizures, some in France, and others
at Salonica, always after much rum.

The man was tall, powerfully built, without visceral disease, speech
defect, or other symptoms except that both pupils showed the typical
Argyll-Robertson phenomenon. The deep reflexes of arms and lower legs
were increased. The superficial reflexes were diminished, and the
Wassermann reaction strongly positive. A seizure was observed by Hewat
and the diagnosis of major epilepsy was revised. The diagnosis of
cerebrospinal syphilis, non-paretic, was preferred to that of paresis
on account of the absence of all the ordinary symptoms of paresis and
of tremor. It might be asked whether these fits were chiefly alcoholic
in origin. However, the patient had two or three fits while in hospital
during a period of eight teetotal weeks. Hewat remarks that the case
suggests that the serum of any patient developing epileptiform seizures
for the first time say between 35 and 50 years of age, should be given
the Wassermann test.


Syphilis may bring out epilepsy in a subject having taint.

=Case 54.= (BONHOEFFER, July, 1915.)

A man of 35 in the _Landwehr_ acquired syphilis some time in the summer
of 1914. He was a good soldier, passed through several clashes, and was
promoted to _Unteroffizier_.

To understand what followed it must be stated that he had been a
bed-wetter to 11, had been practically a teetotaler (Bonhoeffer’s point
is perhaps that otherwise epilepsy might have developed sooner?), and,
when he did drink, vomited almost at once, and had amnesia for the
period of drunkenness. His father drank. His sister had fits as a child.

February, 1915, the _Unteroffizier_ lost appetite, got headaches,
and went to hospital for a time. Upon getting better, he was sent on
service to Berlin. In a Berlin hotel he had his first convulsions and
unconsciousness, biting his tongue. He was confused for several days,
and, when he had become clear, had a pronounced retrograde amnesia
together with a tendency to fabricate a filling of events for the lost
period.

This retrograde amnesia is uncommon in epilepsy and suggests organic
disease. No sign of such was found, or signs of the epileptic make-up.
The serum W. R. was negative. On the whole, Bonhoeffer regards the
epilepsy as “reactive” to the syphilis, as a syphilogenic epilepsy.

Alcoholism caused amnesia in this man in the same way as the syphilitic
epilepsy now did.

_Re_ epilepsy and syphilis, Bonhoeffer states that he has repeatedly
seen syphilis giving no other symptoms than epilepsy develop in
the campaign. At the same time, Bonhoeffer does not find that the
incubation period in paresis can be shortened by war factors; at all
events, by the exhaustion factor in war (see Case 25). It might be
questioned whether the above case (54) was not psychogenic; that is,
whether the syphilis did not act in combination with being sent to
Berlin on service as a psychic factor. However, this epilepsy on the
whole seemed not psychogenic.


Syphilis in a psychopathic subject. Convulsions 5 days after Dixmude.

=Case 55.= (BONHOEFFER, July, 1915.)

A soldier in the reserves, 23, was, subsequently to his being brought
to hospital, described by his wife as a rather over-sensitive fellow,
who could hardly look at blood and was meticulous about the household.
He had always been subject to headaches, especially after hard work.
However, he had passed through his military training well in 1910, not
even having been _bestraft_.

He began service in October and fought at Dixmude on the 19th. On
the 24th in the trench and while being carried back, he had several
spells of pallor, falling stiff, and then having convulsions. Brought
finally to the Charité in Berlin, he had more spells of sudden pallor,
collapse with brief convulsions, tossings in bed, as well as absences,
post-convulsive headaches, and mild bad humor.

There were numerous attacks several days apart in the first seven
weeks. The patient was not of an “epileptic” disposition, though
readily dissatisfied and headachey.

The serum W. R. was positive. Treatment by mercurial inunctions. No
further convulsions. Prognosis doubtful.

_Re_ epilepsy and the war, during the first six months Bonhoeffer
observed 33 cases in the Charité Clinic in Berlin. Twenty of these 33
cases, unlike Case 55, had attacks before the war, although ten of
these had become epileptic rather late, namely, after the period of
active military service, at ages from 22 to 27. The development of
epilepsy like Case 55’s is not without frequent precedent.

Bonhoeffer states that aside from epilepsy directly due to brain
injury by shells, there has been no certain case in which we have the
right to regard the war itself as the total cause of the epilepsy.
Some, like Case 55, are of syphilitic origin. No subject with a severe
long-standing epilepsy has been able to get into the field, according
to Bonhoeffer; when they do, they prove constitutional subjects.


An epileptic imbecile, court-martialed.

=Case 56.= (LAUTIER, 1916.)

A Belgian soldier was condemned by court-martial February 27, 1915, to
five years imprisonment for leaving his post in the presence of the
enemy. It seems that he was mounting guard with two of his comrades and
all three left to eat as no food had been brought to them.

A physician examined the Belgian soldier and declared him responsible,
although a little sick. All three were condemned to imprisonment. The
Belgian attracted attention in prison through crises of anxiety and
agitation; he had terrible nightmares, seeing Germans in his cell and
hearing gunshots. He was accordingly sent to a special infirmary of
the dépôt, whence July 24 to Sainte-Anne, July 26 to Villejuif. He
talked Flemish, hardly understanding French, and spoke slowly and with
difficulty. He hardly knew how to read or write. He had been a truckman.

At 18, this soldier, according to his own account, began to have
nervous crises in which he fell, lost consciousness, bit his tongue,
foamed at the mouth and urinated involuntarily. The attacks were
somewhat rare. His father sent him in 1910 to Gheel where he stayed two
years. Returning home he helped his father in the trucking work.

When the Germans came the family fled to France and, about the end of
1914, he was put into the military service and sent to the front after
a very short period of instruction.

The man had followed the example of his two comrades without taking
the slightest thought. He did not understand the gravity of his act.
He was not remorseful, regretful or angry against his judges. He was
well oriented but quite indifferent. He was a tall, intelligent looking
man with adherent lobules, slight facial asymmetry and evidence of
tongue biting. He wrote like a child and read slowly, spelling out the
complicated words. He was employed at various manual tasks during his
sojourn at the asylum and had no epileptic attack. He was given over to
the Belgian military authorities October 5, 1915.


Seizures in a feebleminded subject--psychogenic components.

=Case 57.= (BONHOEFFER, July, 1915.)

A 21-year old tailor, unused to marching, went into the field in
August. A month later, after a period of long standing, he was
nauseated and fell in a faint. Upon waking, his fingers were stiff
and he had pains in his legs. He got better in the reserve hospital
and was sent back to the line. On the way he had a similar seizure,
with nausea and fainting. On the way back to Berlin, he had a seizure
in the railway station, and was carried to the Charité Clinic. At the
clinic he stated that he could feel an attack come on; that he first
had _Angst_ all over his body, and that it was hot inside of his head.
Latterly he had been able to stop an attack by clenching his teeth,
after which the attack would not proceed except that all became black
before his eyes.

He was observed for four weeks but no seizure appeared. He was
somatically negative; his Wassermann reaction was negative. There was
nothing hysterical about his make-up; he was somewhat surly and of low
mental grade. He was unwilling to walk alone for fear of attacks.

As to the heredity of this soldier nothing is known. He had been
an illegitimate child; he was a sleep-walker in childhood; he had
sometimes spoken out loudly in sleep as a boy. At school he had been
somewhat backward, fought readily with his mates, and often complained
of dizziness and headaches. He could not stand smoking or drinking
well, getting drunk upon two glasses of beer. He had not held positions
well. He became a _pionier_ in 1914, working chiefly as a tailor.

Early in his time as a soldier he had obtained an ulcer of the glans,
which had been excised and burned. There had been no secondary symptoms.

According to Bonhoeffer, this is an example of a not infrequent
condition. Although the attack itself and the habitus of the patient
did not look hysterical, the manner in which the attacks repeated
themselves speaks for psychogenic components. Just as genuine
hysterical attacks may be looked on as reactions to unpleasant
situations, so may these attacks. In fact, we are probably dealing
with an hysterical fixation of the symptoms of emotional fright like
those in the true hysterias following shell explosion. A great many of
the phenomena of Shell-shock, to use the English phrase, are not in
and of themselves of a psychogenic nature, but they are, according to
Bonhoeffer, psychogenically liberated under the influence of unpleasant
ideas.

_Re_ reactive epilepsies, Bonhoeffer considers that there is a group
of reactive epilepsies in which the war process plays an important
part. The prognosis of these cases ought to be relatively favorable. In
point of fact, Case 57, although a feebleminded subject, seems to have
had a relatively favorable prognosis: at all events, no new seizures
appeared under prolonged medical observation. These reactive seizures
may occur in cases with a labile vasomotor system. They are, according
to Bonhoeffer, aligned rather more with hysteria than with genuine
epilepsy. Genuine epilepsy has not been developed in the war cases
observed by Bonhoeffer except where an endogenous factor was clearly
in evidence; or else where there was the requisite antebellum soil for
the development of an epilepsy. In short, genuine epilepsies developing
in the war are all, according to Bonhoeffer, predispositional. The
antebellum soil was clearly in evidence in Case 57. Even before the
war, according to Bonhoeffer, many German soldiers during the period
of military service gave evidence of their epileptic soil by sundry
suspicious phenomena. Among these were fainting spells during hard
drilling and other exercises, spells of enuresis, abnormally deep
sleep, and even phenomena of somnambulism. One of the Bonhoeffer
epileptics had been released during his reservist practice as unfit for
military service, and had only been put into the line at his own urgent
request at the outbreak of the war. Three volunteers concealed their
epileptic history. One man, who had had merely petit mal attacks before
the war, regarded them as of little consequence, entered the service,
and developed epilepsy.


Responsibility of a drunken epileptic.

=Case 58.= (JUQUELIER, March, 1917.)

The question of responsibility arose in the case of a soldier who left
his camp the morning of October 23, 1916, and went to a neighboring
place, where he drank, with four others, two quarts of wine. At about
three o’clock in the afternoon, his captain met him on the street,
lost, and looking drunk. He told him that he would send him to the
trenches in the evening. The man lay down and went to sleep. At about
six o’clock, it was found that he could not put on his equipment alone,
and in fact threatened the other men with his bayonet, and then went
to sleep. He woke up and explained that he had had one of his nervous
crises. He remembered the matter of the bayonet but had forgotten
everything else about the struggle.

This soldier was 29 years old, the son of an alcoholic, and the ninth
child of a mother who died shortly after her tenth pregnancy. He had
had measles and bronchitis as a child, and in childhood had had bad
dreams; at the age of ten he had swooning spells. He became a quarryman
and a habitual drinker, subject to dyspepsia, nightmares, and nocturnal
cramps. There had never been any crises, however, up to wartime.

January, 1916, when a shell burst near him, the first sharply-defined
epileptoid crisis came, and was followed by a number of others,
either on leave or on service, March 8, June 2, and July 13. These
attacks showed a sudden fall without warning, loss of consciousness,
convulsions, tongue biting, incontinence of urine, a period of more or
less coördinate agitation at the time consciousness was reappearing,
sometimes a fugue, and often amnesia for the whole. He had a scar on
the left border of the tongue.

Should this epilepsy be regarded as entailing irresponsibility? He
left camp before the crisis, accordingly in a period when he was in
full possession of consciousness and will, and he had gotten into
an irregular situation by drunkenness before his epileptic crisis
started in. His struggle with his comrades, however, appears to be
a portion of a post-critical dazed state. The medicolegal decision,
therefore, was that he was guilty of leaving his command but not of
the other misdemeanor. Considering the general nature of epilepsy, the
responsibility of this man for the whole adventure is rather slight.
The Council, however, condemned the man to five years of labor, without
admitting that the crisis following so soon the actual misdemeanor
should argue a diminution of responsibility.

_Re_ epilepsy in the army, Lépine notes the serious theoretical and
practical problems to which it gives rise. In the first place, epilepsy
occurs in the army more frequently than in the same number of men in
civilian life. Consequently, the diagnosis as to the really epileptic
nature of the attacks observed is not too easy. Again, the situation
affords much opportunity for simulation (see, for example, the case
of sham fits (Case 78, Hurst), and the case of epileptoid attacks
controllable by the will (Case 79 of Russell)). Wounds may produce it,
and even wounds which do not affect the brain; besides which, a variety
of war conditions, short of trauma, may produce it. When the ordinary
impulsiveness of the epileptic turns into automatism and to epileptic
equivalents (_états seconds_), much of medicolegal interest may
happen. Case 58 was just short of a murderer. Cases of actual murder
in epileptic equivalents have been known under military conditions.
Fugues with amnesia for the phenomena (which look to the military man
like intentional desertions) form another group of epileptic events;
but aside from the manias and the fugues, there are still more dubious
epileptoid phenomena of a delusional and confusional nature, such that
the proof of epilepsy comes only afterward, when frank convulsions
supervene. _Re_ fugues and desertion (the most frequent of military
delinquencies according to Régis), we may think of the fugue reaction,
according to Lépine, as a natural reaction on the part of both the true
delinquent and the mentally sick subject. The loss of liberty, alcohol,
fatigue, minor phenomena of _commotio cerebri_, may lead to states
of mental depression that favor the fugue. It is an affair of the
greatest delicacy for the expert to build up again the exact plight of
the soldier at the time of his desertion. Special inquiry must be made
of the man’s mates. Only in this way can the wheat be separated from
the chaff and punishment allotted to those only who deserve it.

According to Lépine, there are fewer guilty fugitives than there are
innocent ones, or at least partially innocent ones. In the decision,
one takes account of the duration, the course, and the peculiarities
in the termination of the suspicious flight. According to the military
code, there are cases like Case 58 in which the fugue itself was
carried out in an unconscious state, and yet in which the martial
responsibility of the man was absolute. Drunkenness is no excuse for
the fugue, even if the latter is automatically carried out. Of course,
the paretic is not responsible for his fugue any more than the organic
dement, the delirious uremic, or the chronic alcoholic, who is already
severely demented. For a case of this sort, see Case 1 (Briand).

In the differential diagnosis, we must also consider that fugues may be
carried out in confused states as well as at times in various paranoid
states, and even in melancholia.


A disciplinary case: Epilepsy.

=Case 59.= (PELLACANI, March, 1917.)

A Milanese workman, 28, was exposed to the sun on sentry-go and had
an attack of convulsions, on awaking from which he found himself in
hospital. He always had attacks in reaction to emotion. One day, in a
quarrel provoked by jealousy concerning a prostitute, he apparently
lost his mind, whipped out a hunting-knife, and wounded a comrade.
Thereafter he lay unconscious until the next day. The court-martial
decided that he was not fully responsible.

Eventually, he was sent from the front for having insulted and
struck a superior officer. The report read also that he was a prey
to delirium and had frothed at the mouth. In the interior he had
convulsive attacks, with falling and loss of consciousness. He told
of arguing with a sergeant about a bicycle, of seeing darkness before
his eyes like a veil, and of subsequent amnesia. In hospital he had
intense headaches at times, with spells of sullenness, hostility, and
complaints concerning nurses and attendants and other patients. At
other times, he was quiet and comfortable. One day he went into an
excitement and wept, asking to be sent back to the army, striking the
table with his fist and head. He then screamed, flew into a passion,
and fell to the ground in semi-stupor, shaking his body and trying to
kick and knock away those who intervened. He was placed in bed but
remained agitated and unconscious, with anesthesia and frothing at the
mouth. The abdominal and cremaster reflexes were absent in this attack,
and the pupils were rigid and myotic. The pulse was rapid and the
blood pressure high. Afterwards he was sleepy, stupid and weary, and
showed fine rapid tremors of hands, tongue, and eyelids. The abdominal
reflexes now returned in excess, and a marked dermatographia developed.

Upon investigation, it was found that the patient’s father was also an
epileptic and was alcoholic; that one paternal uncle had died in an
asylum; another of apoplexy; that two maternal uncles were chronic
alcoholics (one in an institution); that an alcoholic brother had been
six times convicted of assault and battery; that a sister had howling,
crying, and hair-pulling spells, throwing herself to the ground. The
patient himself had had an early Bright’s disease and had always been
an undisciplined, excitable, and impulsive boy, sometimes kept out of
school. His first conviction was at 18, for assaulting a policeman, and
he had been arrested four further times for assault and battery. He
stated that his convulsive attacks with the veil before the eyes came
on when he was irritated or had taken cold, or had drunk to excess, or
had over-exerted himself. He said he suffered from intense headache,
weariness, and sleepiness after an attack. He always bit his tongue at
the same period. Irritation and exertion sometimes caused attacks of
dizziness and vertigo without unconsciousness. Alcoholism; ulcer in an
inguinal gland. He had been confined in an asylum 40 days for epilepsy,
attacks of which had become more frequent after he had heard of his
father’s death.

_Re_ violence and epilepsy, Lépine remarks that a pure epilepsy
unclouded by alcoholism may occasionally give rise to acts of extreme
violence, but these pure epileptic violences are infinitely rarer than
the alcoholic ones. The Milanese was in point of fact alcoholic, and
in his ancestry were a number of alcoholics as well as epileptics.
According to Lépine, when subjects are “out for blood,” they are almost
always either, like this Milanese, hereditary alcoholics, or else
strongly predisposed subjects, or even the offspring of the insane.


A disciplinary case: Epileptic attacks with amnesia.

=Case 60.= (PELLACANI, March, 1917.)

A Veronese, 23, quarrelled with his comrades, and one day wounded one.
Another time, when reproved by a superior, he struck him with a shoe;
and at still another time, hurled himself upon his superior officer and
bore him to the ground. Yet he seemed to have a perfect amnesia for all
these violent acts. At other times, he had convulsive attacks with a
mental state which seemed to combine anger and depression, after which
he would fall to the ground, lose consciousness, go into clonic spasms,
spit bloody saliva, and cause wounds and abrasions upon his body. Once,
after such an attack, he passed into a brief excited spell. Finally
he was so insubordinate and violent to superior officers, that he was
brought under hospital observation, having been excited and confused
for a day.

Next day he was lucid, oriented, and tranquil; entirely amnestic
for what happened the day before, though his acts were sufficiently
unusual. He had threatened his superior officer and been reproved and
sent to prison to think it over. In prison he had suddenly thrown
himself against another innocent person and clutched him tightly about
the neck. He threw another violently to the ground and then ran to help
the previous victim! Bound fast, he had succeeded in freeing himself
and thrown himself furiously against the prison door, whereupon he had
fallen to the ground in an epileptic fit. He had tachycardia (120) and
a generalized hypalgesia. The vasomotor reactions were excessive.

Upon investigation it proved that his mother had been subnormal and
that the patient had been constitutionally excitable and unstable,
given to attacks of anger and impulsiveness from youth up. In fact, he
had been in prison several times for violence. He described himself
in his restless spells as feeling a trembling all over his body as if
his blood were boiling in his heart and his head, whereupon he would
lose knowledge of what he was doing. He had been a quarrelsome boy,
pursuing his mates with knives and stones. Once, after arguing with
a car conductor, he had broken the car windows, turned everything
upside-down, and thrown the conductor into the street.

Case 60 is clearly in the same group as Case 59. The Veronese falls
into the same frame with the Milanese except that he appears not
to have been alcoholic. The insubordinations of the Veronese were
apparently carried out in a state of unconsciousness. The majority of
insubordinates appear not to be epileptics. Some authors have called
attention to pathological politeness as an occasional symptom in
epilepsy. Perhaps the majority of insubordinate cases are feebleminded
or schizophrenic.


Desertion in epileptic fugue.

=Case 61.= (VERGER, February, 1916.)

A blacksmith from the Rochefort Arsenal, 27 (nothing known as to
grandparents; father, now in the fifties, for 30 years in an asylum
with frequent attacks of furor; mother, 45, well and apparently
well-balanced; brother with the colors, wounded and decorated with the
military medal; a cousin-german, who has had a typical epilepsy--in
the patient himself enuresis up to 13 or 14, later, less frequently;
apparently no tongue-biting; no information as to infectious diseases;
graduate from primary school, apprenticed to a blacksmith; an unskilful
worker; never able to rise to the level of a _frappeur_), in 1909 had
passed the board of review and been put in the sixth division of the
line. Antebellum there was a history that one night at supper, he had
slipped away from quarters and gone 30 kilometres, home. His astonished
mother sent him back to the military post by railway.

Upon the night of May 26-27, 1915, this soldier found himself in the
position of a sentry, opposite the enemy. He told his comrade that he
had to go away for a time, leaned his gun against a tree, disappeared,
and did not return. It was then one o’clock in the morning. At six
o’clock, he was found two kilometres away from the lines, in a village.
He was in front of a barn where his company had been quartered before
taking possession of the advanced posts.

He was brought up before the military authorities; but upon stating
that in civil life he had wandered off several times without knowing
where he was going, he was submitted to neurological examination.
There was available a letter from his family physician relative to his
antebellum military service. It appeared that he had committed a number
of breaches of discipline, and that he was regarded by the physicians
as a _déséquilibré_. He had lived with his mother a very quiet and good
life; there was no history of sexual irregularity, and no history of
illness except a slight catarrhal jaundice. He had frequently suffered
from headaches; there had been slight attacks of vertigo of very brief
duration. He had never fallen in these fits. From his story it was
elicited that he had had absences; his comrades had noticed that he
sometimes stopped stock-still with vague eyes, then shortly regained
his wits and continued upon his task. Sometimes he would not work
without being able to explain why he went away. He would go off for a
period and, upon coming to, discover that he had not eaten his meals.
There were never, however, any convulsive crises by day or night. He
sometimes felt sick, and although there was no medical treatment, from
time to time he took bromides upon his own authority, saying he had
been ordered to do so by his father. Although habitually of a gentle
demeanor, nevertheless he was subject to excessive anger upon slight
occasion.

During the mobilizing and first months of the war, both in quarters and
at the front, however, his conduct had been that of a good soldier.
Suddenly, about March or April, 1915, the nocturnal enuresis began
to be frequent again, occurring twice or three times a week; but the
patient hid this misfortune as far as possible from his comrades. The
captain thought he looked tired and depressed sometimes. Upon the
days following the nights with enuresis, there was intense headache
and marked moral and physical depression. There was no proof of
nocturnal convulsions, and it is very problematical whether there was
tongue-biting.

Another odd feature was that the patient, who had been sober in civil
life, had become intoxicated several times after going into the
army. Physically, he was of low stature, but otherwise well built.
Neurologically, he was entirely negative. There was no sign of venereal
disease. There were a few stigmata of degeneration; for instance, there
was very little hair upon the face, the ears were unequal in size, and
the teeth were somewhat anomalously set. Mentally, he was below par;
for instance, he could not add mentally two numbers of two digits.

As to his desertion, the patient says he does not know what he did;
that he learned of his act only from his comrades in the morning; that
he remembered having left his duty _pour aller satisfaire un besoin_.


A specialist in escapes (epileptic fugues).

=Case 62.= (LOGRE, March, 1917.)

An epileptic fugue with recidivism is described by Logre. He described
himself as a specialist in escapes. As a schoolboy, he had practised
escapes and run away without purpose, and without remembering fully
what he had done. His father would bring him back to school. At first
they had punished him and then would pardon him. These escapades in
his work as a shoemaker caused him to lose various places, but he had
been kept by one employer for a long time nevertheless. From 11 years
on, this patient had never ceased living either in foreign parts or in
prison.

The fugues on military service began to multiply. The military chiefs
did not abide the escapades like the schoolmaster or the employer.
Every punishment he received had to do with some fugue. Three times
he gave himself up to the military authorities. Three times after a
few more days’ service or a week in prison, he left the barracks or
escaped. There had never been any appeal throughout this history to an
alienist. On the declaration of war, he had returned to Belgium and
was put into the army; whereupon in January, he carried out a fugue of
a few hours which was rewarded with eight days in prison. There was a
five-days fugue in July, whereupon he was taken before the council.

Upon investigation, these fugues seemed to have the classical features
of epileptic fugues. They were sudden, unconscious, blindly automatic,
almost completely forgotten afterwards and of a stereotyped and
recidivistic nature. Most of the fugues had been preceded by a slight
excess in drinking. An investigation was made to see if there were any
convulsive antecedents; none were found. This mental epilepsy, then,
it was thought, must be an isolated symptom, free from every motor
symptom. But his mother and one of his brothers had also shown a number
of attacks of some sort of epilepsy. In all three cases there was
impulsivity, unconsciousness, absurdity, recidivism, and refractoriness
to treatment. On these grounds the fugue was regarded as pathological
and as epileptic probably. The patient himself thought that these
_coups-de-tête_ and this mania for running away without knowing where,
made really a very ugly fault, particularly in a soldier.

_Re_ such specialists in escapes as Case 62, Lépine speaks of a type of
military delinquent which he calls _Ceux qui sautent le mur_. Some of
the fugue subjects, as well as other types of imbalance can apparently
be held by no possible kind or degree of discipline. They jump any
guardhouse or any other form of imprisonment through what amounts to
a wild instinct for liberty. In some cases, this instinct appears in
a relatively pure form; that is, without any combined tendency to
dipsomania and without any sexual factor. Some of them are, in fact,
very good soldiers, especially in shock troops. They, in fact, belong
to what one might call the good element among delinquents. In the
French Army some of them have been old legionaries and have even been,
as in Case 62, previously condemned for desertion. They form a curious
minority among the wall jumpers. Wall-jumping makes, so to say, the
entire pathological phenomenon, and the recidivism is a part of the
disease.


A disciplinary case: Epilepsy and other factors.

=Case 63.= (CONSIGLIO, 1917.)

An Italian private in the artillery (father dead of general paresis)
had been a victim of infantile convulsions and of convulsions with loss
of consciousness up to 18 (convulsions with shouts and violence in the
streets of Rome; had to be put in a straight-jacket at the municipal
hospital).

He developed more convulsions during antisyphilitic treatment in the
military hospital. He was a very poor soldier, of the rough and violent
sort, and after eight months of service had to be assigned to a special
disciplinary company, with which he remained for fifteen months. Here
also he was punished frequently, and was given a period of four months’
imprisonment for refusal to obey the officers. Then for a period of
several years he had no convulsions whatever.

During the war he was given to alcoholism, and one day in June, 1916,
he struck an officer and ran away to arm himself. He was at this time
observed by psychiatrists and declared sane. He was regarded as an
emotional and alcoholic epileptic but not as neurotic or psychopathic.
He was again placed in a special disciplinary corps.

_Re_ the convulsions which this Italian developed during antisyphilitic
treatment, it would be interesting to know whether intravenous
injections were used. In case they were used, one might compare
the case of this Italian with Bonhoeffer’s volunteer who developed
epileptic convulsions after antityphoid inoculation.

_Re_ the insubordination and violence of this Italian, compare remarks
of Lépine noted under Cases 59 and 60. _Re_ the “other factors,”
compare remarks of Bonhoeffer noted under Case 57.


An epileptic goes through Mons and two years fighting without symptoms.
Then strange conduct with amnesia.

=Case 64.= (HURST, March, 1917.)

A private, 26, epileptic from 11 to 18 (mother also epileptic) entered
the army at 20, attempted to commit suicide in 1912 (amnestic for this
attempt), and went to France with the expeditionary force in August,
1914. The retreat from Mons and further fighting caused no recurrence
of the symptoms. September, 1916, he was in fact put in charge of eight
men doing guard duty. At this time he was able to get to bed only every
other night. The charge of the telephone worried him, as he had never
before been made to assume responsibility. After two months of this,
he was found one night arresting civilians without cause and driving
them before him with fixed bayonet. He was let off court-martial on the
medical evidence, and at hospital remained confused and suspicious.
November 16, he was seen by a medical officer in a typical attack of
petit mal. Of all this, on reaching England December 19, he had no
recollection, and was keen to return to duty.

_Re_ the remarkable delay in the return of epilepsy to this soldier of
Mons, Bonhoeffer remarks that one of the epileptics observed by him at
the Charité Clinic had passed through nine battles, and another through
18 battles before the first attack of epilepsy. Bonhoeffer regarded the
strenuous marching as a liberating factor of epilepsy in five cases,
actual fighting in seven cases, shell explosions in two cases, and
bullet wounds in three.

_Re_ the apparently psychogenic factor in Hurst’s case (epilepsy coming
on after assumption of too great responsibilities), compare remarks of
Bonhoeffer under Case 57 concerning psychogenic factors. Sir George
Savage has called attention to a form of functional epilepsy following
shock or injury, in which recovery occurs after removal from the
strain, but in which there is a relapse if the men go back to duty.


Therapeutic (antityphoid inoculation) epilepsy.

=Case 65.= (BONHOEFFER, July, 1915.)

A volunteer without psychopathic signs except a slight stuttering, and
without psychopathic history of any sort, went into service at 17.
After he had been a short time in the field, a shell fragment injured
him in the upper part of the thigh. He lay up in hospital four weeks.
He then spent four weeks in the reserve.

He was then given antityphoid inoculation, and a half hour afterward
had epileptic convulsions. These appeared four times more during the
next fortnight, as a rule followed by a delirious excitement. No fever
was reported. After the fourth attack, he was transferred to the
Charité Clinic.

At the clinic there were no attacks, and there was nothing epileptic to
discern in the make-up of the patient. His nervous system was normal
to examination. There was, however, one fact in the family history of
note, namely, that an older brother of the patient, 20 years of age,
suffered from convulsions.

What is the relation of the antityphoid inoculation to the epilepsy?
According to Bonhoeffer, we must not forget the family history even
if we regard the inoculation as the liberating factor. Curiously
enough, the shell injury did not itself serve apparently to bring out
the epilepsy. Bonhoeffer has seen three other instances of epileptic
attacks or epileptoid phenomena following antityphoid inoculation.
However, in the hundreds of thousands of inoculations, it is not to
be wondered at perhaps that there should be a number of instances of
epileptic attacks. One was a man with severe epileptic taint; in the
others, there was a question of pathological intoxication.

_Re_ antityphoid inoculations, a French observer--Paris--remarks that
these inoculations may occasionally start up the symptoms of general
paresis. Compare in this connection also Case 63, in which a syphilitic
developed convulsions during antisyphilitic treatment. The psychogenic
factor of intravenous injection itself, with its possible effect upon
glands of internal secretion, can hardly be distinguished from purely
serological effects. Paris goes so far as to state that he regards it
as imprudent to vaccinate a syphilitic subject. He thinks it might be
better for a syphilitic subject to contract typhoid or paratyphoid
fever than to run the risk of developing paresis. If the soldier
happened to be not only syphilitic but alcoholic, then the danger would
be larger. Possibly, however, both Bonhoeffer’s case of antityphoid
inoculation epilepsy and the cases alluded to by Paris of antityphoid
inoculation, are merely statistical accidents.


Shell-shock; (apparently slight) scalp wound: Jacksonian seizures.
Operation, decompressing the edematous upper Rolandic region. Recovery.

=Case 66.= (LERICHE, September, 1915.)

A Moroccan of the Seventh Tirailleurs was thrown to the ground by the
explosion very near him of a large calibre shell, lost consciousness,
and woke up with a slight contusion of the right side of the head. The
date of this injury is unknown. He was evacuated to the interior, but
stopped May 25, 1915, at the evacuation hospital because his pulse
in the train stood at 51. An hour later in the hospital he had a
Jacksonian epileptic attack, followed by a left-sided flaccid, brachial
monoplegia, and after a quarter of an hour a second crisis, and then
a third,--a sort of epileptic status occupying an hour. The attack
seemed to start in the left hand. After the crisis, hand and arm became
flaccid and inert.

Lumbar puncture in the crisis gave fluid under small tension in a few
absolutely limpid drops. The wound was a superficial skin wound as big
as a 25-centime piece, near the middle line, roughly corresponding with
the upper Rolandic region. It was hardly a wound--a mild abrasion not
passing the epidermis; periosteum and bone intact.

The patient was trephined and a thin layer of clot was found over the
dura mater. The clot was removed and a crucial incision was made into
the dura mater. The brain seemed a little edematous, hemorrhagic and
bruised. It soon began to beat and was tamponed.

May 26, complete brachial monoplegia without seizure.

May 27, seizure at 2 in the afternoon, starting in left arm.

The wound was going well and from this time forward no more seizures.
May 28, a cast was made for the hand.

June 4, lumbar puncture yielded a clear liquid under the pressure of
58. That evening an hour after the puncture, the brachial monoplegia
disappeared. The arm was still a little weak June 5. June 8 the man was
evacuated to the auxiliary hospital at Laversine. June 18, complete
recovery.


Fall and blow to head: Hysterical convulsions. Cure by studied neglect.

=Case 67.= (CLARKE, July, 1916.)

Clarke had seen in the war but one case of hysterical convulsions,
though this particular patient had severe hystero-epileptic fits
occurring in series. The man had never suffered from epilepsy and was
20 years of age. He received a slight wound and fell back into the
trench a distance of six feet, striking but not contusing the back of
his head.

On admission to the hospital he was found drowsy and dull. Fits
occurred a week later, following one another at brief intervals in
series that lasted one or two hours. The arms would be raised and
extended in clonic spasm; the patient would resist violently if held,
and then turn to his right side with rigid extension of legs and back
in opisthotonos. The eyeballs underwent irregular movements, and
there was a well marked hippus. Though the tongue was protruded in
these attacks, it was never bitten. It was doubtful whether there was
a complete loss of consciousness. Between attacks, the patient was
morose and sullen, and showed a varying incoördination of the movements
of the left leg, which was anesthetic to the knee. There was also a
glove anesthesia of the right forearm and hand. Fields of vision were
contracted.

The fits recurred with intervals of a day or two, for a fortnight. The
patient was then strictly isolated in a small room with an observation
window. His bed was made up on the floor. He then had very slight
attacks, as a rule when the nurse came into the ward; no notice was
taken of these attacks and in a fortnight they ceased. The paresis
of the leg and the anesthesia also cleared up without treatment. He
remained in the general ward three weeks longer, at first dull and
listless, but later cheerful and active. Clarke suggests that this
patient was below normal intelligence.


Shell injury with unconsciousness; delayed attacks of epilepsy:
superposed hysterical hemihypesthesia. Previous history consistent with
the hypothesis that a genuine epilepsy had been developed.

=Case 68.= (BONHOEFFER, July, 1915.)

An excellent soldier, of good build, 29 years, a member of the
_Landwehr_, passed unscathed through eleven battles in the 1914
campaign, but finally succumbed to fragments of shell which struck his
chest and the lower part of his thigh. He fell down, nauseated, and
lost consciousness. He is said to have struck about him with his arm
and to have voided urine. There was a second attack three weeks later,
in which he fell upon his face.

In the Charité Clinic he had three attacks, two of them nocturnal, one
in the daytime, followed by a long period of somnolence. He once cried
out suddenly in the night as if warding off an attack. He complained of
headaches, and was often irritated and out of humor. Somatically, there
was a hemihypesthesia on the side of the injury.

The history indicates that this patient up to his sixteenth year had
been a victim of occasional enuresis, often cried out in his sleep or
even rose from bed. Occasionally he suffered from such violent sudden
headaches that he would have to sit down. He was easily irritated, and
had once been arrested for assault. As a soldier, however, he had never
been guilty of any breach of discipline. Mild headaches would follow
drinking. These phenomena in the history pointed in the direction of
epilepsy. According to Bonhoeffer, we cannot entirely exclude contusion
of the brain from the shell injury. However, there were no cerebral
symptoms, and the interval before the occurrence of the attacks rather
indicates that we are dealing with a genuine epilepsy. As for the
hemihypesthesia, this is a hysterical “_superposition_,” which does
not interfere, according to Bonhoeffer, with the genuineness of the
epilepsy.


Shell-wound; musculocutaneous neuritis: Brown-Séquard’s epilepsy.

=Case 69.= (MAIRET and PIÉRON, January, 1916.)

An infantryman, 30, a gardener, was wounded in the right forearm by
a shell fragment, which fractured the ulna, September 7, 1914, at
Revercourt. Despite much fragmentation of the bone and suppuration, the
wound healed with two cicatrices, where the fragments had gone in and
had come out. The scarring process was over in December.

However, in the middle of January, 1915, this man began to suffer from
headaches and insomnia, with vertigo and buzzing in the head, “as if
an airplane inside.” Sometimes arms and legs would stiffen, and the
man would tremble, have to lie down, and even lose consciousness for
a quarter of an hour, waking up tired, wandering, and with feelings
in his head. These crises, at first occurring every week, later grew
frequent. Finally there was a very complete attack, in which he fell
out of bed, got up, made several turns about the room, and went back to
bed; and in the morning, was dull and disoriented. Accordingly, he was
sent to the central military neuropsychiatric service of the general
hospital at Montpellier, November 10.

Besides the two extensive cicatrices, there were motor disorders.
Pronation and supination were almost impossible, as well as extension
of the hand and fingers and abduction of the thumb. There was a radial
paralysis without R. D. Electrical excitability of the extensors
was diminished on the right. The hand was weak. The right thumb was
atrophic. There was a hypertrichosis as well as redness, heat and
perspiration of the right hand. There was a hypesthesia for all forms
of stimulation in the hand, especially in the radial region; less in
the ulnar region. This hypesthesia rose along the posterior surface
of the forearm and covered all the territory of the ulnar nerve;
but there was a corresponding hyperesthesia in the musculocutaneous
distribution, as well as in the internal cutaneous distribution. Above
the scar there was a region of complete anesthesia. The hyperesthesia
rose higher along the circumflex nerve and the posterior branches of
the cervical nerves and included the great occipital distribution, even
involving the superficial cervical plexus, though not the territory
of the trigemini. There was some hyperesthesia of areas governed by a
few dorsal intercostal nerves. There were also spontaneous pains in
these hyperalgesic regions. The _musculocutaneous nerve_ could be felt
to be _thick and swollen_, indicating a perineuritis. There were no
neuropathic stigmata, but the knee-jerks were exaggerated a little more
on the right side.

The convulsions appeared two or three times a day, the pain would get
worse along the arm, rise to the head, following the hyperesthetic
zone, then invade the interior of the head, whereupon objects
would appear to turn and the ears would buzz. The right leg, and
especially the right arm, would begin to tremble. The man would have
to support himself to avoid falling. He saw shadows moving, colored
trees, occasionally persons. When the vertigo got stronger, he lost
consciousness. The extremities of the right side stiffened and carried
on jerky movements. These sometimes extended to the left side. The
seizure lasted from five to fifteen minutes, and sometimes occurred
in the middle of the night. Fatigue followed but headache disappeared
after an attack.

The diagnosis of Brown-Séquard’s epilepsy was made. If the
musculocutaneous trunk was compressed, a crisis was produced with
pain radiating to the head, obscuration of vision, numbness in the
arm, and tremors. Electrical treatment was resorted to for analgesic
effect. There was a certain improvement during May, so that the diurnal
dizziness disappeared. May 19 he had a period of 24 hours without any
vertigo. In June no further improvement occurred.

An operation was performed June 23, 1915. The two cicatrices were
excised, and some fragments of cloth were removed. Three Jacksonian
crises followed the operation, and there was another seizure next day.
Frequent headaches followed without crises. More seizures appeared in
the night during July, and their frequency increased. Pains persisted
along the arm and in the back of the head; the musculocutaneous
perineuritis was still intense. Prolonged baths for the arm were begun
August 4, two baths of two hours each, at 40 deg. each day. Following
August 10 there was an improvement, which stopped as soon as the baths
were omitted, with diminution of the vertigo and the hyperesthesia.
This improvement continued; the baths were made to last three hours.
There were no attacks from August 21 to 26 whereupon they then returned
for two days. The pains had much diminished in the arm but persisted in
the occiput. A few night attacks occurred August 30 and 31, September 5
and 6, as well as September 19 and 20, 25 and 26, and 27.

The occipital pain had now become less; the musculocutaneous nerve
was not so large. Only a few headaches followed during the months
of October, November, and December. After November 3 the baths were
stopped and the arm was kept wrapped in a warm compress. There
was still a certain hyperesthesia, the knee-jerks had become less
exaggerated. Massage and mechanotherapeutic exercises were begun. There
were no more attacks after September 27.

_Re_ Brown-Séquard’s epilepsy, Lépine remarks that besides the case
of Mairet and Piéron, Hurst and Souques have published cases. Lépine
himself has observed two cases: one followed a nerve wound in the
foot; another, a penetrating wound of the chest. As a rule, such
Brown-Séquard epilepsies appear a number of months after trauma; as
a result of irritation in the scar. Lépine’s subjects were taken for
simulators because they had not received any _cranial_ wound. The
prognosis should be guarded, though the outcome in Case 69 appears to
have been favorable.


Epileptic episode at 24 years following bullet-wound of hand, in a
soldier who had had convulsions in childhood (sister epileptic).
Reactive epilepsy? Epilepsia tarda?

=Case 70.= (BONHOEFFER, July, 1915.)

A man in the reserve, 24, bore the stresses of the war very well
in the campaign in East Prussia until he was shot in the hand at
Deutsch-Eylau. He had always been well aside from rheumatism, and was
discharged with a good record from his military service.

Sent to the reserve hospital for his hand injury, he had, two or three
times in the night, convulsions with loss of consciousness and dilated
pupils; after which there was a thirty-six hour period of depression
with refusal of food. Thereafter this soldier had amnesia for both
the seizures and the subsequent depression. He was observed six weeks
longer in the Charité Clinic but had no more attacks, and indeed
nothing more of note either mentally or somatically.

The history showed that there had been convulsions in the third and
fourth years of the patient’s life. There had been, however, nothing
epileptoid in the later childhood or developmental years of the
patient. However, a sister of the patient had suffered since childhood
from convulsions. It remains a question whether this episode is to be
regarded as reactive epilepsy--reactive, namely, to experiences in the
war--or whether we are dealing with a true epilepsia tarda.

_Re_ this episode following bullet wound, the compiler has placed
it after Mairet and Piéron’s case of Brown-Séquard epilepsy, but
apparently Bonhoeffer regards his case as probably a reactive one.
Unlike the case of Mairet and Piéron, Bonhoeffer’s case had an
epileptic soil (convulsions in childhood and epileptic sister). _Re_
the so-called reactive epilepsies, see remarks by Bonhoeffer under Case
57.


Epilepsia tarda in a lance-corporal without hereditary taint or
previous history save dizzy spells and excitability.

=Case 71.= (BONHOEFFER, July, 1915.)

A reserve lance-corporal, 24 years--a soldier from 1911 to 1913
without disciplinary record, and in his second year becoming
lance-corporal--was in the campaigns in Belgium, East Prussia, and
Poland, making long marches and going through several battles. In the
middle of October, 1914, he fell from a horse and suffered a contusion
of the thorax, after which blood appeared in the sputum. In November he
was brought to the reserve hospital in Berlin, and there had convulsive
seizures. Before transfer to the Charité Clinic, a seizure occurred,
and he was brought into the clinic in a characteristic dazed state.
Thereafter he was clear but often out of humor and irritated. Three
weeks later came a brief attack, probably epileptic in nature, with
restless half-delirious sleep following.

There was nothing in childhood or in the family history to indicate
epilepsy. However, the patient himself stated that from 1913 onward,
after his period of military service, he had from time to time felt
attacks of dizziness after exertion, and that he had become more easily
excitable than before.

The attacks in the lance-corporal are probably not to be attributed to
the thoracic contusion, according to Bonhoeffer, because of the long
period that elapsed after the thoracic injury, and their development
nocturnally without special occasion. According to Bonhoeffer, we are
probably here dealing with a late epilepsy.

_Re_ late epilepsy, see also under Case 57. Bonhoeffer makes a
considerable point of the lateness in attacks of epilepsy in some of
the military cases, pointing out their beginning at the ages of 22 to
27 in the period of peace practice undergone by soldiers. The theory
is that cases of severe and long-standing epilepsy are known to the
authorities, so that they would not ordinarily be in military service
except under conditions of concealment or in case of error. The present
case (71) appears to be the nearest that Bonhoeffer has found to a case
of epilepsy without heredity and without acquired soil. All that can be
regarded as evidence of soil is the dizzy spells and excitability.

_Re_ thoracic contusion, compare remarks of Lépine under Case 69, on
Brown-Séquard epilepsy following thoracic wound.


Convulsions by autosuggestion.

=Case 72.= (HURST, November, 1916.)

A private, 27, is described as a typical martial misfit--in private
life a music hall falsetto singer, and afterward a valet. He joined
the army in 1915 and proceeded to France, and worked in a canteen.
A week later, men broke in and threw a mallet at him, whereupon he
immediately had a fit, and was dazed, dumb, and unable to walk for two
days. Thereafter occasional further fits occurred, with nervousness
and insomnia. He was sent home in September, 1916. Discharged to duty,
he again in December returned to France, had six fits in the first
week--three in hospital, two on the boat, and between two and four for
four days after admission. The diagnosis of genuine epilepsy was made
in France by a medical officer who had seen one of the convulsions.
However, he had never passed urine or bitten his tongue, had no family
history, and had never had fits before going to France.

He was hypnotized and given the suggestion that he would have a fit.
In the convulsion which followed the plantar reflexes remained flexor,
but otherwise the convulsion was quite like the genuine epilepsy. He
was told that he would not have any more convulsions, nor did he have
any more except on Feb. 16, 1917, when some talk was made to him about
returning to duty. Bromides used in France did not help the epilepsy
at all. This patient developed a gait and speech defect copied from
two patients in the wards. These symptoms, due to autosuggestion,
disappeared on persuasion.

_Re_ autosuggestion, Bernheim has returned to the fray (1917) in a
book on automatism and suggestion, dealing only in small part with war
problems. The most general formula for suggestion appears to be that
it is an _idea accepted_. A suggestion offered but not accepted is
in effect not a suggestion at all. Any accepted idea, says Bernheim,
is from the psychological point of view as well as from the medical
point of view, a suggestion. A suggestion may be direct or indirect,
reasonable or unreasonable, brought about by

(_a_) mere verbal assertion,

(_b_) hypnotic state,

(_c_) persuasive explanation, rational or emotional,

(_d_) emotion (that is, emotion not the effect of any form of
suggestion offered by the physician, but emotion brought about by some
event affecting the sentiments of the subject).


Epilepsy of emotional origin.

=Case 73.= (WESTPHAL and HÜBNER, April, 1915.)

A lieutenant without neuropathic tendencies (except that his mother
was in a hospital for the insane) was under shell fire for some time.
Finally, a shell burst near him, whereupon headaches and transient
spells of confusion followed. Shortly upon the news of the death of
his Major, he had a spell of violent excitement and confusion, dancing
about on the ground and breaking things up. He passed into a stuporous
condition with a suggestion of catatonia. There were a few isolated
delusions to the effect that he was poisoned. After sleeping a long
time, he suddenly cleared up. There was an extensive amnesia covering
a period of weeks. He had forgotten the Major’s death and everything
thereafter. He complained of headache, difficulty of thinking, and
forgetfulness. An agoraphobia developed, as well as great sensitivity
to sounds, and a feeling as if the bed and surrounding barracks were
moving. There were a few illusions of a visual nature. He had complete
insight into his condition. Conduct was normal. There was general
hyperesthesia and ageusia.

According to Westphal, this case of deep disorder of consciousness of
some duration in a healthy person is probably one of a dazed state
following the so-called “affect epilepsy.”

Is Case 73 Shell-shock? Note that, in Case 73, the shell explosion
at first occasioned mere headaches and confusional spells. The true
occasion of the convulsions appears to have been the news of the death
of a superior officer. It is, of course, possible that the transient
spells of confusion were actually epileptic equivalents. Lépine
remarks that Pierret and others, observing such spells of confusion
often accompanied by agitation, have inquired whether manic depressive
psychosis is not a kind of epilepsy. This question remains unresolved.
These phenomena of epilepsia larvata (see also Case 81 of Juquelier and
Quellien) are to be sharply distinguished from attacks of confusion
occurring in pronounced epileptics. These latter attacks often follow a
crisis and suggest exhaustion; sometimes they last several days.


Fatigue; fear; hysterical convulsions. Visual aura (approaching fire
wheel) built up after the third crisis (scotoma after look at sun).

=Case 74.= (LAIGNEL-LAVASTINE and FAY, July, 1917.)

A sapper, 23, with his company under heavy bombardment, October, 1916,
was overcome by weariness and fear (he had always been of a timorous
disposition). The order for the rear came, but the convoy was hardly en
route when the sapper felt a griping in the pit of the stomach and the
blood going to his head; whereupon he lost consciousness and went into
convulsions.

This incident seems to have made a powerful impression upon the
sapper. A fortnight later, while working in the trenches, he had more
epigastric sensations with vague discomfort. He thought about the
earlier crisis and about his wounded comrades, and again fell down
and had more convulsions lasting a quarter of an hour. The tongue may
have been slightly bitten in this seizure. In the genesis of this
second seizure we may consider that the feeling of discomfort and the
epigastric sensations served to recall the first seizure, so that
the second one may be regarded as due to autosuggestion--that is, as
hysterical.

A little later, on a hot day in the trench, while working, the sapper
turned to a comrade and saw a great black spot on his face. He turned
toward another and saw another great black spot on this face also.
He was frightened, felt strange sensations, fell, and had a third
convulsive crisis. The black spots that he saw were due to a scotoma,
the result of a transient glance at the sun.

After this scotomatous episode, his crises always had a visual aura.
He would feel rather uncomfortable, leave the supper table, feel a
gastric sensation, warmth in the face, and oppression. He would go out
in the cold for the air, look about for something, appear frightened,
fix his gaze upon a certain point, and cease to reply to questions. His
head would jerk back suddenly, and he would utter strangled cries of
fear. He was now evidently prey to a terrifying hallucination. In ten
minutes, everything had gone again, leaving him trembling with emotion.
He would then relate how, after the epigastric sensation had begun,
he tried to see if he could make out something abnormal; whereupon a
little fiery wheel would appear and roll up nearer and nearer, so as to
almost touch his eyelids. He could see his comrades to the right and to
the left of the wheel; he could hear questions but could not answer.
Just as the fire wheel was about to blast him, consciousness was lost
and the fits came on.


War strain; anxiety; confusion; fugue. Demotion and detail to the
interior.

=Case 75.= (BARAT, November, 1914.)

A lieutenant, 25, an officer in a regiment on active duty near the
front, was called before a special board charged with desertion in
the face of the enemy. He had been assigned to a certain position but
not only had not complied with the order, but had wandered off to the
British sector and been arrested there as a spy.

The prisoner was well developed, without stigmata; heredity, negative.
His career in the army had been courageous and he had been advanced
several ranks and was about to be given a medal for bravery. He said
that he had been under a severe strain for several days.

One evening he had been given the order to attack. The artillery opened
fire. He found that the Germans had erected barbed wire defences. The
loss of men was terrific. His order was to shoot all who held back. A
poor territorial crouched down and would not go forward--supplicating
the prisoner not to shoot him. The prisoner spared him.

The next night the order to attack the German trenches was again given.
This time he was overcome with anxiety and discouragement. The last
he remembers was the order to attack. Next day he felt sick and his
mind was foggy. He remembered leaving his regiment and wandering round
for several days until he fell into the hands of the British and was
arrested. Then he understood what he had done.

The prisoner asked to be allowed to return to the front. The testimony
of one of the lieutenant’s men verified his statements. On the day
before he left the front he had been anxious, had cried often, and
would speak to no one. On the day he left the trenches without
permission, he was nervous and disoriented.

There was no doubt that simulation could be ruled out; the differential
diagnosis lay between a “confused state of emotional origin” and an
“epileptic dazed state.”

For epilepsy there was a history of attacks with falling to the ground
and loss of consciousness, without involuntary micturition or biting of
tongue, during the time when he was a sergeant. Moreover, irritability
and unwarranted suspiciousness had been present at these periods.
However, there were no other epileptic symptoms; these two attacks were
isolated and of quite long duration, leaving no headache or malaise
after them. Also there was no basis for the diagnosis “epileptic
dazed state,” since there was no abrupt commencement; the loss of
consciousness was never complete (the subject was able to converse with
persons while the attacks were on); and some remembrance was present of
incidents during the attacks.

For Barat, the important points are that the attacks were preceded by
long periods of anxiety and the disturbances resulted more from moral
than physiological causes.

The importance of the psychological factors lead the author and his
colleagues to the diagnosis “Mental confusion of emotional origin.”

The board decided to return him to the interior and give him a barracks
position at the reduced rank of drill sergeant.


A solitary epileptic episode in an artillery officer (slight concussion
of the brain two years before) following extraordinary campaign stress
(38 artillery battles in two months).

=Case 76.= (BONHOEFFER, July, 1915.)

A first lieutenant of artillery, 35, was able to count 38 artillery
clashes in which he had taken part in two months of very strenuous,
almost daily fighting. Then appeared headaches, anxiety, dizzy
feelings, insomnia. Finally one day suddenly, after eating, the
lieutenant sustained a loss of consciousness with convulsions, which
sent him to his home reserve hospital. The officer had felt nothing
before his convulsions came on. The medical report, however, yields no
doubt of the epileptic character of the attack.

When he was examined, there was a slight psychopathic depression
with a feeling of insufficiency, anxiety, insomnia, restless dreams,
over-sensitiveness, and a pessimistic outlook on the future. There were
no epileptic traits whatever. There was nothing alcoholic, luetic, or
arteriosclerotic about the officer. There was nothing in the childhood
or youth of the patient, though there had been a fall two years before,
with phenomena of concussion without sequelae. In fact, this fall with
concussion had led to no medical examination.

As to the relation of the concussion two years before to the epileptic
attack, Bonhoeffer is inclined to interpret the case as one of genuine
“reactive” epilepsy on the basis of continuous overstrenuous work for
a period of weeks. He regards the previous concussion as soil for this
epilepsy.

_Re_ amount of stress occasionally required to bring out epilepsy,
compare Hurst’s Cases 64 and 80. It may be recalled that Bonhoeffer
is decidedly of the belief that exhaustion has not brought about
any actual psychoses, calling attention to the remarkable absence
of psychoses among the Serbians after their exhausting campaigns. A
general review of war experience indicates, according to Bonhoeffer,
the marked power of resistance of the healthy brain.


Nocturnal narcoleptic seizures accompanied by spells of somnolence in
the day, both to be regarded as due to the “brain fag” of trench life.

=Case 77.= (FRIEDMANN, July, 1915.)

A tradesman, 23, had been in the German infantry since the beginning
of the war. Never sick, he had been, in a general way, nervous; and
a brother had had, at the age of 30 years, some sort of severe brain
disease, in which he became blind, dying a year later.

The man was for a long time in the trenches and proved himself a
courageous and stalwart soldier. He went to hospital after a slight
bullet wound of the leg, with a benign paralysis of the peroneus.

In the hospital he began to show a somewhat pronounced emotional
depression, with a nervous tachycardia.

Friedmann reports the case on account of certain peculiar seizures
which, upon the man’s own story, had begun five weeks before, in
the field, although he had told no one about them. He had never
felt anything like them before. At first, they came three to five
times almost every night. He would suddenly wake and find himself
unable to move, to speak, or even to think. These seizures, however,
were not accompanied by any feeling of anxiety or any respiratory
distress. Consciousness remained clear, and after 10 or 15 seconds,
he could begin to think normally again. It was clearly a question of
psychopathic absences of a mild narcoleptic type, occurring, however,
only at night.

Daytimes, also, throughout the whole period in which the nocturnal
absences occurred, there were seizures of another description. During
the many hours in which he had to sit in the trench, about twice a
day for half an hour long, he would plunge suddenly into a sort of
irresistible lethargy. Without any external occasion whatever, there
would be a feeling of great fatigue. In the spell he could not move or
think, would lean his head upon his hand. He was unable to overcome the
feeling of weariness and became convinced that he was ill, and that
the fatigue could not be natural. However, he did his work like the
rest. Friedmann interprets these spells as a kind of imperfect sleep.

The patient was physically healthy and stalwart, mentally not
excitable, and tolerably tranquil in the midst of shell fire. He would
never have been reported sick had it not been for his wound. Aside
from the tachycardia, of which he himself complained little, nothing
wrong was found in the hospital. There was, to be sure, a feeling of
discomfort without any hysterical tinge, and sleep was restless. Aside
from the peroneus palsy, the injury made a good recovery. The nocturnal
attacks persisted; bromides and even luminal failed of effect. There
was, however, no longer any somnolence by day. In fact, for the five
weeks of observation, there was no change in his condition.

Friedmann states that mild emotional alterations are not infrequent in
the trenches with minds disposed thereto, although emotional shock,
especially in shell fire, is the most frequent cause. However, these
particular seizures are quite unusual. The stresses of field service
lead to a sometimes complete paralysis of mental power, interfering
transiently with service. There is no evidence of sudden circulatory
disturbances such as would bring about dizziness, pallor, nausea,
or fainting spells. According to Friedmann, the regulative brain
functions, especially those that maintain consciousness, become weak
on account of a condition which he terms _Gehirnmüdigkeit_, or, as we
should say in English, brain fag. The situation forbids due completion
of sleep. Thus, the explanation of the daytime attacks follows rather
obvious lines of brain fag. The accidental awakening it is, which at
night produces the absences; the wakenings are due to the general
restlessness of the patient. The general weakening of cerebral function
produces the disorder at the moment of wakening, since the regulative
factors of consciousness are already out of order. The condition in
the absence rather closely resembles the state of consciousness just
before going to sleep, and also perhaps the state of consciousness
during the process of awakening. It is as if the process of waking were
somehow delayed a few moments. Friedmann is interested to show the
relation of such absences to the so-called _gehäuften kleinen Anfälle_,
originally described by him in 1906 as occurring in children, and
distinguished from epileptic attacks. These attacks, after lasting for
years, finally disappeared completely. The same sort of thing in adults
was symptomatic of some other disease, such as neurasthenia, and was
not a true entity. In children these attacks failed to be attended with
any mental injury, nor were there any pronounced epileptic phenomena.
Bromides had no effect upon them, and they already showed a somewhat
striking and peculiar appearance, involving interruptions ten seconds
long of capacity to think, speak, or move, without disturbance of
consciousness or automatic movements. Sometimes the attacks occurred
from six to 100 times in the day, without in any respect interfering
with the general condition of the child. The occurrence of such series
of mild seizures is nothing but a syndrome. To be sure, some cases
turn out to be cases of genuine epilepsy with an eventual degenerative
process. Some forms belong in the spasmophilia group, and some among
the hysterias. However, according to Friedmann, there is a narcoleptic
_petit mal_ that is an entity by itself, proceeding after a period
of years to complete recovery without complications. It is this form
which may be regarded as a peculiar kind of brain fag. The case of the
soldier may be supposed to be one which will prove to have this benign
outcome.


Sham fits.

=Case 78.= (HURST, March, 1917.)

An unwilling conscript developed numerous fits on board ship coming
from Jersey, three days after enlisting. _Fifty_ more developed during
two days in hospital. He was sent to Netley.

On the hypothesis of hysteria or malingering, he was hypnotized. A fit
was suggested to him, but did not come off. The Sister was informed
in the patient’s hearing that the man was clearly shamming, as in all
genuine cases a fit would occur after this treatment. A fit with marked
opisthotonos immediately occurred. This fit immediately stopped when he
was ordered to stop it and to wake up.

The man after waking promised to have no more fits.


Epileptoid attacks, controllable by will.

=Case 79.= (RUSSEL, August, 1917.)

A man was received in No. 3, General Hospital: Diagnosis, epilepsy. He
was shortly sent to the convalescent camp and then returned, having had
two attacks. Russel watched for another attack, felt it was not genuine
and “put the situation up to” the soldier whose story was as follows:
He had been at the front without leave for twelve months since the
German retreat. Leave was due him. A sister’s letter said his brother
was severely wounded and his mother was praying for his return. When he
thought these things over an attack came. He could, however, control
the attacks. Russel told him, if he would play the game, he would be
sent to the base with a recommendation for leave. In ten days the man
was remarkably changed and had no further attacks.


Hereditary epileptic taint brought out by two years service with
eventual shell-shock and burial thrice in one day.

=Case 80.= (HURST, March, 1917.)

A private, 24, in the army from 16, never epileptic (sisters
epileptic), was wounded four times in the war from September, 1914.
Shell fire did not worry the man, but he gradually became depressed
after his father and five brothers had died in active service. He
was blown up and buried three times in one day in July, 1916. He was
unconscious for two hours after the second blowing up, but carried on
for two hours more until blown up for the third time.

After this, he became nervous and shaky, and began to sleep badly, and
a month later had a typical attack of major epilepsy. Fits occurred
with increasing frequency. As many as 19 occurred in a single day. Rest
and bromides caused the fits to cease, and there had been none for six
weeks at the time of his discharge.

_Re_ the extraordinary delay in the bringing out of this epileptic’s
taint, refer back to Case 76 of Bonhoeffer, with its discussion, and to
another case of Hurst (64).

_Re_ Shell-shock and its relations to epilepsy, see below, discussion
under Cases 82-84 of Ballard, who has erected a theory of Shell-shock
as in some sense epileptic.


Shell-shock: Epilepsia larvata.

=Case 81.= (JUQUELIER and QUELLIEN, May, 1917.)

A soldier, 29 (father alcoholic, died in hospital for the insane),
a decorative painter without plumbic history, non-alcoholic,
non-syphilitic, was wounded once, September, 1914, but returned to the
front in 1915.

May, 1915, a shell burst near him. He lost consciousness, regained it a
few days later at Brest, and was so far recovered that he could go on
leave in seven days. While on leave, he had short attacks of delirium,
followed by a total amnesia; there was, however, no crisis, fall, or
convulsion. After the first attack, he had for 24 hours malaise and
headache, but got well and went back to his dépôt. Shortly afterward
more attacks of this sort recurred, and he went to hospital and thence
to the neurological centre at Tours. Whence, August 9, 1915, he got a
two-months’ leave for “mental disorder post-confusional, _second état_,
probably hysterical (_commotio cerebri_), and organic hemiparesis.”

November, 1915, after returning to the dépôt, there were more spells
and he went again to hospital. Invalided December, 1915, he passed a
year at home, but the spells continued. Although the epileptic nature
of these attacks was maintained by Francais at Évreux, he was placed in
the auxiliaries, December, 1916, but had to go to hospital almost at
once, and, February 28, 1917, entered the neurological centre of the
9th Region for the second time. Here, when called to be examined two
days after admission, he was observed in an attack. He suddenly rose
from the bench, made a few steps, seemed to be listening and anxious,
as if he ought to be on guard. He looked up, seemed to be looking for
something whose noise was approaching, lowered his head, made a slight
jerking movement, and said, “Poum!” as if to express the noise of an
explosion. He took a few more steps, the same movements were repeated,
and the same “Poum!” was uttered. This lasted for about a quarter of
an hour, during which the patient was unaware of his surroundings. He
could be guided all about the hall without resistance, but did not
respond to orders, commands, noises, or contact. In short, the patient
was in the midst of a hallucinatory dream at his post in the trenches,
undergoing a bombardment. He was placed in a chair; remained motionless
for a few seconds, woke up, and answered questions. “Where am I? Oh,
yes; I must have been sick because my head feels bad.” In answer to
the question. “What did you see; what was there?”, he said, “I don’t
remember anything. I never remember. I don’t know.” The patient was
dull and weak after the spell.

These spells varied in number but occurred once a week. The patient was
able to tell of certain attacks that had occurred while he was out of
doors at home.

Now and then, there was another theme in the hallucinatory delirium,
namely, a pencil drawing of a woman’s picture, of no great artistic
worth but carefully done, at which the patient was much astonished on
awaking.

It seems as if auto- and hetero-suggestion can be eliminated from the
genesis of these attacks. Neither hysterical nor epileptic crises have
preceded or ever alternated with these seizures. Nevertheless, on the
organic side, the patient had a general increase of tendon reflexes on
the left side, most marked in the knee-jerk, and fell to the left in
voltaic vertigo. There was a left hemiparesis, apparently of organic
origin, which had been determined as far back as July, 1915.

There was no true dementia. Past memories were but slowly recalled,
and inattention interfered with the fixation of recent memory. He
complained of troubles in his sleep and dreamed of war experiences
somewhat analogous to those in his attack of amnestic delirium. After
the seizure, there was a marked hebetude and mental inactivity, torpor,
and a severe headache. The case was presented to a special commission
as one of epilepsia larvata in a person hereditarily predisposed who
had never before presented epileptic signs, suffering from a disease
characterized by frequent short attacks of hallucinatory and delirious
automatism, following shell explosion which had at the same time
produced a slight left-sided hemiparesis and mental inhibition.

To illustrate an epileptic theory of Shell-shock; three cases:

    1. Fugue; minor symptoms: later, epilepsy.

    2. Epileptic confusion eight months after explosion.

    3. Mine explosion: stammering replaced by mutism; mutism
    replaced by epilepsy.


=Case 82.= (BALLARD, 1917.)

Atmospheric concussion from shell explosion, October, 1915, was
followed by unconsciousness in a soldier described by Ballard.

Blindness for a month followed recovery of consciousness.
“Neurasthenia” (anxiety neurosis) after return of sight. Apparently
nearly complete recovery after latent period of a few weeks. Return of
blindness in one eye in December. Five days automatic wandering (the
man was found in a west country town five days after leaving home to
rejoin his dépôt and seen by a medical officer who reported that he
was dazed and amnestic for that period); admission to second Eastern
General Hospital, December 15.

On admission he proved to be suffering from minor hysterical symptoms
such as an inability to open his eyes and to see clearly when the
lids were raised. The symptoms rapidly cleared up under suggestive
conversation and did not return except for amnesia and slight emotional
depression. He remained well until December 25. On that day he began
for the first time to have definite epileptic fits and nocturnal
epileptic delirium. In January he was discharged as an epileptic. There
was no epileptic temperament or feeblemindedness. Finally, there had
never been any personal or family neuropathic or psychopathic history.


=Case 83.= (BALLARD, 1917.)

A soldier was blown up, April, 1915, and had a spell of
unconsciousness. Later, pains in the head, slight amnesia and a
condition of asthenia developed.

He was eventually admitted to the second Eastern General Hospital at
Brighton, January, 1916. At the time of admission he was semiconscious,
stuporous, confused, disoriented, anxious in a dull sort of way,
talking about his expectation of “a sailor with a card.” Speech was
intelligible, though fragmentary and infrequent. The man obeyed
commands but gave no replies to questions. The mental processes were
slow and impaired.

According to Ballard, we have here a case of epileptic confusion, eight
months after the initial concussion. This particular attack ceased
three days later, leaving amnesia for the attack and a certain amount
of mental retardation. The man was not epileptic in temperament and his
personal and family history proved negative.


=Case 84.= (BALLARD, 1917.)

A soldier was buried in a mine explosion, October, 1915, and for
several days thereafter was unconscious or semi-conscious. He emerged
deaf and subject to stammering and a condition termed “neurasthenic.”
The stammering was soon replaced by mutism, which lasted several weeks.
The mutism was then supplanted by epileptic fits.

He was observed by Ballard in a dreamlike, disoriented and inaccessible
state, in which he was anesthetic to pin pricks, lay awestruck, dumbly
following with his finger hallucinatory airplanes. Flexibilitas cerea
was also shown at this time.

Next day he emerged from the dreamlike state with mental processes
somewhat slowed, disorientation for time, amnesia for the attack,
memory disturbance and a return of the stammer. On the next day
following, all these symptoms had disappeared except amnesia for the
attack. Another spell of epileptic fits occurred later. It seems that
the man had had a convulsion thirteen years before and occasional
convulsions since. In fact, he, seven years before, had had what
was called “a stroke” and residuals of a slight hemiplegia were
still present. (There is no statement in the case report relative to
syphilis.)


Emotion; shell fire: Epileptic equivalents.

=Case 85.= (MOTT, January, 1916.)

A man, 19, suffered from shock due to emotional stress and shell fire.
He had terrifying dreams. After a short time, he developed paroxysmal
attacks of maniacal excitement. Just before the first attack he had
been helping in the kitchen, lay down on his bed, went to sleep, woke,
startled, flushed, and sweating, and made for the door as if terrified.
He remained in this state as if suffering from hallucinations of sight
and hearing, and without ability to recognize his wife, the doctors, or
the Sisters. When two strangers in uniform came in to observe him, the
adjutant became violent, as if the uniforms had started terror anew.
The attacks lasted from a few hours to a few days, coming on suddenly,
without apparent cause. One day he tried to get over the wall of the
playground. He came back and buried his head in his hands. Major Mott
spoke to him, whereupon he got up, looking terrified, made for the
door, and four orderlies were required for his restraint. At Napsbury
Hospital, to which he was sent, he made a complete recovery.

Mott suggests that we are dealing with a psychic equivalent of epilepsy.

_Re_ epileptic equivalents, compare notes from Lépine under 58 and 59.



IV. PHARMACOPSYCHOSES

(THE ALCOHOL, DRUG, AND POISON GROUP)


Pathological intoxication.

=Case 86.= (BOUCHEROT, 1915-6.)

A Territorial infantryman, aged 37, was in the habit of drinking a good
deal without getting drunk, and at the front drank a good deal of bad
brandy. He had just taken a considerable quantity when his regiment got
the order to charge. The charge was hardly over when the man became
greatly excited and hallucinated. He thought he was surrounded by
Germans and tried to transfix his comrades with the bayonet. Howling
and struggling he was carried to the rear.

He was soon brought to the asylum at Fleury after howling all night
and seeing the Boches and animals fighting among themselves. His hands
and tongue were tremulous and there were cramps in the calves of his
legs. On the 6th he expressed astonishment to find himself in hospital
and was found to have but slight memory of what had happened. He
remembered, however, that he had tried to kill his comrades. With the
deprivation of alcohol he became rapidly normal and was sent back to
the dépôt in a few days.

_Re_ alcoholism under army conditions, Lépine remarks that alcohol
has played in this war a rôle analogous to that of malaria in the
epidemiology of some countries. Many of the victims are, to start with,
unbalanced subjects and _détraqués_ who are hereditary alcoholics.
Alcoholism, according to Lépine, dominates the pathology of the
interior and has a marked bearing upon conditions at the front. In
fact, alcoholism would have been disastrous in France had not measures
been taken against it; measures still insufficient (1917). More than
one-third of 6000 cases studied by Lépine during three years have
shown alcohol as a sole or, at all events, principal cause of the
difficulty. It would be within reason to state, according to Lépine,
that if we throw in cases in which alcoholism was a partial factor,
more than half, or even more than two-thirds, of the mental cases
had been strongly influenced by alcohol. Lépine thinks there may be
effects like those of anaphylaxis. Certainly, the startling and sudden
effects in so-called pathological intoxication, as in Case 86, suggest
the critical and vehement effects seen in the sensitized anaphylactic
subject.

                                CHART 4

                  PHASES OF WAR PSYCHIATRY IN FRANCE

      I. Antebellum phase of PSYCHIATRIC NEGLECT: Groundless fear
         that recruiting would be disorganized by psychiatric
         sifting processes.

     II. Phase of ALCOHOLISM OF MOBILIZATION: Hospitals unprepared.

    III. Phase of the MARNE: Alcoholism restrained by law;
         psychoses few; psychiatrists optimistic.

     IV. Phase of TRENCH WARFARE: Overemotionality; and of HIGH
         EXPLOSIVES (January, 1915); now psychiatric services were
         systematically established along evacuation lines.

      V. Phase of SYSTEMATIC WAR PSYCHIATRY: Filterwise system of
         management (_a_) near trenches, (_b_) in main body of
         army, (_c_) on evacuation lines, (_d_) special hospitals.

                              Chiefly from data of Chavigny, 1915.


Pathological intoxication: criminal prosecution stopped.

=Case 87.= (LOEWY, 1915.)

An orderly, in private life a teacher, one day about _noon-time_, when
going on duty, called the commanding officer to account because he (the
orderly) had had to wait. He said he had been ordered to come at _two_
o’clock and it was already long thereafter! He was severely reprimanded
but addressed a number of the officers present with questions having
no relation to military service. In fact, he seemed to have forgotten
entirely that he was on military service.

This was the more remarkable as the teacher-orderly had many times
distinguished himself upon dangerous patrol expeditions and in critical
situations, winning the confidence of his superiors and the likelihood
of promotion to corporal. He had been a discreet, earnest, and clever
soldier.

Loewy observed him during this affair and noticed that he did not
by language or movement suggest intoxication or hilarity but merely
a certain excitement. He was entirely oriented for time, place and
person, and his outward behavior was correct enough except for his
military rank.

Sent to his quarters near by, he gave the impression to his immediate
superior officer of deep drunkenness. He murmured something and soon
fell into a deep sleep. After waking, he had an almost complete
amnesia, knowing only that something disagreeable had transpired. He
remembered that he had been offered several little glasses of cognac
brandy by a comrade, and that he had drained them off quickly before
going on duty. He said that he had never drunk cognac before, and in
fact had drunk nothing for a long time.

The diagnosis of pathological intoxication was made, and the soldier
was thereby cleared of his dangerous situation; a criminal prosecution
was not instituted. He thereafter behaved with entire sobriety and
modesty, and he achieved his corporalcy and later became file leader.


Desertion in alcoholism may deserve the term “pathological.” Case of
fugue.

=Case 88.= (LOGRE, July, 1916.)

A “deserter” said: “I went because I drank a glass. I just went,
_comme ça_, without any motive.” He was somewhat feebleminded and,
in explaining the impulsivity of his act, he added: “I went like a
broken-down beast. I walked straight ahead, without knowing where I was
going and if I had been going to be killed, it would have been all the
same to me.” He could not that afternoon remember very well; but next
morning, after having slept, he regained full consciousness. He said
that he then found himself in a field near a cemetery. He had carried
his gun and equipment with him, but had lost them somewhere, and from
a military point of view, his desertion was complicated by loss of
effects. On coming to, he said to himself, “Where am I? How foolish
after fifteen months in the line! Probably I have deserted again.”
In fact, he had a month before left his post under exactly the same
conditions in the midst of a period of alcoholic excitement.

This alcoholic fugue is typical: drunkenness, impulsive and
subconscious ambulatory automatism, with partial amnesia,
disorientation, with mislaying of objects, followed by sleep and
immediate return to normality.

_Re_ fugue, see discussion under Cases 58 and 59. The French military
code cannot excuse victims of fugue even though executed in a quite
unconscious state, if the fugue is due to alcohol. There was a certain
procursive suggestion in the fugue of Case 88, who went “like a
broken-down beast,” straight ahead, without knowing where he was going.


Alcoholism: Amnesia experimentally reproduced.

=Case 89.= (KASTAN, January, 1916.)

February 15, 1915, a German soldier drank beer in the canteen and at
roll-call appeared tipsy. He then went to bed, but rose an hour later
to go to town. A quarter of an hour later, he went to a clerk’s house
and asked for paper, on the ground that the next day he was going to
march to Warsaw. The clerk gave him no paper, which he then tried to
get by force. A policeman arrested him and he said, “You just wait,
lame dog!” Upon examination he denied that he had ever been guilty
of any crime but had been in institutions on account of delirium. In
point of fact, this man had grown up in very bad surroundings, amongst
quarrels and disputes of his parents, who kept a disorderly house. At
19 he had been convicted of incest. He finally admitted having been
convicted for rape. It was found that he had once run out into the
front trenches; had been removed by an advance guard to a stable,
and then wondered why he was not in school. He described a number of
attacks of delirium although he had not drunk more than moderately.

He was given an experimental dose of 50 c.c. of alcohol, and in ten
minutes became excited, tried to get out of bed, attacked other
patients without reason, and was able to speak neither spontaneously
nor in response to questions. In a period of two hours he became clear
and asked what the trouble was. He knew only that he had taken alcohol.

_Re_ the experimental excitement produced in Kastan’s case by the
exhibition of alcohol, it is of note that Bérard has been much
impressed by the agitation that surgical cases of alcoholism undergo
when anesthetized. It may be that the anesthetics act similarly to the
experimental alcoholism of Kastan’s case. According to Bérard, these
phenomena of the anesthetized wounded (who are men recently evacuated
from the front and other hospital cases) are of larval alcoholism
brought out by the anesthesia. Bérard wonders whether rum issues at the
front are at all responsible therefor.


Desertion, drunk. Contributory factors.

=Case 90.= (KASTAN, January, 1916.)

Gottlieb S. left the barracks, January 25, 1915, met friends and drank
with them, remaining all night in the railway restaurant and waiting
room. He was promptly arrested.

According to the patient, he had always drunk a good deal and had once
fallen from his horse in the campaign, and become unconscious. After
this fall, he said he had been able to stand less alcohol than before.

There is doubt as to the syphilis of Gottlieb. He said he had been
infected once, but his further statement that he had six relapses is,
of course, questionable. As to the hypothesis of feeblemindedness,
it appears that in childhood he had learned badly and had been a
stammerer. He had been a herdsman, and after that a laborer. He finally
became a travelling man for a specialty photographer.

He had previously been convicted of an embezzlement, brawling, and
breach of the peace.

As to his military crime, he said he had been celebrating the emperor’s
birthday the last three days, being urged on by acquaintances and
drinking whiskey. He was, in fact, on a spree and did not eat properly.
He had met a student in the railway station and had forgotten all about
his military service. He remembered having spoken with the waiter,
remembered telling the student that he was going to commit suicide, and
the student had drunk seltzer with him. January 29, he for some reason
drank no more, and then it occurred to him that he ought to go back to
duty. He remembered that he was easily led astray. He had once thought
of becoming a tanner but had been dissuaded from the trade because of
its bad smell.

    The analysis of this case must consider, first, syphilis.
    Supposing, however, that this hypothesis is not substantiated
    by laboratory findings, the hypothesis of feeblemindedness
    might well be raised. It seems possible, if not probable,
    that this patient was in the subnormal group, lying between
    normality and feeble-mindedness proper. The value of mental
    tests would here be extreme. There seems to be no evident
    epilepsy, and the majority of the phenomena can perhaps best be
    explained by alcoholism. Possibly the case is one of so-called
    pathological intoxication. The patient’s own story that,
    although he had been always subject to drink, he had been less
    tolerant of alcohol since a fall from his horse, seems to be
    entirely consistent with the post-traumatic history of numerous
    cases, so that it would hardly be wise to consider that alcohol
    accounts for the whole story. We must raise then in succession
    the hypothesis of syphilis, feeblemindedness, alcoholism, and
    coarse brain disease, bearing in mind also early stammering.
    As to the utilization of such a man, it would appear that a
    supervision of him with absolute countermanding of alcohol in
    view of the decrease in tolerance of alcohol since the fall
    from his horse might perhaps preserve this man for some form of
    military service.

_Re_ German and French war alcoholism, Soukhanoff remarks that the
conditions in these countries were in strong contrast to those in
Russia. In Russia there was a great decrease in the number of cases of
acute alcoholic psychosis; particularly at the time of mobilization,
there were few cases of alcoholic psychosis. He says that during the
Russo-Japanese war, alcoholic psychoses constituted a third of all the
mental cases observed. This figure corresponds with that quoted above
from Lépine (see under Case 86). Soukhanoff, writing in 1915, had not
observed personally a single case of alcoholic psychosis. Incidentally,
the number of cases of psychosis in the Russian army had remained in
general small.


Desertion by mild alcoholic dement.

=Case 91.= (KASTAN, January, 1916.)

Emil S. made a number of statements when he came for examination.
He had once had a treatment by injections. Both his mother and his
grandmother had been insane. He said that his brother was an officer in
the navy, but this statement was found to be false.

According to his story, he had lost touch with his troop at the end
of September, 1914, and had lived in several lodgings in T---- up to
October 19, when he was arrested. He said that he did not know that a
man who had lost touch with his troop had to report.

A week after his arrest, S. entered a shop and asked for coffee, saying
that he had a furlough of 24 hours and wanted cake for his comrades.
He said he was the owner of an estate and would send a roebuck for the
cakes. The shop-man gave him cakes to the value of one mark. Bystanders
said that he had been lodging in T---- for about two weeks. It seems
that he had told his landlady that a city official had quartered him
upon her and that he was on furlough. He went away in the morning and
came back in the evening. He had written to a bank of which he had
once been a representative, asking for money. One night he had lodged
with another landlady, being given a meal, and he had there stated
that he was in the City of T---- on duty and that his horse was in the
barracks. He offered a thousand marks for his board and lodging.

At another lodging he had given himself out as a courier. In fact,
the letter to the above-mentioned bank had been signed “Otto S.,
Land-owner, at present, courier.”

    “If I do not revoke this in person or by writing on January
    1, 1915, I beg you to pay to Mr. and Mrs. M. of T----, one
    thousand marks and deduct it from my balance.

    “This is to be considered as my last will. As witness: present:
    Joseph B.”

The letter was addressed “To the direction of Commercial-Counsellor
P----.” There was no stamp on the letter.

A second letter reads:

    “Honored Sir, Commercial Counsellor:

    I beg you to send by return mail to the address given below
    1000 marks, and deduct this amount from my account. I have been
    in Russia. Well, things are moving now. Thank God, we have
    reached the point we have. Write me please more in detail about
    my property and estate and give me your very valuable advice.

    With best regards to your esteemed wife, I remain

           Sincerely and respectfully yours,

                   Otto S., at present courier,
                          otherwise, land-owner.”

As for this Commercial-Counsellor P., P.’s son stated that his father
had been dead for three years and a half.

S. gave himself out in T---- as a land-owner, falsifying his name,
asking for beer to the amount of a mark a day, borrowing from his
landlady ten marks, paying nothing, but remaining on friendly terms
with the landlady and her women lodgers, making a contract with a
superintendent ostensibly for his estate, and borrowing money from him.

Observed in the clinic, he said he was a bank representative and had
been very nervous since being divorced in 1911. The divorce was due to
his wife’s adultery. Sometimes he would not know really what he was
doing, once even tried to shoot himself, and again once threw a burning
lamp into his wife’s face without knowing it.

He had gone to the City of T---- without furlough in October because
others used to, too. Only five days later had he noticed that his troop
was no longer there; and upon inquiring about the troop he could find
nothing as to its whereabouts.

He had been a heavy drinker and was always somewhat intoxicated, which,
according to the patient, made him forget everything. He had drunk 20
glasses of beer and liquor daily. He wrote to P. because he knew his
father.

As for the frauds, he said he knew nothing about them. He did not know
even the baker from whom he had gotten the cakes. In fact, he had been
drunk the whole day long.

He said that he had learned badly in school and had not passed any
examinations. In active service he had already been convicted of
drunkenness once. Referring to his treatment by injections, he said
he would rather be dead. He had only sought diversion in looking
over estates. Both his ability to reckon and his memory had suffered
greatly. He and another patient eloped from the clinic one day but were
captured a few hours later.

    Remarks: Details are lacking as to the physical and laboratory
    side of this case. On the whole, there appeared to be no
    convincing features of paresis or cerebrospinal syphilis.
    The phenomena are very possibly in part alcoholic. There
    appeared to be no sensory disorders, and in particular no
    hallucinations. The intellectual disorder is chiefly amnestic.
    There is little or no evidence of emotional abnormality. The
    curious conduct seems hardly to indicate a primary disorder of
    will. The main feature psychologically appears to be amnesia
    coupled with an inability to reckon. To be sure, the letters
    are written externally in sufficiently good form; the amnesia
    does not appear to extend to details. It is a question of
    whether the disorientation which one suspects is not merely
    amnestic. On the whole, however, it would appear that there
    must have been at various times disorder of consciousness,
    as indeed is indicated by the patient’s own account of his
    ignorance of the cake-roebuck episode.

    Dismissing the hypothesis of a syphilitic dementia, we might
    cling to that of alcoholic dementia more or less punctuated
    by acute alcoholism. Yet it is also possible that the patient
    was actually somewhat feeble-minded; this would be consistent
    with his own statement. The question might arise whether
    this soldier could have been excluded by careful psychiatric
    examination before entering service. It would seem that a
    knowledge of the insanity of the mother and grandmother, and an
    inspection of school records, if available,--to say nothing of
    the episodes which may or may not have been accurately related,
    between himself and his afterwards divorced wife--would have
    sufficed to throw doubt upon the military effectiveness of
    this man. We know also that he had already been convicted of
    drunkenness on military service before the episodes mentioned.


Desertion by alcoholic. Contributory factors.

=Case 92.= (KASTAN, January, 1916.)

Carl B. was a soldier about whom the captain thought that his
intellectual power had been weakened by drink. An inquiry after
arrest showed that he had been odd also at home. He had once been
sued for perjury, but the suit had been stopped for lack of evidence.
He had been several times convicted of drunkenness. It appears that
on March 30, 1915, after mounting guard, he said nothing and went
home, remaining at home until the next day and then returned to
the guardhouse in the street-car. He declared, this time, that the
non-commissioned officer had given him permission to leave, although
this statement was not correct.

Again, on April 6, B. was about to leave the quarters, but the surgeon,
finding him drunk, kept him back. He did not go home that night, and
the next day when he was wanted at the hearing, he could be found only
in the afternoon. He replied confusedly and somewhat irrelevantly to
the questions asked. On arrival at the clinic he was in tears and much
depressed. Given 50 grams of alcohol, he became somewhat livelier.
Upon examination, his perceptions were found diminished; he felt, he
stated, a cracking and crackling in his neck. In his cell he had felt
as if sparrows were roosting in his face; he had heard voices and
seen pictures, and had not known what he was doing. He asserted his
innocence, blaming his imprisonment for all his troubles. He had been
in the habit of drinking three liqueurs and two glasses of beer a day.
He had been drawing a pension since a fall from a scaffold.

A sister had suffered from continual headaches. The patient himself had
three sickly children and ten of his children were dead; there were
also two premature births.

The analysis of this case would clearly show the benefit of
considering, first, the hypothesis of syphilis. Not only is the history
of his children suggestive, but the impairment of mind noted by the
captain as due to alcohol may very possibly be syphilitic in origin.
Examples in division he could not solve, and it is a question whether
his leaving guardmount is not in part related to disorientation for
time. There appears to be no evidence of feeblemindedness and none of
epilepsy (though a sister suffered from continual headaches). Alcohol
may account possibly for the entire picture and is particularly
consistent with the false voices and figures, the sparrows in the
face, and the sensations in neck and the tickling in the ears. It is
possible, also, that intolerance to alcohol had set in since the fall
from the scaffolding for which a pension was being received. It does
not appear necessary to consider any further of the groups of mental
disease. Syphilis, alcohol, and a post-traumatic brain condition, all
may play a part. Alcohol is able probably by itself to produce a number
of these symptoms, and these alcoholic symptoms would be probably the
more readily produced in virtue of the post-traumatic intolerance that
we may assume.


A disciplinary case: Alcoholism.

=Case 93.= (KASTAN, January, 1916.)

A German soldier, brought up for examination for disobedience and
insubordination with intoxication, was found already to have been
convicted 33 times of a variety of crimes. Once he had drunk a bottle
of shoemaker’s polish, evidently with suicidal intent.

In the canteen he had assaulted superior officers and tried to strike a
sergeant. He said he had been attacked by the sergeant and pushed into
a cell, whereupon he had lost his mind.

He came from a family of drunkards, and had been himself very alcoholic
formerly. On the day in question, however, he had drunk very little.
According to his account, he had fits of this sort if any one injured
him. He was amnestic and had forgotten his previous convictions.
Anything he might have done, he said, had happened a long time ago, in
his youth. For example, concerning a theft, he said that it was merely
that he had fallen into some Christmas trees and stuck fast there, and
no one wanted to be paid. Tremors of hands, feet, head. Analgesia of
thorax.

_Re_ alcoholism and disciplinary cases, we find alcoholism bulking
large in Lépine’s account of military delinquency. Fugue subjects are
not infrequently alcoholic. Minor disobedience is also often alcoholic.
Acts of violence are characteristically alcoholic, or executed by
subjects with hereditary alcoholic taint. (Such acts were in France
especially common before the anti-absinthe law in 1915.) Alcoholic
episodes and impulses often culminate in arson. No doubt, espionage
employs alcoholism for a portion of its technique, though delusional
mystics and subnormal hypersuggestibles are more often the purveyors
of information to the enemy. The theft list, also, shows its share of
alcoholics. Alcoholics are less common amongst those who, contrary
to rules, assume shoulder-straps or other decorations. Here the
sub-normals and victims of imbalance, as well as the drug cases, are
more likely to figure if the matter is psychiatric at all.


Remarks upon an atrocity.

=Case 94.= (KASTAN, January, 1916.)

April 15, 1915, a German soldier went with three comrades to a farm, to
select a sheep for slaughter; they were obliged to go to three farms.
The man carried a revolver and cartridges in his pocket. He threatened
the farmer that he met with this revolver, and desired to rape the
farmer’s daughter. He was very drunk, and said to the non-commissioned
officer who was called in at the time, “You have served only a year
longer than I have.” He staggered, struck violently with his hand at
the sergeant, and gave insolent replies.

He had already choked the peasant’s daughter, scratched her face, and
bitten her fingers, hand and arm. She could not run away as she was
lame. The soldier held the revolver to her face and shot it off several
times, offered sex assault, scratched her feet with his spurs, and
tried to twist her neck. The non-commissioned officer threatened to
shoot him, and he then became still. He said to the first-lieutenant
before whom he was taken, that he would do anything but allow himself
to be beaten, and at this moment moved his arms about in the air, and
bloody foam came from his mouth. The first-lieutenant previously had
always thought him to be normal except for a strange flicker and unrest
of the eyes. There was a history that he had already once attacked a
servant girl. The man had amnesia for the affair, only remembering how
the non-commissioned officer had come on a white horse. He remembered
nothing about the peasant and the girl. He said that he had been given
to earache on the right side in winter. There was a history of his
having fallen from a tree in childhood, becoming unconscious. He had
been a sufficiently good scholar up to the second class in school. He
had been an excellent soldier.


Alcoholism: Atrocity.

=Case 95.= (KASTAN, January, 1916.)

September 15, 1914, a German soldier was missed. He had said that
he wanted to get to the enemy quickly, and that he was going to
march alone against the Russians. A shot was fired that night by
this soldier, on the ground that he had been insulted by a civilian,
although no civilian was present.

September 21, a farmer in a wagon reached a farm, where he found the
soldier aiming at a woman. He fired, wounded the woman severely, and
jumped on the farmer’s wagon and rode off with him. It seems that
the soldier had come to the farm at noontime and accused the woman
of treachery, ordering her to come with her husband to a certain
farmhouse, where she should be placed against the wall and be shot. The
soldier had shot her and wounded her husband also. According to the
woman, the idea was to take revenge because she had denounced certain
persons as spies.

He was arrested during the night, and told how he had left his troop
because he could not get at the enemy. He had been informed that there
were spies who ought to be shot; there had been talk in a certain inn
about it. He did not know he had wounded the husband, and he only
wanted to give that dangerous woman a piece of his mind.

After wounding the woman, he had given himself no further thought about
her, but had gone to partake of the holy sacrament at the pastor’s. He
then had drunk another glass of beer and gone to bed. He was, in fact,
still drunk at the time of arrest. He had not been aware that he would
be punished for the crime of going alone against the Russians.

Some days later, he wrote that he did not intend to kill the woman,
that he had been drunk at the time and was always a bad man when drunk;
that he had other times when he absented himself from home for days
when drunk. He had had, he said, a number of attacks of delirium, in
which he had seen animals. At one time, he had fallen on his head.
On the day in question, he had drunk 1½ litres of liquor. He was
remorseful for his deed.


A disciplinary case: Alcoholism; amnesia.

=Case 96.= (KASTAN, January, 1916.)

A German soldier, New Year’s Eve, 1915, got away from his company,
drank whiskey, and came back drunk. He bothered his comrades so that
the non-commissioned officer had to call for help; whereupon the
soldier said, “A man who comes on late and hasn’t been in much, hasn’t
much to say. If it is a non-commissioned officer, I shall hit him
in the snout.” The officer kept talking to him kindly but he cried
“_Halt’s Maul_, you crooked …!” He staggered up to the lieutenant
without saluting, but at a slight push fell prone into the straw.

It transpired that the man had not been intoxicated enough to lose all
control of himself. He did not remember anything about what he had
done; he had drunk a half-bottle of rum during the evening. There was a
demonstrable lack of memory. He did not know the German provinces, and
thought that Bismarck had once been war minister. There was a tremor,
hypalgesia of the left leg and analgesia of the left arm and left
shoulder.

It was found that he came from a strongly tainted family, with
two insane sisters and three insane cousins. He had been a good
soldier during his service, but had accused his father of alcoholism
baselessly. He had always been difficult to manage when drunk and had
been convicted nine times: five for dangerous assault and battery. He
drank up to 1⅓ litres of whiskey a day if he got time, and also took
ether. For some ten years he had been amnestic for what he did while
drunk; nor, according to his wife, had he been able recently to stand
so much alcohol. He said that he had had a fall from a wagon in 1911 or
’12, after which he had been unconscious.


Antebellum, run over by an automobile; intolerance of alcohol; episodes
of amnesia after moderate alcohol.

=Case 97.= (KASTAN, January, 1916.)

A German soldier was advanced in rank February 26, 1915, and in honor
thereof drank six or seven glasses of beer. On his way home, he met a
captain and failed to salute him. When called to account, he said he
could not see, and made remarks about regrettable behavior. He refused
to go along with the officer. Afterwards he remembered that he had been
stopped by an officer but had forgotten subsequent happenings.

March 24, he was riding in an electric car with a lieutenant. He said
to the lieutenant who had unbuckled his sabre, “It is a piece of
insolence and improper to unbuckle the sabre.” He repeated the phrase
on questioning. He was then asked to give his name, and replied, “I
know my name but what is your name, Mr. Lieutenant?” He looked drunk at
the time but afterwards remembered nothing.

Physically he was tremulous and showed blepharospasm. His face grew red
on bending over.

This man had been run over by an automobile in 1910, after which he had
become excitable, slow-thinking and forgetful. The spinous processes
were painful on pressure, as was also the hip joint. The history
showed that he had been convicted six times of various crimes, such as
disturbing the peace, embezzlement, and the like. Since this accident
he had not been able to work effectively. He had gone into the army in
a spirit of enthusiasm.


Adventure with a stranger in Paris.

=Case 98.= (BRIAND and HAURY, 1916.)

A soldier had seven days’ leave in Paris, beginning December 27, 1915,
and the first day drank a good deal of wine with another man on leave.
They met, in some place that the patient had forgotten, a well-dressed
man whom they did not know, and all three fell to drinking. The
stranger told them he knew a trick to prolong the leave to 3 or 4
weeks. “All I have got to do is to prick you, and it will cost only 100
sous.” The operation was done at the café after payment in advance.
The operation was a puncture with a needle between the middle and ring
fingers of the left hand. Next day there was a phlegmon of the dorsal
surface of the hand, and he was put into hospital saying that he had
gotten a barbed wire prick in the trenches. The surgeon who opened the
phlegmon was surprised at its gummy appearance, gangrenous odor, and
greenish tint. In point of fact, petrol had been injected.


Morphinism: Tetanus.

=Case 99.= (BRIAND, 1914.)

Mdm. L. was a morphinist. After the outbreak of the war, she went to a
general hospital to recover from morphinism, but was too excited to be
kept there. Accordingly, she had to be sent to Sainte-Anne, but upon
arrival she developed distinct signs of tetanus.

It seems that Mdm. L. was the widow of a Colonial who had given her the
first injections ten years before, for dysentery. She tried several
times to stop. Daily dose 1.5 grams.

She was in a cachectic state, and according to her mother, took no care
of her syringe, trailing it about everywhere. Her thighs, arms, and
anterior aspect of the body were covered with scars. There were small
phlegmons in places. Did she inoculate herself with bacillus tetani
from an infected needle? In any case, she died of tetanus.


Medicolegal question concerning a morphinist.

=Case 100.= (BRIAND, 1914.)

A man worked in Paris on the ’Change, where there are a number of
syringe victims. He had been brought up in Paris but was not a
Frenchman. Enthused by his friends and the prey of deep emotion, he
enlisted. He was of an introspective nature and himself wondered
whether the morphine did not have something to do with his enlisting.
He said, “I had been unnerved for a number of days by reading the
papers, and after a number of heavy injections, I went to a recruiting
station and signed on.” In his regiment, he continued the injections,
but shortly found that he would be unable to replenish his diminishing
stock of drug. He explained his unhappy fate to the corps physician,
and was sent to Val-de-Grâce. He asked to be retired, alleging that
he was under the influence of a poison when he went to the recruiting
office and had therefore committed an illegal act.


Social effects of the war on two drug addicts.

=Cases 101 and 102.= (BRIAND, 1914.)

Fernand and Emilienne were two recidivists in morphinism. Although
neither was over 22 years of age, both had been several times convicted
of shop-lifting. They stole only if they had no money for morphine.
Prostitution served to care for Emilienne, while Fernand was at times a
cocaine seller, and at times made money in devious ways at Montmartre.
Emilienne’s patronage scattered with the war, and it was the same with
Fernand’s. Accordingly, there was no money for either morphine or
cocaine. Moreover, the shops being not crowded were easier to watch. As
Emilienne did not care to be arrested and sent off as an undesirable,
she presented herself at the hospital for the insane at Sainte-Anne.
Fernand shortly joined her there.



V. ENCEPHALOPSYCHOSES

(THE FOCAL BRAIN DISEASE GROUP.)


Left-sided hemiplegia and aphasia: Contrecoup and local lesions.

=Case 103.= (LHERMITTE, June, 1916.)

A soldier of 23 was wounded in the left parietal region and showed a
_left_-sided hemiplegia with aphasia. The speech difficulty, although
very marked, retrograded almost completely, but the hemiplegia remained
severe. This hemiplegia was a spastic one, of a classical nature, with
Babinski sign and exaggeration of tendon reflexes. Lhermitte thinks
that the left hemisphere was directly affected by the contusion, as
in point of fact there was an actual loss of bony tissue, but that it
would not be necessary to suppose the ipsilateral hemiplegia was due to
an absence of pyramidal decussation. The transient aphasia was probably
due to direct affection of the tissues on the left side of the brain;
the permanent hemiplegia was doubtless due to a lesion of the opposite
hemisphere produced by contrecoup. It appears that sometimes a surgeon
may be led to superfluous surgical intervention in a case of such
paradoxical hemiplegia, since the surgeon may believe that a bullet
or shell fragment has traversed the brain substance to the opposite
side of the skull, when as a matter of fact the brain parts have been
injured merely by contrecoup.

_Re_ such amnesia, it is of note that many head cases, even if they do
not show amnesia, show a conspicuous euphoria and lack of understanding
of the seriousness of the injury in question and of the necessary
treatment. According to E. Meyer, there are constantly to be found
in head cases disturbances of perception and lack of coördination
(especially for time), perseveration, difficulty in thinking and
calculating.

                                CHART 5

                           COMMOTIO CEREBRI

      I. SENSES: Asymmetrical hyp- or anesthesia (with hyperalgesia
         and osseous hyperesthesia).

     II. MOTILITY: Disorder, muscular or reflex. General or
         unilateral hyperexcitability.

    III. VASOMOTOR CONTROL: Dermatographia. Cardiac, splanchnic
         disorder; also, Headaches, Vertigo.

     IV. EMOTIONS: Disorder.

      V. INTAKE OF IDEAS: Disorder. Persistent lacunae of memory.

     VI. INTELLIGENCE: Disorder of recollective memory.
         Speech-disorder. Intellectual inertia. Overimagination
         (hallucinations, tremors).

                                           Mairet, Piéron, Bouzansky.


Gunshot wound of head; alcoholism: Amnesia.

=Case 104.= (KASTAN, January, 1916.)

A German soldier had a bullet pass through his right eye and lower
jaw, leaving a fistulous opening from the mouth. He said that he was
completely blind, but ophthalmological examination cast doubt upon the
blindness. There had been immediately after the injury a number of
severe attacks of dizziness, which lasted several hours; and another
attack developed after he had come back from hospital, to which he had
gone by reason of his pains.

He was to be arrested on account of a disciplinary crime and had
ostensibly gone to his mother’s house, there to await arrest. The
non-commissioned officer found him in a saloon. As soon as the phrase,
“You are my prisoner!” was said, the soldier lost track of his
surroundings. He had drunk a few glasses of beer but did not himself
think he was drunk at the time. He was insulting and violent when asked
to proceed with the officer, and a policeman was called in to take
charge. He then lay down in the street and had to be put upon a wagon,
still firing abusive phrases at his captors.

Upon examination, aside from the effects of the gunshot, excessive
knee-jerks and tremors of the body were found. The eyebrows met but
there was no other sign of bodily stigmata. There seems to have been no
hereditary disease, or any history of severe alcoholism, though the man
had been convicted previously of violence and theft. The amnesia is to
be ascribed to effects of the head injury.


Bullet in brain: Crises; cortical blindness; vertigo; hallucinations.

=Case 105.= (LEREBOULLET AND MOUZON, July, 1917.)

An invalided soldier, 40, was sent to be observed, Oct. 23, 1916,
because he wanted his pension renewed. He had been retired a year
before for diminution of binocular vision with impaired perspective
of objects in the right half of the visual field. He had now become
completely blind.

He had been wounded, March 12, 1915, in the Argonne, without losing
consciousness. He was wounded at ten o’clock at night and waited until
the next day to walk to the ambulance and was at this time able to see
perfectly. Arriving at the ambulance he lost consciousness. He was
trephined but remembers nothing about the trephining.

His memory grew better from his arrival at a hospital in the rear in
April. An attempt was made to remove the bullet in May, 1915. Though
the surgeon’s finger was pushed as far as the tentorium the patient
did not lose consciousness or sight, but on leaving the operating
room he fainted and, after a few days of restlessness and delirium,
he became completely blind. There was a cerebral hernia difficult to
reduce. Vision became a little better and light and persons could
be distinguished at the time when he was retired. A month after the
operation there was a convulsive crisis beginning in the left arm,
affecting the legs and ending in unconsciousness. Several similar
crises occurred in August, sometimes with and sometimes without loss
of consciousness. Later these crises began to be limited to the left
side and then to be ushered in by visual hallucinations. At home he
was unable to care for, clothe or feed himself. The crises became more
frequent. The visual hallucinations began to dominate.

This situation lasted to February, 1916, when the blindness which had
been increasing since the onset of the hallucinations became complete.
The crises now became less frequent and intense. Headaches not severe
were exaggerated after seizures. The patient acted like a totally
blind person and said that he had before him a uniform and constant
gray without any light or dark spots or any color. Upon this background
bizarre pictures, caricatures, disguised persons, animals or nameless
things appeared colorless without relief, in silhouette, but highly
suggestive of reality to such a degree that at first, according to the
patient, he had made gestures to reach, or push aside these pictures.
The crises were Jacksonian.

Pallor, perspiration, shivering, irresponsiveness, clonic spasms of
left arm followed. The patient always had a premonition permitting him
to get into bed if he was sitting, for example, in his chair. Sometimes
there was a dizzy sensation as if the body were being rotated to the
left. This sensation did not occur at the beginning of the seizure and
the patient fought against it, turning to the right. Sometimes he felt
as if he were sliding at great speed down an inclined plane. Headaches
and sleepiness followed, but there was never any complete loss of
consciousness of memory.

The eye grounds proved normal and all the photomotor reflexes were
normal, though there was no pupil reflex to pain. The patient could
write readily to dictation printed letters. It would seem that these
printed letters mean that he had visual memories, as he traced the
characters as if from a design. Speech was monotonous with some
stuttering; but his speech had always been of this sort according to
information. He walked with difficulty, not merely on account of his
visual but on account of his equilibration disorders. Outside of his
seizures he always turned to the right and if left to himself standing
he turned to the right. If asked to walk straight ahead, he always
turned to the right. Silent and uncommunicative, he was amiable and
sometimes even gay. He often had troublous dreams, sometimes seeing
his relatives. He said he could bring up in his mind the faces of his
relatives and even the appearance of the Salpêtrière. Reflexes and
sensations were normal. There was a traumatic rupture of the tympanum.
Lumbar puncture showed a slight excess of albumin and 1.8 lymphocytes
to the cubic millimeter. The Mauser bullet was found by X-ray in the
left calcarine region with its base touching the median line, and
applied to the inner table of the skull about a centimeter above the
internal occipital protuberance pointing forward, outward, and upward.
He was treated on a salt free diet with bromides. The seizures grew
fewer and at the time of report two months had elapsed with nothing
but a slight vertigo and frequent nightmares. Intellectually also the
patient had improved.

The case is one of cortical blindness. The seizures are explained by
the vicinity of the right Rolandic region to the lesion. The rotatory
vertigo is to be explained by the contact of the Mauser bullet with
the tentorium and vermis of the cerebellum, which may also explain
the difficulties in orientation that occurred between the crises. The
visual hallucinations are doubtless due to lesion of the calcarine
region.


Tunisian theopath with mystical hallucinations; gun-shot wound
of occiput (bullet extracted): After the trauma, Lilliputian
hallucinations and micro-megalopsia.

=Case 106.= (LAIGNEL-LAVASTINE AND COURBON, 1917.)

A. ben S. was sent to Villejuif with the diagnosis: “depression,
feeling of impotence, discouragement,” having been found on the public
street. He was indifferent, almost completely mute, and was at first
considered not to understand French. In a fortnight, however, he was
talking freely and was then found to be afflicted with hallucinations,
melancholia, and delusions, apparently following trauma to the skull.

A. ben S. might have been about thirty years old, and was of a rich
family, indigenous in Tunis, well educated in the Koran and Arabic
literature.

Upon examination, this Tunisian gunner showed contraction of visual
fields, poor color vision, and general hypalgesia. During examination,
the man seized the needle and plunged it deeply under his skin,
exclaiming that a prophet felt nothing and that he could be cut into
bits without feeling pain.

It seems that he had had divine visions from early childhood. In his
youth he had once gone to a mountain near his home and talked with
Mohammed and Allah. Of course, Allah did not appear in human form, but
he appeared like a ball or a wheel of fire, slowly turning. Mohammed
was a tall man, with a long white beard, his eyes darting rays of
fire, and his forehead bearing a gleaming bright body. Allah was heard
talking to Mohammed. Orders were given concerning the sun and stars.
Subterranean treasures were displayed, as well as Paradise full of
yellow, blue, and green houris, transparent, such that, when food was
taken, it could be seen going down their throats. Hell too was visible,
and the devil very tall and black, an eye behind and another on top.
There were also many genii--little men who climbed over the Tunisian’s
body. Sometimes in dreams, Allah carried him to all countries of the
earth. It was hard to tell whether these effects were hallucinations
or vivid imaginings. The Tunisian had been wounded after several months
of service by two bullets in one day: the one causing an insignificant
lip-wound; the other entering the skull behind. After several months
the bullet had been extracted by trephining.

His further history was obscured by the fact that he wove delusional
elements into his story. He said, for example, that he had been
court-martialed, though there was no evidence that this was a fact. It
is probable that after his wound the patient in a delirium felt that he
was going to be shot. The visual hallucinations were very interesting,
being Lilliputian. He would see three or four hundred Tunisian gunners
walking along, knee-high or taller. Sometimes they all would stop and
aim at him. He also showed micromegalopsia, real objects changing their
height under his eyes. Both the Lilliputian hallucinations and the
micromegalopsia dated from the trauma to the skull. There was no change
whatever in the mystical delusions concerning Allah and Mohammed. These
he had before the trauma.


Meningococcus meningitis with apparent recovery: Dementing psychosis.

=Case 107.= (MAIXANDEAU, 1915.)

A soldier in the Heavy Artillery, 42, developed occipital headaches and
Kernig’s sign, December 27, 1915.

December 31, at the Hôtel-Dieu, he showed myosis, slight photophobia,
meningitic tâche, temperature 39.6, pulse 84, heart sounds dull. Lumbar
puncture: hemorrhagic fluid.

January 1, the headache was intense, neck stiffness increased, Kernig’s
sign less marked; morning and afternoon temperature 39.2. Lumbar
puncture yielded hypertensive cloudy fluid and 30 cubic centimeters of
serum were administered.

This dose was repeated January 2 and January 3, on which date there was
no headache.

January 4, Kernig’s sign and neck stiffness were diminished; fine râles
at the bases without dulness. 30 cubic centimeters of electragol were
injected intravenously.

January 5, Kernig and neck stiffness slight. Meningitic tâche;
exaggerated knee-jerks; unequal pupils; temp. 36.6 morning, 39.4
afternoon; respiration 36; pulse 120; no râles; splenic enlargement.

6, no headache or photophobia; constipation; fine râles, right base;
spartein; meningococci found in hypertensive spinal fluid. 30 cc. serum.

7, more râles; exaggerated heart sounds; intestinal worms in stools.

8, temperature fell to 37; pulse to 90.

9, patient worse; involuntary stools; Kernig’s sign; stiff neck; fever.
30 cc. serum injected.

10, 20 cc. injected.

11, delirious all night; tetaniform stiffness of neck; more râles.

12, delirious, incoherent words, Cheyne-Stokes breathing.

13, less stiffness, Kernig almost absent; pupils normal; Romberg sign
slightly developed; pulse 120.

14, a few râles at right base.

15, pains in elbows, knees and hands with joint swelling; moist râles;
temp. 38.4; pulse 140. Digitalon.

16 and 17, serum erythema of thorax; edema of left knee; pulse 150;
spartein 16.

17, ice pack over heart.

18, edema of knee diminished; no headache, delirium or pupillary sign.

19, improvement. Temperature normal thereafter.

20 and 21, fine râles. Then all symptoms disappeared.

Recovery was predicted, but on January 28 it was observed that the
patient was untidy, made mistakes in dressing, such as trying to put
his legs into the armholes of his shirt, and denied the most evident
facts: His _képi_ on his head, he said it was not. Face drawn; skin
yellow. Appearance of asthenia. Deep depression and hebetude. At this
time the knee-jerks were exaggerated, pupils unequal, vermicular tremor
of tongue; the patient walked on a broad base with tremulous legs
suggesting contracture and weakness.

February 8, in a similar state the patient wandered about his room,
moving his bed and chairs about, answering questions with an absent
air. He had now been taught to be less untidy.

March 5, stiff neck and Kernig’s sign were distinct. He made believe he
was on his farm. Ecchymosis of right upper eyelid: he had fallen (his
sheep had pushed him over!). The improbability of this idea did not
persuade him to think it had not happened. He walked after the manner
of a tabetic.

In April he became bedridden, unable to walk, with marked stiffness and
Kernig’s sign. He had at this time periods of excitement in which he
would tear the bedclothes. He was invalided as demented.


Meningococcus meningitis.

=Case 108.= (ESCHBACH AND LACAZE, November, 1915.)

During his eleven months captivity at Grafenwöhr, Eschbach and Lacaze
had the opportunity of observing the case of a soldier, 24, who
sustained a shell-wound in the left lung and was made prisoner August
20, 1914, at Chateau Salins. He got well of his wound, but February
16, 1915, began to cry out and was restless in the night. He was found
on the straw muttering words among which only the word, “Head, head,”
could be distinguished. He was irresponsive, possibly deaf. Suddenly he
had a convulsive crisis and whenever touched he would have jactitations
and cry out. Otherwise, he was calm and stuporous. The pupils were
widely dilated. In short, he showed a mental confusion associated with
paroxysmal excitement due to cerebral and cutaneous hyperesthesia. The
first symptoms had occurred the morning before, when he leaned his head
against a wall and complained.

Lumbar puncture yielded intra- and extracellular meningococci. The
patient was isolated. In the afternoon he became less agitated,
kept his eyes closed, mumbled, repeated gestures, would spit in his
hands, rub his hands together, rub his neck, shoulders and body, or
else he would pass his hands over his forehead and through his hair.
Occasionally he would seize the straw and draw it to him with all his
strength. Once when asked, “What is your name?” he said, “Not true. Not
true.” Hallucinations appeared to have been added to the situation. The
neck was a little stiff to forced flexion. Temperature 37.8. Lumbar
puncture under chloroform anesthesia; antimeningococcus serum was
injected. Next day quieter; able to get up and walk. Slept, mumbled
less, was able to answer simple questions, desired to urinate and
finally succeeded.

February 19, no mental disorder. Headache and lassitude. Neck stiff,
Kernig’s sign marked. Lumbar puncture yielded a fluid now puriform;
antimeningococcus serum injected. February 20, lifting the head
produced opisthotonos. Labial herpes. The fluid yielded, besides
meningococci, also endothelial cells. Serum injected. February 21,
fibrin in fluid; serum injected. February 22, no head symptoms. Herpes
more intense, involving also arms. Tongue coated. Temperature 37.5,
evening 38.3. February 23, meningococci and lymphocytes in fluid.
February 24, left knee swollen. Serum injected; puncture fluid showed
meningococci and polynucleosis. Fluid from knee showed polynuclear
cells without organisms. February 25, patient reached evening
temperature of 39.5; serum injected. A few meningococci, altered
polynuclear leucocytes. February 26, patient rigid, tongue coated,
serum injection. Rare meningococci, degenerated polynuclear leucocytes.
February 27, rigidity decreased, evening temperature 37.7. February
28, Kernig’s sign absent. Herpes dry. Serum injection. Fluid clear;
lymphocytes and polynuclear cells; no meningococci. March 6, painful
inguinal gland on the left side. March 7, epididymitis left (mumps two
years before, with headache two weeks and double orchitis). March 9,
serum eruption. March 17, epididymitis practically absent. Lymph node
painful. Later data impossible to get, except that there was apparently
an arthritis of the hip and a sacral decubitus with eventual recovery.


Shell-explosion: Meningitic syndrome, fourteen months.

=Case 109.= (PITRES AND MARCHAND, November, 1916.)

A soldier sustained shell-shock at the distance of a meter at
Saint-Hilaire, September 26, 1915. He lost consciousness and blood
flowed from his ears. He arrived, September 28, at the neurological
center in Bordeaux in a semistupor, knowing that he had been shocked
and had lost consciousness. He groaned, cried out, and kept stroking
his head with his right hand; lay on the right side; showed Kernig’s
sign right, ptosis, and stiff neck. Headache was increased on moving
and noises. Patient constantly asked for food, but refused to drink.
Lumbar puncture yielded a yellowish fluid, due to laked blood. October
3, headache, ptosis, left internal strabismus, temperature 38.5.
October 4, lumbar puncture, slightly blood-tinted fluid. October 5,
improvement; gap in memory for period since shock. No strabismus,
ptosis diminished, temperature normal, improvement continued. Kernig’s
sign and headache persisted. He lay doubled up on the right side, eyes
closed, right hand on pillow. Defense movements on touching the neck
or occipital region. The condition of semistupor often passed off in
the afternoon, when he could talk, write or play cards. He had always
smoked, even at the beginning of his disease. Lumbar puncture yielded
a normal fluid December 12, 1915. He was sent February 23, 1916, to a
hospital in the country, but came back May 9.

It seems that several days after transfer he had had an attack of
delirium in the night, having lost consciousness, and tried continually
to get up out of bed, saying that he wanted to go to Verdun to fight.
This spell lasted several hours and on the days following came mutism,
refusal of food, and a state of stupor. Nutritive enemata were given.
As he grew better he sometimes ate a great deal, sometimes nothing,
even wanted poison from his family, and wrote to a comrade that he
wanted to commit suicide.

May 9, he was clearer, told of seeing the shell, which he said he had
not heard, nor did he know how he had gotten to a hospital. His head
and spine had hurt him ever since the shock. He had had difficulty
in urination for two days after the shock. He could not remember
the delirious attack in the country hospital. He gave various data
about his life, but not fully. He refused to lie on the left side,
or to walk, because of pain. He could lift either leg from the
bed, but hardly both. There was an irregular coarse tremor of the
extremities. The right hand was weaker than the left; there were no
reflex disorders; no change in the eye grounds. There was a patchy
analgesia. May 26, stupor reappeared as before, with semimutism. June,
the patient presented the appearance of a dementia praecox in stupor,
with stereotyped gestures and attitudes, without catatonia. The patient
was sent to a hospital for the insane at Cadillac. November 9, 1916, he
returned to the neurological center, as mental and cerebral disorder
had disappeared. There still persisted a difficulty in remembering
facts since the shock and there was still a functional paresis of the
legs.

We here deal with a case of a meningitic syndrome following shell-shock
and lasting fourteen months.


Brain abscess in a syphilitic: Matutinal loss of knee-jerks.

=Case 110.= (DUMOLARD, REBIERRE, QUELLIEN, 1916.)

An unmarried subaltern officer, 30, entered an army neuropsychiatric
center, April 8, 1915, looking exhausted and bearing a ticket “nervous
asthenia, evacuated for neurological examination.” He said he had had
scarlet fever at ten; strongly denied syphilis, of which he presented
no trace; had not been excessively alcoholic and had had no nervous
seizures. Detailed information showed that he had been a normal child.
He left his two years’ military service with promotion and was a man of
above the ordinary intelligence.

He was wounded in the right buttock with a shrapnel bullet about the
end of September, 1914. He went back to his regiment two months later
and had shared in a number of actions up to the time of his evacuation.
He said he had been very tired for several weeks, and had finally been
sent to the physician. There were pains in the kidney region and in
the head, especially on the right side. The head felt empty. He could
not sleep, but did not dream. Ideas were not distinct. Memory had
become impaired. He could not keep his accounts right, and was afraid
something might go wrong.

There was no pain or nervous or reflex disorder of any sort except for
the knee-jerks and Achilles jerks (see below). A special examination
proved complete normality of eyes. There was a slight hesitation in
words, but no dysarthria. There was a slight tremor of the tongue and
fingers.

As to the tendon reflexes, April 9, on waking, the knee-jerks were
absent, but later in the day gradually came in evidence again. The
Achilles jerks were also absent at first, but could be obtained after
a prolonged examination and after percussion of the calf. In the
afternoon, after exercise, the knee-jerks and Achilles jerks were
easily demonstrable. The left Achilles jerk was always a little weaker
than the right. Massage brought these jerks out to virtual normality.
April 10 and thereafter, similar findings; percussion of the muscular
masses of the thighs and calves always brought out the reflexes.

Lumbar puncture yielded a clear fluid with hyperalbuminosis, 20 cells
per c.mm. (lymphocytes and mononuclear cells 95 per cent) and a
positive W. R. Iodide of mercury treatment was given April 18.

April 23, the patient went into a coma, with trismus, stiff neck,
Kernig’s sign, sluggish pupils, incontinence. He was transferred
to a special hospital, showed on lumbar puncture, April 23, 85 per
cent polynuclear leucocytes, and died April 27. The autopsy showed a
yellowish, quasidiffluent softening of the size of a small egg in the
first occipital gyrus on the right side. The authors comment on the
fact that the only objective sign in this case was the variable tendon
reflexes of the lower extremities, “_l’unique cri de souffrance des
centres nerveux_.”


Early recovery from a spinal cord lesion.

=Case 111.= (MENDELSSOHN, January, 1916.)

Mendelssohn reports a soldier, who was sent to a Russian hospital,
April 12, 1915, with a diagnosis of chronic appendicitis. Operated
on next day, the patient appeared to be passing through a normal
convalescence, when ten days later, he had an intense headache and some
trouble in vision, which disappeared the next day, only to be followed,
two days later, by the patient’s complaint that he could no longer
urinate or rise from bed.

In fact, Mendelssohn found a complete flaccid paraplegia with urinary
retention, without fever or pain. Knee-jerks and Achilles jerks were
absent, and there was a slight extension of the great toe on plantar
stimulation. There was disorder of sensation, with heat sensibility
abolished, painful points poorly localized, and position sense poor.
Electric reactions normal. Pain on pressure in and about the lumbar
vertebral region. Cerebrospinal fluid showed lymphocytosis and an
excessive albuminosis.

This paraplegia lasted six weeks. At the end of May, the patient began
to be able to move his toes and to lift his heel. Improvement was
gradual and progressive. Early in June he could walk if supported.
The weak knee-jerk then began to reappear and the urinary retention
gradually disappeared.

This patient was not hysterical, although a bit emotional. Perhaps,
according to Mendelssohn, an organic lesion was grafted on a neurosis.
Perhaps the spinal lesion was infectious. At any rate, a presumably
organic paraplegia had recovered in two months and a half.


Shell-explosion: Meningeal hemorrhage: Pneumococcus meningitis.

=Case 112.= (GUILLAIN AND BARRÉ, August, 1917.)

An infantryman, 20, came to the Sixth Army Neurological Center, October
13, 1916, as a case of “choluria, due to shell explosion; epistaxis
needs watching.” He was somnolent, had waked vomiting, pulse 108.
Kernig’s sign, defensive movements of the legs on stimulation, with
flexion of leg on thigh and of thigh on pelvis, plantar reflexes
flexor. Puncture showed typical meningeal hemorrhage. Two days later,
temperature 40, pulse 70, that is to say, a bradycardia in proportion
to the fever. Vomiting, pulse persisted. Next day the patient was
moaning and semi-delirious and showed stiff neck, Kernig’s sign,
accentuation of vasomotor disorder, plantar response flexor with leg
retracted, thigh flexion both homolateral and contralateral. The
spinal fluid upon the next day, that is, four days after his arrival
at the clinic, showed a purulent fluid in which there was an excess of
albumin, no sugar, diplococci extracellular (proving on culture to be
pneumococci and able to kill a mouse in twenty-four hours).

As a rule such hemorrhages remain aseptic, and in fact meningeal
hemorrhage is said by Guillain and Barré to have, as a rule, a
favorable prognosis. The above described case was the only one of
infected meningeal hemorrhage that had occurred in the Sixth Army
Neurological Center.


ANTEBELLUM cortex lesion: right hemiplegia; recovery. Struck by
shrapnel on right shoulder: Athetosis.

=Case 113.= (BATTEN, January, 1916.)

A British soldier, aged 27, showed a somewhat remarkable phenomenon.
It appears that at five years of age, this man had had poliomyelitis,
affecting the left leg. At 20 years of age, he had had pneumonia, and
this had been followed by a paralysis of the right arm and leg with a
loss of speech. The man recovered from this illness, although he never
quite regained full control of the right hand. It is evident that
this lack of control was not marked, else the man would not have been
enlisted, and it is Dr. Batten’s opinion that at all events he could
not have shown pathological movements of the right hand at the time of
enlistment.

However this may be, in October, 1914, the soldier was struck on the
right shoulder with shrapnel. Apparently he was not wounded, but
thereafter he was not able to use the right arm well, and in two
months’ time he had become unable to manipulate his rifle. On January
13, 1915, he was sent home. The remnants of the old poliomyelitis of
the left leg were shown in a general weakness of that leg as compared
with the right. _The movements of the right hand were those seen in
athetosis._ The movements were independent of volition. The patient
had difficulty in releasing his grasp. He improved rapidly during the
six weeks he was in hospital, although the movements of the right hand
never became entirely normal.

In this case, according to Batten, “the stress was sufficient to bring
into prominence the symptoms due to an old cerebral lesion.”


Hysterical versus thalamic hemianesthesia.

=Case 114.= (LÉRI, October, 1916.)

A soldier, 40, had been suffering for a number of months with pains in
the left side of the trunk and feelings of weakness in the left arm and
leg. In the summer of 1915 he was on leave and while walking, fell,
lay down, and found he could hardly move his left arm and leg. Two or
three weeks later he got up, walking with a stick. After some time in
hospital, he was sent back to the trenches, a little weak.

He had shortly, however, to be examined neurologically again. He could
hardly raise the left leg and his passive resistance was poor on this
side. The left side was almost completely anesthetic to all forms
of stimulus, although an intense faradic current yielded a feeling
like that of a fly. Nor was the tactile sensation absolutely nil,
as it could be got with a flat finger on the upper arm and thigh.
Cold and heat sensations not well localized. The hemianesthesia was
sharply limited at the median line and affected the buccal, lingual
and nasal mucosa. Deep sensibility was almost abolished on the left
side. Stereognostic sense was lost and the sense of position was lost
absolutely for hand and foot.

The patient said that he heard less well on the left side. There was
also a slight contraction of the left visual field. The reflexes
were lively, but equal on both sides. A diagnosis of hysterical
hemianesthesia was apparently called for, but psychoelectric treatment
failed. The plantar reflex was, in fact, completely absent on the left
side, as well as the corneal reflex. The faradic current failed to
produce as marked a dilatation of the pupil on the left side as on the
right. The forehead wrinkles were less marked on the left side. The
mouth deviated slightly to the right. The left nasolabial fold was a
little less marked. The tongue did not deviate, but was a little narrow
on the left side. The palate deviated a little to the left. The left
side of the trunk seemed a little less developed than the right, and
the scapula stuck a little less closely to the body on the left side,
when the arms were raised. The left buttock was a little narrower than
the right and the left gluteal fold was less marked. In combined
flexion of thigh and trunk the left foot readily left the floor. There
was a left-sided hypotonia in forced flexion of the forearm. There were
no tremors of the limbs in repose, except a few contractions of the
left lower extremity. In movement, however, there was a marked tremor
and in coördination the finger to nose test could not be performed.
Speech was slow and hesitant, sometimes stuttering. Food was sometimes
taken into the air passages. Headaches were localized on the right
side. They had begun when the first symptoms began. There was mental
disorder, with gaps in memory. In short, the case is probably one of
thalamic disease, though there were no pains except a few in the left
side of the trunk at the beginning of the disease. The diagnosis of
hysteria was at first made in this case, but the rule that hysterical
hemianesthesia is never found without auto- or hetero-suggestion caused
the alteration of diagnosis to thalamic.


Shell-explosion: Syndrome suggesting multiple sclerosis.

=Case 115.= (PITRES AND MARCHAND, November, 1916.)

A soldier, 40, carriage painter, underwent shell-shock at Voquois,
May 2, 1915, following ten hours’ bombardment. At the time he felt
tinglings. The bombardment had just ceased when he fainted suddenly
while repairing a telegraph line. There was no loss of consciousness.
He could not move his arms or legs, was able to spit, and did not
suffer at all except for the tingling. He was evacuated to the
interior, where the diagnosis of psychopathic double paraplegia,
Kernig’s sign, zones of anesthesia in the legs, was made. He
was immediately treated with gray oil, and got an injection of
neosalvarsan, and iodides. He grew slowly better. He could lift a
leg from the bed, but then both legs began to tremble. The arms had
recovered their movement, before the legs, but always trembled in
movement.

November, 1915, he was able to get up; two months later, he walked
alone.

At the neurological center, which he entered December 17, his gaze
was fixed and there was a slight exophthalmos. The folds of the face
were smoothed out. The nose was deep set (as a result of a fall at the
age of eight). In the upright position he could not remain still, but
trembled markedly on the left side, so that he had to make a few steps
to keep his balance. He was unable to stand on his left leg. He walked
on a broad base, in little steps, and rather unsteadily on account
of tremors augmenting upon movement. General muscular weakness; left
hand slightly weaker than right. He could not lift both legs more than
20 cm. from the bed and in the process they both trembled, trembling
together. There was also intention-tremor of the arms, a little less
marked than that of the legs, of an irregular rhythm. The arms trembled
as a whole. In a state of rest there was no tremor. There was a slight
muscular stiffness and the patient himself felt difficulty in relaxing.
Patellar reflexes absent, even on reinforcement; Achilles jerks
absent. Speech monotonous and tremulous, but not scanning; syllable
doubling observed by the patient. Manuscript tremulous and, on account
of tremors, illegible. Hypalgesia of legs, more marked distally.
Deep sensibility of tendo Achillis and patellar reflexes lost. Pain
on compression of eyes diminished. Formication in arms. W. R. of
blood negative. Slow improvement followed and the patient left the
neurological service May 4, 1916, able to walk more easily and without
tremor. The knee-jerks and Achilles jerks were still absent.

We here deal with a syndrome in part that of a multiple sclerosis, that
is, the intention-tremor, gait disturbance, muscular rigidity, and
weakness.

_Re_ multiple sclerosis, Lépine remarks that there are numerous army
cases of pseudo multiple sclerosis which are actually hysterical or
hystero-traumatic cases of hypertonus and tremor. The true cases of
multiple sclerosis, according to Lépine, are of interest inasmuch as
they are usually found in officers. These men have apparently at first
but a slight motor disorder, quite compatible with desk work. We have
usually under-rated the cortical element in multiple sclerosis. Spells
of confusion, delusional ideas, sometimes grandiose, start up without
warning in these cases. To be sure, alcohol and syphilis sometimes also
enter these cases etiologically. Any case of localized tremor ought to
be carefully examined psychically, and such cases in general ought not
to be given responsibility.


Coexistence of hysterical and organic symptoms in two cases of mine
explosion.

=Cases 116 and 117.= (SMYLY, April, 1917.)

A soldier was blown up by a mine and rendered unconscious. Upon
recovery of consciousness, he was dumb, unable to work, very nervous,
paralyzed as to left arm and leg. The paralysis improved so that in
the hospital at home the patient became able to get about. However, he
threw his legs about in an unusual fashion. Several months later, the
patient was much improved.

Shortly, however, there was a relapse. Transferred to a hospital for
chronic cases, the patient was unable to walk without assistance on
account of complete paralysis of the leg. Insomnia, general tremor, and
a bad stuttering developed, with a habit of starting in terror at the
slightest noise.

Hypnotic treatment was followed by almost complete disappearance
of the tremor. The patient began to sleep six or seven hours a
night; nervousness diminished, and the stuttering slowly improved;
but neither the paralysis nor the anesthesia of the left leg was
affected by suggestion. The leg remained cold, livid, anesthetic, and
flaccidly paralyzed to the hip. Though a slight improvement has since
been produced by faradization, the patient still can walk only with
assistance.

A man was injured in 1906 by the fall of a heavy weight on his back. In
1914 he went to France as a soldier, and eight months later was hurled
into a shell hole so that his back struck the edge. He was rendered
unconscious. Upon recovery of consciousness, the right leg was found to
be swollen, and there were severe pains in the legs and back.

Since return home the patient had gone from one hospital to another,
for the most part unable to walk, suffering from agonizing pain in the
head and eyes, unable to sleep, and in the night subject to horrible
waking dreams.

                                CHART 6

             MINOR SIGNS OF ORGANIC HEMIPLEGIA (LHERMITTE)

       I. Hyperextension of forearm (hypotonia).

      II. Platysma sign: Contraction absent on paralyzed side.

     III. Babinski’s flexion of thigh on pelvis (spontaneous, upon
          suddenly throwing seated subject into dorsal decubitus).

      IV. Hoover’s sign: Complementary opposition (on request to
          raise paralyzed arm, presses _opposite_ arm strongly
          against mattress).

       V. Heilbronner’s sign of the broad thigh (hypotonia).

      VI. Rossolimo’s sign: flexion of toes on slight percussion of
          sole.

     VII. Mendel-Bechterew sign: flexion of small toes on percussion
          with hammer of dorsal surface of cuboid bone.

    VIII. Oppenheim’s sign (extension of great toe on deep friction
          of calf muscles); or Schaefer, or Gordon (on pinching tendo
          Achillis).

      IX. Marie-Foix sign: withdrawal of lower leg on transverse
          pressure of tarsus or forced flexion of toes, even when leg
          is incapable of voluntary movement.

At first able only to bring himself to an upright position and to rush
a few steps, he later acquired considerable control of his feet and
legs through crutches. The insomnia persisted.

Smyly regards this case, like Case 116, as more neurological than
mental.

_Re_ organic neurology, much of great value has been reported.

Sargent and Holmes say that, contrary to expectation, there have been
few war cases of bad sequelae of cerebral injuries, such as insanity
and epilepsy. During early stages, after infection of the head wounds,
there is dulness and amnesia, irritability and childishness,--symptoms
which disappear during and after repair of the wounds. Mental disorder
requiring internment is surprisingly rare. During 12 months only eight
cases were transferred from the head hospital in a year to the Napsbury
war hospital, where cases of insanity attributable to the service are
sent; and in but two of these could the persisting mental symptoms be
attributed to head injury.

Col. F. W. Mott confirms the opinion of Col. Sargent and Col. Holmes,
remarking that from all the London County Council Asylums, only one
case of insanity associated with gunshot head wound had been admitted,
and that this was one of a Belgian who died from septic infection
of the cerebral ventricles. Yet all cases of insanity in invalided
soldiers belonging to the London County Council area (about one-seventh
of the population of the United Kingdom) are transferred to these
asylums.

Again Sargent and Holmes point out that both generalized and Jacksonian
epileptiform seizures are comparatively rare in patients suffering from
recent head wounds; even convulsions in later stages have been as yet
less common than was feared. Thus, after evacuation to England, fits
occurred in 37 (6 per cent) of 610 cases with complete notes, and in
only eleven of these 37 cases were the convulsions frequent. Sargent
and Holmes remark, however, that the practice of giving bromides
regularly to all serious cranial injuries until the wound is healed,
and for some months afterwards, seems advisable. In 33 of the 37
convulsive cases there have been severe compound fractures of the
skull, and in four of these a missile was still present in the brain.
Five secondary operations were performed with good results, after
drainage of small abscesses in two and removal of spicules of bone in
three. The In-patient and Out-patient records of the National Hospital
for the Paralyzed and Epileptic were searched for epileptics already
discharged from the army, but notes of but two patients attending this
hospital for epilepsy were found.

As for other neurological complications aside from septic infection
and hernia formation, there are a few subjective symptoms that may
necessitate the invaliding of soldiers. The most common of these is
headache, usually in the form of a feeling of weight, pressure, or
throbbing in the head, which headache is increased by noise, fatigue,
exertion, or emotion. Attacks of dizziness also occur, and nervousness
or deficient control over emotions and feelings. Changes of temperament
are found in some soldiers, who become depressed, moody, irritable, or
emotional, and unable to concentrate attention.

Foix, under the direction of P. Marie, worked upon aphasia in 100
cases, reporting results at a surgical and neurological meeting, May
24, 1916, in Paris. Only lesions on the left side of the brain have
produced important and lasting speech disorder, although lesions on the
left side may leave behind them a little dysarthria or difficulty in
finding words in conversation. It is, of course, hard to tell speech
disorder from stupor or clouding of consciousness. Foix notes certain
specialties in speech defect according to which region of the left
brain is affected.

First: Prefrontal lesions produce a transient dysarthria, lasting but
a few weeks, and right-sided prefrontal lesions produce just as much
disorder.

Occipital lesions produce no speech disorder.

Second: Patients with right-sided hemianopsia due to lesions of
occipital regions were not aphasic and could read or write perfectly.
Lesions of the left visual centers certainly do not affect reading.
If, however, the injury is not to the visual centers, but is upon the
lateral part of the occipital lobe, then alexic phenomena appear, and
these the more the lesion approaches the temporal-parietal region.

Third: Central convolutional lesion produces a variety of disorders
according to the site and extent of the lesion. There is no aphasia
with the crural monoplegia due to superior paracentral disorder. But
slight aphasic disorder accompanies the brachial monoplegia of middle
central lesion, though writing, reading, and calculation are slightly
affected, and the more so the more the lesion extends posteriorly to
the stereognostic regions. The lower down in the precentral region the
lesion appears, the more likely is the Broca syndrome to be observed.
But if the hemiplegia is chiefly a brachial monoplegia, the aphasic
disorder may remain slight, involving reading, writing, understanding
of words, the spoken word, articulation, and calculation.

Fourth: Lesions of the lateral-frontal region produce more or less
marked aphasic disorder, just as do those of the inferior part of the
precentral gyrus. This aphasia is more apt to occur when the wound is
deep. However, no case of permanent aphasia has been observed in cases
of lesion of the lateral-frontal region (termed in Foix’s nomenclature,
the precentral region, but referring to the tissues in front of
the precentral (or ascending frontal) gyrus of the more familiar
nomenclature). Almost absolute, or absolute, anarthria follows the
wound, and the patient is hemiplegic. This hemiplegia may last from ten
days to two or three months. After a time there is no longer more than
a slight dysarthria, and writing becomes good again; reading remains,
perhaps, a little difficult. A complete or almost complete cure is the
rule.

Fifth: When the retrocentral region is injured, various aphasic
syndromes appear. The retrocentral region is the parietal-temporal lobe
except the superior part of the parietal lobe and the anterior part
of the temporal lobe, which latter two regions when injured do not
allow any marked aphasic disorder. Lesions of the middle or posterior
temporal region are particularly important for speech, and produce more
marked disorder than lesions of the angular gyrus or the supramarginal
gyrus. At first, words cannot be spoken, for a period of a fortnight
to three months. Speech returns progressively, with an increased power
of comprehension. At the same time, the patients begin to read and
write. But there is no further spontaneous progress after a period of
six or eight months, and then special reëducation must be started.
These speech disorders of retrocentral (parietal-temporal) origin are
either aphasic syndromes or slight remains of psychical disorders,
or again, a disorder practically limited to alexia. The true aphasic
syndromes concern the spoken word, understanding the words, writing,
and calculation. The disorder is not especially dysarthric and consists
particularly in loss of vocabulary. It might be called an amnestic
aphasia (Pitres). These cases have well-marked intellectual disorder
and their power of calculation is especially poor. As to the aphasic
traces, which are more important to understand than they are extensive
in point of fact, they relate particularly to calculating power, to
vocabulary (slowness in finding words), and to reading (reading without
comprehension). As to the cases of alexia, these are cases of lesions
of the posterior part of the parietal-temporal lobe, and are usually
accompanied by a hemi- or a quadrantanopsia.

To sum up, cases with central lesions (precentral and postcentral
gyrus) have hemiplegia and a Broca aphasia without much tendency to
cure. Cases with lesions anterior to the central convolutions have a
transient anarthria and their recovery is ordinarily complete. Cases
with retrocentral lesions have an aphasia suggestive of Wernicke’s
aphasia, and ordinarily leave behind them extensive defects in
intelligence and language. These cases should be taken account of
from the standpoint of compensation, since they are much worse off
for work than many cases with amputations; and though their disorder
looks slight, it quite interferes with working at a trade. From the
point of view of military effectiveness, the retrocentral cases are not
very good soldiers, and especially not good officers, as they do not
understand commands completely.


Neuropsychiatric phenomena in rabies.

=Case 118.= (GRENIER DE CARDENAL, LEGRAND, BENOIT, September, 1917.)

A farmer, 34, mobilized in veterinary work, fell sick at a station
for sick horses, April 25, 1917. He breakfasted well, drank coffee,
and went to the _abreuvoir_ at eleven o’clock. He told his mates that
he felt bad in his head. He fainted over a table at the eating house,
refused to eat or drink. At noon he went out into the court, vomited
and went to lie down. A physician thought he was suffering from angina
because of the pronounced dysphagia. He entered the hospital at eleven
o’clock at night on the 25th. He was found next morning on his back,
with a fixed and haggard look, crimson face, masseter and phalangeal
spasm at times. Respiration irregular, interrupted by moans. The pulse
would go up to 120 during agitation and then go down to 50 as soon as
the patient lay down again. Pupils slightly dilated and unequal. As
the patient came from a sick horse dépôt, the first question was that
of tetanus, suggested somewhat by the jactitation of the limbs and
the trismus. A violent headache began and the patient cried out, “My
head! My head!” Painful vomiting movements, with very slight bilious
material. Convulsive movements increased. The pulse was slow. The
diagnosis “meningitis” was suggested, despite the absence of fever
and the absence of Kernig’s sign. Lumbar puncture gave limpid fluid
with a normal lymphocytosis, without increase of albumin or reducing
substance. The bacteriological smear and culture were negative.

Soon another sort of symptoms appeared. The patient would rise, cry
out, threaten his neighbors. He was calmed with morphine. There were
periods of excitement alternating with periods of calmness, during
which he would reply sharply but accurately, being somewhat vexed by
the questions, and would walk up and down without offering a word. When
a glass of water was offered to him, as soon as his glance met the
glass his eyes expressed fear. He drew back in repulsion and cried out
in terror. When the liquid was out of his sight the hydrophobic spasm
ceased. This hyperesthesia of the sensorium was so intense that the
mere sight of the shining glassware of the laboratory brought out a
sharp crisis.

He was sent that evening to the neuropsychiatry center, walking jerkily
and as if slightly drunk, with a number of small gesticulations and
murmurings. He was immediately isolated, undressed himself and went
to bed. He did not move in his bed, and seemed to sleep. The next day
he got up, dressed and had a small spell of excitement, but was quiet
enough on the medical visit, though the floor was soiled with urine
and vomitus and the clothing was in disorder. He now had a pronounced
phase, deep sunk eyes, drawn features and anxious look; dilated pupils
and an expression of mixed fear and anger. His breathing was hard and
he kept his hand on his heart. He was oriented. He suddenly rose and
said, “I am thirsty.” A glass of milk was given him. He hesitated a
moment, plunged his mouth and hands into it and aspirated the drink
without making any swallowing movements. He pushed away the glass, spat
a little, and vomited a small quantity of a black liquid. Then followed
an anxious crisis, and he fell upon his side, absolutely immobile,
without breathing for a few seconds. Again in the sitting posture, he
was taken with contractions of the limbs and face. The tendon reflexes
were at this time normal.

A quarter of an hour later the attendant found him dead, in the sitting
posture, leaning against the wall, mouth open, arms dependent, hands
extended, pupils dilated--a death in syncope. The brain was found
congested. There was a slight effusion of blood over the posterior
aspect of the brain. There were no hemorrhages or softenings in the
brain substance. The muscles were of a dark red to black. The adherent
lungs were very slightly congested at the base. The stomach contained
a quarter of a liter of black, inodorous fluid in which there was
much bile and little blood. There were numerous small hemorrhages of
the mucosa near the great curvature. The spleen was large, the liver
congested. The Pasteur Institute confirmed the diagnosis of rabies.
There is no history of the man’s having been bitten by a dog.


Tetanus: Psychosis.

=Case 119.= (LUMIÈRE AND ASTIER, 1917.)

A soldier wounded May 18, 1916, was given antitetanic serum May 26th.
The wounds healed, but on June 16, that is, 29 days after the trauma,
contractures began, at first localized. There had been numerous wounds
of legs and scrotum by shell fragments and the contractures were
limited to the right leg and scrotum. There was no trismus or any
lumbar symptom.

During the next few days the contractures became general, the
temperature rose, a shell fragment was found by X-ray at the root
of the thigh and was surgically extracted. B. tetani was found upon
inoculation of media with material from the shell fragment. Persulphide
of soda and antitetanic serum 90 cc. in three days were given
intravenously. The temperature fell and the general health was greatly
improved. July 6, hallucinations and terrors, worse at night, set in.
The man believed himself surrounded by flames, that daggers were being
plunged into his old wounds, that his hair was being pulled. These
symptoms lasted a fortnight only, whereupon the patient recovered.

This case and six others accompanied by cerebral disturbances all
recovered, and all the patients retained a perfect memory of their
delirium and of their hallucinations.

The chronological distribution of these cases was odd. One case was
found early in the war; then no other cases of cerebral disorder
presented themselves until the group observed at the end of 1916.
Besides flames and daggers, zoöpsia was several times observed. One of
the cases showed these symptoms without having been given antitetanic
serum.

_Re_ tetanus in the war, see in the _Collection Horizon_ a book by
Courtois-Suffit and Giroux on _Les formes anormales du tétanos_.


Tetanus fruste versus hysteria.

=Case 120.= (CLAUDE AND LHERMITTE, 1915.)

Claude and Lhermitte describe a condition of _tetanos fruste_. The neck
was absolutely rigid. The patient had not been wounded in any way and,
being regarded as a pure neuropath, was sent to the Centre Neurologique
at Bourges.

The differential diagnosis lay between true tetanus and the hysterical
pseudotetanus or pseudomeningitis. In pseudotetanus there is a
contracture of the superficial and deep neck muscles, especially the
trapezii, sternomastoid, and deep muscles. The condition somewhat
suggests that of acute meningitis or tetanus, and especially suggests
tetanus because it is often associated with masseter contracture
(hysterical trismus). The head is immobile, stiff, and inclined
backward; eyes directed above, throat slightly prominent. Upon attempts
to move the head, intense pain occurs. The pain and contracture
sometimes even suggest a suboccipital Pott’s disease. This form of
hysterical pseudotetanus is of sudden onset, as a rule following burial
in a trench or else contusion, or a slight wound in the cervical
region. Pressure on the spinous processes produces no pain, nor does a
blow upon the head; and an X-ray examination will definitely eliminate
the hypothesis of Pott’s disease.

To return to the Claude-Lhermitte case of limited true tetanus:
It showed marked modifications in the tendon and bone reflexes.
Upon percussion of the zygoma, of the occiput, or of the clavicle,
there was a marked further contraction in the contractured muscles.
Although there was no apparent spasticity in the legs, there was an
ankle clonus and a bilateral patella clonus, combined with a distinct
exaggeration of all bone and tendon reflexes. In such cases also there
is hyperexcitability of the nerves and muscles to faradic and galvanic
currents.


An officer’s letter concerning local tetanus.

=Case 121.= (TURRELL, January, 1917.)

The following letter from an officer who had had local tetanus and was
treated by Turrell by ionization Dec. 6 and 7, 1915, by diathermia Dec.
7 to 22, and occasionally by static breeze ionization and chlorine
ion to relieve contractions from Dec. 29, 1915, to Feb. 4, 1916. The
tetanus was in the muscles of the legs. Of course diathermia is a
purely symptomatic treatment and does not replace antitoxin serum or
other specific treatment; thus its effect in relieving the contractions
of local tetanus is precisely like its effect in the treatment of
sciatic neuritis or lumbago.

                                                   November 15, 1916.

    “Dear Major Turrell,

    “I have been meaning to write to you for some time, as I knew
    you would be interested to hear how I was getting on. Your
    letter has just been received, and I am only too happy to give
    you any information I can with regard to my leg. I was wounded
    in the left leg on October 13, 1915, by high explosive shell,
    and arrived at Oxford on October 22. There was no operation as
    the surgeon in charge did not consider it advisable to remove
    the pieces of shell: my leg seemed to be getting better, and
    after about a month I was able to hobble round with sticks. My
    foot at this time used to swell a great deal towards night,
    and the foot seemed then to gradually stiffen up with violent
    pains at intervals, this gradually spread up the whole leg to
    about the knee, and I was compelled to take to my bed again.
    The pain at times was very bad, similar to a very bad attack of
    cramps, and then my leg became rigid and stiff, and at other
    times used to get horrible jumps and it was impossible to keep
    it still, and whenever the doctor or nurse looked at it it
    used to stiffen up at once. The night seemed to be the worst,
    and consequently I got very little sleep. I often had to get
    up in the middle of the night on crutches to try and obtain
    relief, my leg was so cramped and sore. It was about this time
    that you first visited me and prescribed a course of electric
    treatment for my leg, and I shall never be able to thank you
    enough for the relief it gave me. I cannot remember the names
    of the different treatments, but the first one--diathermy, or
    heat pads--certainly relieved the pain, and after the first
    two or three visits to you I got immense relief. I never
    looked back after this, and, although the progress was slow, I
    gradually lost all pain and was able to get sleep at night. The
    nervous jumps slowly disappeared and my leg became gradually
    normal except for contraction of the tendons. I was unable to
    straighten my ankle or knee, and it was thought at one time
    that my tendo Achillis would have to be severed. Gradually
    the knee straightened and I was able to get my heel to the
    ground. I was for some time on crutches, and was able to leave
    the hospital on February 5, 1916, walking with sticks.… I am
    now able to walk comfortably, but am unable to flex the ankle
    more than at right angle to my leg. The circulation is not
    very good, and I feel anything tight round my calf. I am still
    getting Boards, and have not been passed fit for overseas yet.”



VI. SOMATOPSYCHOSES

(THE SYMPTOMATIC, NON-NERVOUS, GROUP)


Dysentery: Psychosis.

=Case 122.= (LOEWY, November, 1915.)

Out of a large number of dysentery patients, many of whom had very
serious symptoms, but one of Loewy’s patients became psychotic.
Loewy in fact had discharged this one as normal, and he had been put
on the wagon train (no opium or alcohol) to go to a sanatorium. As
the fighting shifted, the sanatorium site changed and could not be
reached with the wagon. Finally, the wagon train met the battalion
once more and Loewy was told that the man was “dying.” At this time he
was afebrile, without collapse symptoms, with a strong and normally
frequent pulse, and with few signs of exhaustion. Yet the guard had
thought that he looked moribund. Both upper eyelids were drawn rigidly
up but conveyed a different impression from that in maniacal or
anxious conditions. The expression was that of staring astonishment,
helplessness, and apathetic lack of orientation. The patient recognized
Loewy, spoke to him as “Herr Doctor,” said he was doing quite well;
he was found to be well oriented. There was no fabricating tendency
even as to the number of stools (although Loewy had noted such in
bad dysenteries of the _Shiga-Kruse_ type). He was apparently hard
of hearing, as if at the beginning of a typhoid fever. He showed a
retardation in his intake of ideas, and his voice in answering sounded
absent-minded. There was an expression of absent-mindedness, and the
patient seemed markedly unconcerned about his health, the direction of
the journey, the terrible rain, etc. These phenomena are attributed by
Loewy to attention disorder.

The patient had been out of reach of fire for days. Loewy reports the
case as one of beginning amentia or as an exhausted state resembling a
Korsakow condition, recalling one of emotional hyperesthetic weakness
(Bonhoeffer).


Typhoid fever: Hysteria.

=Case 123.= (STERZ, December, 1914.)

A soldier entering hospital for typhoid fever, October 2, 1914, was
discharged to another hospital and again, November 10, to a hospital
for nervous disease. The typhoid was serious and complicated by
delirium. After defervescence, the patient was weak and could not stand
or walk, especially on account of pains and weakness in the left leg.
Sometimes he had had pains in the sacrum and left hip. He complained
of tinnitus, deafness, dizziness, headache. He said he had fallen from
a cart, had been sick for three months, since which time he had been
under medical treatment for his present condition. He had, he said,
been given a small pension.

The gait disorder sometimes amounted to a real astasia-abasia. The
left leg became stiff and was dragged behind. There was a paresis
demonstrable in dorsal decubitus, of the left side, especially of the
leg, without atrophy. There was a hypesthesia of the whole left side
of the body, with the exception of the head. Hyperesthesia of the left
leg, hip and upper sacrum. The left corneal reflex was diminished.
Moody, hypochondriacal, lachrymose. The general attitude of the patient
was affected and theatrical. Paradoxical innervations were frequently
found on test. There was no neurological disorder except for the
absence of the right Achilles jerk.

The absence of this Achilles jerk may be regarded as a residuum of the
previous accident. The localization of the pains points to a neurotic
lumbosacral plexus disorder on the left side. Superimposed upon this
picture are the hysterical phenomena. The typhoid fever and its
attendant neuritis are therefore to be interpreted as the liberating
factor for a severe hysteria in a subject already disposed to such
symptoms through previous accident.


Dementia praecox versus post-typhoidal encephalitis.

=Case 124.= (NORDMAN, June, 1916.)

A butcher, 29 (aunt insane, sister melancholy, one child stillborn,
deformed), had had several days convulsions at eight; went through
military service without incident; was at the Marne and was evacuated
October 19, 1914, with typhoid fever,--a severe fever with a delirium
prolonged into the last weeks. Three months convalescent leave was
given, passed at Paris with the man’s aunt, but he had become strange.
One day he wanted to strangle neighbors of German origin; another day
departed for Dunkirk and then returned, having lost all his documents.

February, 1915, he went back to the front, did strange things and was
soon evacuated to Tarascon. In April he went back to his dépôt; May 18,
to the hospital at Rennes for erythema. June 15, he was given 15 days
in prison for setting off a cannon too quickly and then running off
through the fields. August 11, he was interned at Rennes for stealing
a priest’s cap. September 12, two months convalescence. December 10,
headaches. Back to Rennes January 14, February 18, Val-de-Grâce, then
Maison Blanche.

Here he was found sometimes sad, immobile; at other times laughing and
singing. He was very irritable on small occasion. Once on leave he
had a fugue with complete amnesia, though alcohol may account for the
latter. His memory was vague, especially for his crimes and for recent
events. He was emotional, indifferent even in the presence of his wife
or aunt. Sexual indifference. He often complained of his head, saying
that he felt it blocked and that he could not think. The headache was
frontal and would last several hours. The man would, however, not
complain spontaneously. He was physically, in general, negative.

This case might possibly be due to a post-typhoidal encephalitis, but
Nordman believes rather that it is a case of dementia praecox. Perhaps
the convulsions at eight produced a slight brain lesion, brought to an
issue by the typhoid fever.


Paratyphoid fever: Psychosis outlasting fever.

=Case 125.= (MERKLEN, December, 1915.)

A Breton farmer, 34, had paratyphoid alpha. Admitted to hospital
September 3, 1915, he had headache, anorexia, asthenia, coated tongue
and tense abdomen, algosuria; later, abdominal swelling, borborygmi in
the right iliac fossa, rose spots, dicrotism, albuminuria, bronchitic
rales. The disease was severe, and was complicated by sacral decubitus
and ran a month.

At first somnolent, September 8th the patient went into a state of
mental excitement with agitation and delirium. He got out of bed, cried
out, sang, talked to his neighbors, complained that his papers (colis)
had been stolen, as well as his watch and tobacco; that his horses’
hoofs had been injured, and the like.

He grew calmer in a few days, and now no longer tried to get up,
remaining inert in his bed. The occupation delirium persisted--he was
not being paid what he owed, and the like. He had hallucinations;
looked for scissors, and one day said, “Here they are!” At intervals he
appeared lucid and responded appropriately to questions.

The fever dropped and the paratyphoid disease appeared past, but the
mental state remained for three weeks without change, having the same
periods of lucidity when he would be regarded as cured, but falling
again forthwith into his post oniric ideas. He was soon sent to a
convalescent hospital and was not wholly well for another month.


Psychopathic taint brought out by paratyphoid fever.

=Case 126.= (MERKLEN, December, 1915.)

A soldier, 31, was a victim of paratyphoid alpha, entering hospital
October 21, 1915, with the usual symptomatology: fever, asthenia,
headache, abdominal swelling, tongue coated and red along its edges,
diarrhoea. After admission he passed into a deep toxic state.

He woke up in the night with a cry, got up afraid, and refused to go
back into his own bed. He was mute, except for curses addressed to the
nurses. After two hours he went to bed and to sleep. Next day he sat
quietly with a depressed look, occasionally groaning deeply, talking in
brief phrases about his anxiety, wanting his wife telephoned to, saying
that he would not see his children, was going into the four planks, and
the like.

This situation lasted about a week. He became afraid of medicines and
thought he had been poisoned, saying that he would rather be shot
than poisoned and complaining that, though he had served France for
fourteen months, they now wanted to kill him. In the night time he
was agitated. He gave vent to cries, and threats, but this delirious
state rapidly decreased and he became calm the night of September 27th.
The upper extremities showed a tendency to catatonia. From this time
forth, during the remaining month, the patient was immobile, mute,
fearful, and mistrusting, depressed and always wore a cunning look. His
disorientation decreased and he passed good nights. He would answer
questions by groaning. He would say, “They think I am a Tartar.” The
end of the mental disorder coincided with the cure of the paratyphoid
fever. According to Merklen, the paratyphoid bacillus in these cases
serves to bring out a psychopathic taint. This particular patient had
always been of a sad demeanor, uncommunicative, very impressionable and
emotional. Two other cases had always been somewhat below normal.


Diphtheria: Post-diphtheritic symptoms.

=Case 127.= (MARCHAND, 1917.)

A farmer, 37, was evacuated March 20, 1916, for diphtheria. April 1,
paralysis of tongue and uvula, impairment of vision. These symptoms
rapidly improved, but paralysis of the legs appeared and then of the
arms. This paralysis lasted until he was sent to the neurological
center June 28 for post-diphtheritic paralysis, wherein it was found
that voluntary movements of the legs could be performed, though
painfully and of slight extent, that walking was impossible, that there
was a considerable atrophy of legs and arms, that the knee-jerks,
Achilles jerks and plantar reflexes were absent. There was complaint of
pains in the legs and over nerve trunks.

Improvement followed, the atrophy gradually passed away, and the
voluntary movements of the legs became more extensive; but by October
the reflexes had not yet reappeared. Yet the patient had begun to
walk on crutches and soon was able to get on with canes only. The
improvement did not continue. He did not raise his heels and dragged
his toes. There was now a clonic tremor of the legs as soon as the
weight of the body was put on them. During movements of legs carried
on in dorsal decubitus there was found an irregular tremor of the legs
with twisting of the trunk. The muscular strength was well preserved.
There was a slight muscular atrophy. The tendon reflexes had now come
back, though the right Achilles jerk was weak and the plantar reflexes
were absent. There was a hypalgesia of the legs which ceased sharply
at the middle of the thighs. There was a slight hypoacusia on the left
side. Visual fields normal. The patient complained of feelings in the
inside of his bones. Electrical reactions normal.


Diphtheria: Hysterical paraparesis.

=Case 128.= (MARCHAND, 1917.)

A soldier, 24, was evacuated June 24, 1915, from Roussy for diphtheria
and was treated by serum, receiving 80 cc. in 8 injections. A few
days later there was a paralysis of the uvula with regurgitation of
liquids from the nose; but patient was able to go on convalescence July
21. A few days later, however, he noticed that his legs were weak.
Vertigo, vomiting and painful walking followed, and his convalescence
was increased a month. The paralysis got progressively worse.
September 10, he went by automobile to Libourne where he stayed two
months. He arrived at the Neurological Center at Bordeaux November 9
with diagnosis “polyneuritis of legs.” He could not walk and could
hardly flex thighs on pelvis or legs on thighs. Voluntary movements
of extension and flexion of feet and toes were limited. There was
neither atrophy, pain nor reflex disorder. Both legs were analgesic,
as was also the abdomen up to the umbilicus. There was complaint of
dorsolumbar pains and of stomach trouble and lack of appetite; vomiting
after meals frequent, pulse 120.

January 3, the patient was able to lift his legs a few centimeters
above the bed but not together. There was now a slight muscular atrophy
especially on the left side. Knee-jerks lively, analgesia limited to
legs, no vomiting, pulse rapid.

The patient was sent to a hospital in the country May 8 to July 8. He
was now much better. His legs were able to support his body but he
could not walk. Slight atrophy of left leg. There was hypalgesia now in
the feet and legs below the knee. There was no pain on pressure over
the nerve trunks. The electric reactions normal. The patient could now
walk on crutches. He was invalided on the temporary basis, December 12,
1916.

It does not appear that in this case the hysterical paralysis was
preceded by polyneuritis.


Malaria: Amnesia.

=Case 129.= (DE BRUN, November, 1917.)

A soldier lost all memory of his hospital stay in Salonica and the
voyage home. He could only remember a little about the hospital at
Bandol. There is a period of transition to full memory in malarial
cases characterized by sure memory, vague on certain points,
alternating with phases of almost complete amnesia. The soldier
in question had very inexact memories of the Bandol Hospital, and
could only remember about his fevers, that they began about noon and
terminated about four o’clock. Twice he had been found in his shirt,
walking, unconscious, in the passageway of the hospital. Having
obtained leave for convalescence, three months after his memory gap
began, he went to Paris, and probably had attacks at home. He vaguely
remembered afterward being carried by automobile to the Pasteur
Hospital, December 1. There he remained to the end of March, 1917,
without preserving anything but the vaguest memories of an intermediary
period of more than six months. The memory in these malarial cases
often remains permanently altered and there may even be a retrograde
amnesia, carrying back to facts prior to the gap and an anterograde
amnesia relative to facts after the main gap.

Thus, there is in the febrile period a retrograde amnesia and in the
post-febrile period a retrograde or anterograde amnesia. One group of
subjects are severe cerebral cases, and the memory gap appears to run
back to a period of true mental confusion. But there is another group
of patients who preserve throughout the febrile period an absolute
consciousness of all acts, and yet the memory gap is just as sharp and
definite as in the confusional cases.


Malaria: Korsakow syndrome.

=Case 130.= (CARLILL, April, 1917.)

A stoker, 45, was admitted to the Royal Naval Hospital, Haslar,
November 6, 1916, from the Fifteenth General Hospital in Alexandria, to
which he had come from a hospital in Bombay about three weeks before.
At Alexandria he was anemic and showed an edema of legs which had been
present for six weeks. Cylindruria; no albuminuria. At Haslar there was
no cylindruria and no edema, and nothing but weakness, gouty arthritis
of left wrist, right ear and left great toe. Red cells 4,650,000,
leucocytes 10,000 (52 per cent polymorphonuclear, 46 per cent
lymphocytes). He was rather dull mentally. December 10th, Dr. Fildes
found malarial organisms in the blood on the occasion of a hyperpyrexia
(104°). Quinine was given. December 14th, he was transferred
neurological. According to the patient’s own story, he was born June
10, 1868, lived in Fulham, had a daughter aged 12 years, had recently
seen his wife at the hospital: all this seemed plausible enough.

Later, however, he said that the year was 1899, that King Edward was
king, that the war was between England and some field forces, etc. This
well-nourished, pale, simple-looking stoker spoke quietly and politely;
told about intermittent fever; about being eight years on the active
list, becoming a reservist and being called up for the war. He read
intelligently, could do sums, but did not know the name of the hospital
and was confused about the war. He recognized that his memory was not
as it should be; constantly stroked his moustache and chin. He was
happy and contented.

The gait was normal, systolic blood pressure 140 mm.; no evidence of
alcoholism. Blood, January 15, 1917, contained 5,050,000 reds, 10,300
leucocytes (63 per cent polymorphonuclear, 37 per cent lymphocytes).
There was a bilateral absence of the ankle-jerks, repeatedly confirmed
at subsequent examinations. Wassermann reaction was negative. Puncture
fluid contained no cells.

Instead of living at Fulham, this stoker lived at Portsmouth, and had
not been seen by his wife for four years. He had done 18 years’ active
service and had last sent his wife a letter from the Sailors’ Home
at Bombay, November, 1916. They had been married 21 years. He caused
astonishment with his wife and friends by announcing that Lord Roberts
and General Buller were in command at the battle of the Falklands.
He continued to say that he lived at Fulham. He was discharged home,
January 22. It seems as if he were living through the period of the
Boer war.

Carlill considers that alcoholism may be ruled out, and there is no
likelihood that the gout was the cause of the neuritis. He believes
that the neuritis was probably malarial. Possibly the illness suffered
in Bombay may have been beriberi or it may have been malarial
nephritis.


A complication of malaria.

=Case 131.= (BLIN, August, 1916.)

A Senegalese corporal of machine gunners, 21 (early life normal save
for sore throats and coughing), was a robust, well-developed man of 75
kilos when he entered the hospital at Konakry, February 15, 1916. He
was given the diagnosis: malarial anterior spinal paralysis.

It seems that he had joined a Colonial regiment, April 8, 1915,
attended classes as a recruit, left Bordeaux November 1 for Dakar,
arriving there November 11. He stayed there some sixteen days, during
which time he slept without mosquito-netting. November 16, he left for
Konakry, and had his first febrile symptoms November 27, with vomiting,
headache, and prostration. His temperature ran as high as 41, but by
December had fallen to normal, after quinine.

The corporal was sent away, cured, to his company at Kouronesa,
December 6. There was more fever, headache, and vomiting during the
railway trip. Quinine again relieved the fever, but a bloody diarrhoea
set in so that it was only at the end of January that he could go on
service.

February 6, another attack of fever, with shivering and perspiration,
lasted for some three hours. He could hardly stand by himself and had
to be helped in walking. Next day, another spell of three hours of
fever; definite paralysis set in, affecting both legs. February 8 the
arms were attacked by paralysis which, unlike that of the legs, was a
progressive one, attacking first the shoulders, then the elbows, the
wrists, and finally the hands. All the body muscles were in a state
of flaccid paralysis, as well as the muscles of the face. The patient
was now afebrile. February 9 there was a slight speech defect; the
tongue was slightly paralyzed, and swallowing became painful. The jaw
movements remained normal. The muscles of the face were intact and the
patient could whistle, move his lips, and move his eyeballs normally.
Vision normal. The pupils were fixed in dilatation, more widely on the
left side. There was a slight contracture of the vesical sphincter,
necessitating the catheter. The tendon and cutaneous reflexes were lost.

By February 14, when the patient was sent to the Bellay Hospital,
muscular atrophy had made its appearance. No plasmodia could now be
found in the blood, which showed 71 per cent polynuclear leukocytes, 20
per cent mononuclears, 9 per cent lymphocytes.

This state lasted til February 25. Despite the fact that the patient
ate well, emaciation rapidly progressed. The buttock showed a very
few signs of decubitus. Upon this date there was pain from a marked
orchitis of the left side, the cause for which remains unknown (no
history of gonorrhœa; catheter used for the last time, February 15).
The temperature which attended the orchitis came down in three days;
the patient’s appetite was singularly good, but the muscular atrophy
increased. The speech defect meantime disappeared, and the patient
swallowed more readily.

March 7 a slight and hardly perceptible movement could be noted in the
fingers of the left hand. Two days later, similar movements appeared in
the right. March 11 he could spread his fingers in a kind of creeping
movement. Next day slight movements were possible with the legs, and
March 13 the knees were movable. March 14 the patient could lift his
head from the pillow. The range of movement now increased all over the
body. According to the patient, those parts were the first to regain
power that had been attacked last. This certainly seemed to be the case
with respect to the left upper limb, in which first the hand and wrist,
then the elbow and shoulder, successively recovered power. The legs
regained their power in the same way proximad. March 17 the patient
could sit up and grasp objects with the left hand. The cremaster and
plantar reflexes appeared,--the former, more on the right; the latter,
more on the left. The left pupil remained in wider dilatation than the
right.

The treatment was by quinin and potassium iodide, with massage. The
patient was apparently on the highroad to complete recovery, and left
for France March 21, weighing 63 kilos.


Trench-foot: Acroparesthesia.

=Case 132.= (COTTET, September, 1917.)

A fantassin, 36, carpenter by trade, went into the trenches October,
1914, and had two attacks of trench-foot, first in January, 1915, when
there was a painful swelling of the foot and secondly in July, 1916,
when there were some bullae on the dorsal aspect of the feet. These
were not serious and the fantassin did not report sick.

He was wounded, August 27, 1916, by shell fragment on the right elbow,
was evacuated to the ambulance where the fragment was extracted and
then to a hospital which he left cured with a seven days’ leave.
Although he had not suffered in any way from his feet while in
hospital, and had not been exposed to cold, the bullae reappeared on
the feet just as they had been in July. They in fact now formed a sort
of exanthem occupying symmetrically the dorsal surfaces of the toes.
The bullae contained serum. They were confluent, varying from pin head
to a nut in size, were as a rule round, but sometimes irregular. The
eruption went on to a cure rapidly and on the twelfth day the bullae
had dried up. This patient had hypesthesia up to the knees, hypesthesia
of the dorsal surfaces of the feet, hyperesthesia of the plantar
surfaces and ankles, hypesthesia of the forearm and the elbow and of
the dorsal surfaces of the hands with possibly exaggerated sensibility
of the palma surfaces. Hypesthesia of the face was limited to a small
part of the right ear. The reflexes were normal and there was no
atrophy. The name “paresthetic trench acrotrophodynia” was given to it.

In a service of eighty beds Cottet found within two months fifteen
instances of these acroparesthetic disorders regarded as neuritic
changes in trench-foot of a latent and lasting character which would
have remained unobserved unless there were disorders of sensibility. In
fact similar disorders of sensibility may be found without any history
of _gelure des pieds_, forming a latent type of neuritic alteration
hardly noticed by the patient himself. In twenty-six cases Cottet found
sixteen with hypesthesia of the ears and of the nose.


Bullet injury of spine; bronchopneumonia: état criblé of spinal cord.

=Case 133.= (ROUSSY, June, 1916.)

As to the development of eschars, Roussy reports the case of a
lieutenant wounded September 25, 1915. There was a penetrating wound
of the interscapular region. The bullet had entered on the posterior
aspect of the right scapular region and had emerged at the level of the
first dorsal vertebra. October 1, a neurological examination showed
flaccid paraplegia, knee-jerks normal, Achilles jerk weak on the right,
plantar reflexes flexor, cremasteric reflex absent on the right, and
both abdominal reflexes absent. There were pains in the legs and arms.
There was retention of urine with overflow. A slight dulness on the
right; temperature from 38 to 39 degrees.

Four weeks later the knee-jerks had become very weak, and the Achilles
jerks were now absent. There was an extensive diffuse atrophy of the
lower leg and thigh muscles, and a hypesthesia of pronounced degree had
developed throughout the legs, over the buttocks, and in the lumbar
region. Anal and vesical sphincters relaxed; dejections voluminous;
sacral decubitus as well as healed eschars. December 5, the patient was
transferred to the Army neurological center; temperature rose; there
was much expectoration; paracentesis yielded no fluid; pneumococcus
in the sputum. Cystitis had developed despite extreme care. Extensive
edema of the legs developed. There was increased dulness on the right
side, coughing and dyspnea. Death, January 17.

The autopsy showed a bronchial pneumonia of the right lower lobe,
confluent, imitating a lobar pneumonia. The left lung also showed
extensive confluent bronchopneumonia at the base as well as
disseminated areas and edema of the middle and apical portions.
Infectious splenitis, large fatty liver, swollen kidneys, no
pyonephritis.

The spinous processes of the 6th and 7th cervical vertebrae were
injured. There was no obvious gross disease within the theca except
that there was a slight adhesion between the dura mater and the
anterior surface of the spinal cord at the level of the 7th cervical
and highest dorsal vertebrae. There was, however, a depression on
the anterior surface of the spinal cord at a lower level, namely, at
the level of the 4th dorsal vertebra. Microscopic examination showed
myelomalacia with small cavities in the 1st and 4th dorsal segments,
suggesting the _état criblé_.

According to Roussy, these patients injured in the spinal region are
particularly sensitive to cold and support transfer badly even when the
disease is short. Such patients should be evacuated to the interior
after the shortest delay possible. Sometimes these patients show rib
fractures; these are in the posterior portions of the ribs and are due
to the fall of the man when struck. It might be possible even that the
spinal lesions should through the action of the sympathetic nervous
system favor lung infection.


Shell-explosion: Hystero-organic symptoms; decubitus; radicular sensory
disorder.

=Case 134.= (HEITZ, May, 1915.)

A soldier, 32, was bowled over in a first-line trench by the bursting
of a shell that he did not see coming, September 14, 1914. He regained
consciousness only in the middle of the night, finding himself half
covered with water. He was taken up by the stretcher-bearers at
eleven in the morning. Paralysis in the legs was then absolute. There
were pains in the legs and in the back, but there was no evident
lesion. Knee-jerks, plantar reflexes, and abdominal reflexes absent;
cremasteric reflex absent on the left, weak on the right. Tactile
sensations, on the contrary, were almost intact except for a slight
diminution over the feet and the external aspects of the lower legs.
Sensitiveness to pin-prick, however, was abolished throughout both
lower extremities, and diminished in the abdomen and back up to two or
three centimeters above the level of the umbilicus; that is, including
the territory of the first lumbar and the last three dorsal roots.
Sensibility to heat was abolished in the feet, the external aspect
of the lower legs, and the posterior aspect of the thighs, but was
preserved in the second and third lumbar territory, in the anterior
aspect of the thighs, as well as in the region below the umbilicus.
Micturition was impossible. Constipation the first few days yielded
spontaneously September 20. There were signs in the bases of both
lungs, corresponding with a suffocating feeling. September 22, he was
evacuated, almost well, without signs of pulmonary congestion, having
regained the power of urination and some capacity to move the legs
sidewise. February, 1915, after evacuation to a hospital at Vic, he
showed sacral decubitus, soon reaching the size of a hand, as well as
trochanteric decubitus; traces of albumin in the urine, sacral and
sciatic pains (recalcitrant to morphine).

He began to improve December 25. Camphorated oil and the sitting
posture relieved the pulmonary congestion; the temperature, which had
oscillated round 38 degrees, fell; the decubitus scarred over; the
knee-jerks reappeared to some extent, and movements began. February 5,
the patient had become able to walk without crutches. There was still a
two-franc sized area of decubitus over the sacrum, and still a little
spinal pain in walking.

It is difficult to consider this case only functional in view of the
decubitus, to say nothing of the radicular distribution of the sensory
disorder. Heitz brings this and the previously given case (No. 1) into
relation with Elliot’s case of transient paraplegia (see Case 210) and
Ravaut (see Case 201).


Shell-shock (windage?); typhoid fever; “neuritis” actually hysterical.

=Case 135.= (ROUSSY, April, 1915.)

A Colonial soldier was sent back from the front, September 12, 1914,
for nervous disorder due to the shock of the windage of a bullet.
He had not lost consciousness. Under observation at his station, he
got typhoid fever, and was cared for at Paris from the beginning of
October. About October 15 he began to feel pains in his left shoulder,
neck, and arm. The diagnosis, neuritis, was made and was strongly borne
in upon the patient, so that upon the cure of his typhoid, he went out
on two months’ leave with a complete impotence and much pain of the
left arm. At the end of his relief, he was evacuated to Villejuif.
January 24, it was found that he had no somatic phenomena whatever,
despite the fact that the left arm and a part of the forearm was
powerless, and so painful that the patient cried out when his arm was
moved. There were a few cracklings in the scapulo-humeral joint.

Hot air and reëducation cured the man in less than two months (March
20), though the disorder had lasted for four months. The patient had
been retired for hysteria before the war and had re-enlisted.


Bullet wound of pleura: Reflex hemiplegia and double ulnar syndrome.

=Case 136.= (PHOCAS AND GUTMANN, May, 1915.)

A soldier, 26, was wounded in the enfilading of an Argonne trench
December 17, 1914. He felt the bullet like an electrical shock, and
fell. He had been leaning forward at the time and suddenly felt the
left half of his body go paralyzed and his mouth pulled to one side.
He did not lose consciousness, and spat up a good deal of blood five
minutes after falling. He lay in the trench all night, unable to move
his left leg except by the aid of his right. He was evacuated next
day. There was a five-franc piece wound at the upper border of the
left scapula, four finger-breadths from the median line. There were a
few lung signs which rapidly cleared up. December 28, the hemiplegia
was better, although neurological examination showed weakness of left
upper extremity, abolition of deep reflexes, and certain skin changes
of the left hand with edema (_main succulent_), decreased resistance of
muscles of lower extremity to passive motion, especially of adductors
and flexors, exaggerated polykinetic left knee-jerk, ankle clonus,
Babinski reflex, abdominal and cremasteric reflexes absent on left,
platysma paralysis left, with complete paralysis in the inferior
distribution of the facialis; whistling impossible. Also the left eye
could not be closed singly. Synergic movements of the lower part of the
paralyzed face when the right hand of the patient was grasped.

There were also sensorimotor disorders in the ulnar distribution on
both sides, with complete anesthesia to pin prick. There was also an
area of hyperesthesia of the anterior and postero-internal aspect
of the right forearm from below the elbow to the wrist. The tendon
reflexes were weak but distinct on the right side. The left arm had
feelings of pain, with _élancements_ and formication from the shoulder
to the fingers on the ulnar distribution. There was, of course, also,
local hyperesthesia due to the wound of the thorax.

Lumbar puncture showed a fluid normal in all respects. We deal with
a hemiplegia of organic nature, associated with the bilateral ulnar
syndrome. The hemiplegia followed the trauma immediately. When the
ulnar phenomena appeared is unknown.

The lung complications cleared. The pains disappeared; motion returned
up to the level of the facialis. The patient got up and three months
later went on convalescence, still presenting Babinski, exaggerated
knee-jerk and weak arm reflexes on the left side. The bilateral
ulnar syndrome had disappeared six weeks after the patient entered
hospital. Phocas and Gutmann cite a considerable literature on
nerve complications of pleural trauma, among them syncopes of grave
prognosis; a relatively frequent pleural epilepsy (forty-five per cent
fatal) or epileptic status (seventy per cent fatal); and the rare
hemiplegia. Accidents and death have followed exploratory puncture of
the pleura. Air embolism is probably not the cause. Phocas and Gutmann
prefer the theory of a reflex disorder starting from the pleura.


Hysterical tachypnoea.

=Case 137.= (GAILLARD, December, 1915.)

A man, 23, came to the Lariboisière November 29, 1915, in a hurry
to show evidence that he had been invalided for valvular lesion of
the heart. In point of fact, the interne found a murmur at the base.
Yet there were things in the military papers suggesting caution. The
patient next morning showed no malaise, dyspnoea, or any evidence of
serious disorder. The contractions of the thorax beat in time with
contractions of the alae of the nose, about 112 per minute. Here, then,
was a cardiopulmonary patient. The heart impulse was exaggerated; the
patient could not or would not stop breathing to aid the auscultation,
but almost absolutely normal sounds could be heard at the apex and the
base. A valvular lesion could be excluded. The lungs were perfectly
normal. The patient was requested to stop his gymnastics, which might
have succeeded elsewhere but could not at the Lariboisière!

How could the man have established the synchronism of pulse and
respiration and synchronous tachypnoea and tachycardia? Why should he
persist in this form of sport, since he had already been invalided?
The family history was not especially suggestive (father albuminuric,
died at 59; mother well, probably tuberculous). Scarlet fever at eight;
occupation, tourneur. After four months of service there was gastric
disorder followed by typhoid fever (despite vaccination, according to
the patient). Convalescent leave at Paris, during which leave he had
swollen legs and albuminuria. May, 1915, gastric difficulty; valvular
lesion determined; examination; invalided. At home, a variety of
complaints, for which treatment was unsuccessful.

During further examination it was noted that in auscultation the head
of the examiner was lifted, as if there were hypertrophy of the heart
or an aortic aneurysm. The synchronism was less exact on December 2;
112 beats to 128 respiration. Was this man a simulator? Had he become
the victim of his own enterprise? There was no evidence of simulation.
It was a question of a monosymptomatic hysteria. Gaillard discontinued
the _manière forte_ and undertook a softer treatment, but the _manière
forte_ had caused the family to want to take him away. Perhaps they
feared a too efficacious treatment. He then escaped observation. It is
probable that the tachypnoea ceased during sleep. It was not so marked
after the medical visit was over.


Soldier’s heart.

=Case 138.= (PARKINSON, July, 1916.)

A corporal, 21, who had been a miner and entirely well up to enlistment
in August, 1914, went to France in 1915. In June, came shortness of
breath and palpitation on exertion; later, precordial pain (fifth
space, between nipple and median line) and giddiness on walking. Like
all cases of true so-called “soldier’s heart,” this soldier had no
physical signs indicative of heart disease, yet reported sick for
cardiac symptoms on exertion. In this particular case, as in about half
of forty cases reported by Parkinson, there had been no disability in
civil life.

August, 1915, the soldier was admitted to the casualty clearing
station, where the apex beat was found in fifth intercostal space
internal to the left nipple line. The first sound was duplicated in all
areas. The second sound was duplicated, though not loudly, at the base.
After nine months’ treatment, this man went back to light duty with
slight symptoms.

According to Parkinson, the absence of abnormal physical signs in
the heart of a soldier should not prevent his discharge from the
army if under training or on active service he shows breathlessness
and precordial pain whenever he undergoes exertion well borne by his
fellows. A simple exertion test, such as climbing 25 to 50 steps,
reproduces the symptoms in such a patient. The rate of the heart at
rest is a little higher than that of normal men, though the increase on
exertion is greater. Nevertheless, it has been proved that the increase
of rate on exertion bears no relation to the symptoms elicited and is
therefore without value in judging the functional efficiency of the
heart.


Soldier’s heart?

=Case 139.= (PARKINSON, July, 1916.)

A sergeant, 36, had been in the army from 17 to 29, but in 1908 he
had acute rheumatism and was discharged from the army. He then became
a furnace man and had shortness of breath and palpitation on severe
exertion with syncope three times.

He re-enlisted in August, 1914, and had an attack of orthopnea and
edema after exposure at a review. However, he improved and went to
France in May, 1915, where he again had symptoms; namely, precordial
pain and breathlessness on severe exertion. One day while carrying
telephone wire under fire, the sergeant felt a sudden pain in the
region of the apex beat, shooting down the right arm. “I thought I
was shot.” He fell down, very short of breath. His left arm remained
sore and weak. Two days later came a similar attack, this time with
unconsciousness, and the left arm was now useless. Two days later he
was admitted to hospital, where slight breathlessness but no pain and
no enlargement of cardiac dulness could be found. No further details
are available but it seems clear that this man is unfit for duty.
According to Parkinson, it is probable that the infection indicates the
presence of some degree of myocardial disease.


Strain and shell-shock: Acceleration of diabetes mellitus.

=Case 140.= (KARPLUS, February, 1915.)

An infantryman, aged 22, previously healthy and from a healthy family,
was struck by a shell fragment in the forehead and lay for several
hours unconscious. He did not vomit. He had a number of furuncles on
his body and his urine, upon examination, showed a severe diabetes
mellitus which increased despite treatment. Upon an attempt to withdraw
carbohydrate, the sugar suddenly sank from six to four per cent.
Acetone at the same time increased. An abrasion had been noticed by the
patient a few days before the shell explosion on the spot rubbed by the
_tornister_. The patient said that since his accident he had had to
urinate every night several times and was often very thirsty, neither
of which tendencies had he had before. A month before he became _merod_
he had had an injury of the hand produced by a shell fragment. He had
undergone tremendous strain.

The chances are that the excitement and the strain had more to do with
the diabetes mellitus than the shell explosion.


Dercum’s disease.

=Case 141.= (HOLLANDE and MARCHAND, March, 1917.)

An adjutant in a chasseur battalion was buried by a shell explosion,
which killed his lieutenant beside him, January 5, 1915, at
Hartmannsweilerkopf. Hematuria followed; ten days later, fever with
anorexia, and the appearance of two or three lipomata on the anterior
surface of the thighs. Remaining at his post, the adjutant took part
in an attack, March 5; was evacuated on the 8th; “lipomatosis with
febrile reactions.” He spent eight days at Bussang, and thence went to
the hospital at Pont-de-Claix. Here marked albuminuria was noted; the
lipomata increased in volume; others appeared in the arms. The patient
was transferred to the Des-Genettes, where the diagnosis nephritis
was added to the previous diagnosis, and a milk diet was prescribed.
Convalescence of five months was proposed. The lipomata increased in
volume and in number. The patient was then hospitalized at Avenue
Berthelot, placed in the auxiliaries, and stationed eight months at his
dépôt.

When he was observed by Hollande and Marchand, four nut-sized tumors
were found on the anterior surface of the left thigh; two smaller
tumors: one of them painful to pressure, lay on the inner aspect,
another the size of a small egg lay in the right thigh, and there
were two others on the internal aspect and two on the external aspect
of the thigh. A nut-sized tumor was found on the inner border of the
right forearm, and below it another lenticular tumor. A nut-sized
tumor was found on the left forearm below the elbow on the internal
border. Small tumors were found on the buttocks. There were no tumors
below the knees, in the upper arms, or on the thorax. There were 14
tumors in all. The smaller the tumor the more sensitive, and there
was more pain when the tumor had just appeared and during the first
days of its growth. There was no spontaneous pain; pain only upon a
blow or pressure. Diminished knee-jerks, especially the right; no
other neurological disorder, although the patient complained of often
having something before his eyes. There was a marked diminution in
the memory. Heart was in the 5th space on the nipple line, pulse 110;
Wassermann reaction negative; red blood cells, 3,520,000, white cells,
6500; albuminuria, hematuria, leucocytes, and urethral cells in the
urine. The temperature had now become normal. The lateral lobes of
the thyroid were slightly larger than normal, but not painful. Sella
turcica was unchanged upon X-ray. Exploratory puncture of a tumor
showed much free fat, without fatty acid crystals and with some fat
cells. The cells could not be cultivated in test tube. The authors
believe it doubtful whether this instance of Dercum’s disease is
related with the shell explosion.


Hyperthyroidism.

=Case 142.= (TOMBLESON, September, 1917.)

A private, 22, was selected by Col. Garrod for hypnotic treatment by
Tombleson from among the hyperthyroid cases. He was admitted April 3,
1916, with a typical hyperthyroidism, with manual tremor, enlarged
thyroid, pulse 120, blood pressure 136-40, and hemic murmur. Tombleson
induced deep somnambulism at the first hypnotic sitting and suggested
an increase of nerve strength and steadiness. The suggestions under
somnambulism were repeated for ten days. An occasional added suggestion
was given as to lessening of the thyroid. At the end of the ten days
the patient declared himself quite well.

Eight of twenty consecutive functional cases treated by hypnotism by
Tombleson were cases of hyperthyroidism and in virtually all of these
an effect like the above was registered.


Shell-shock; thrown against wall, stunned, emotional: Paroxysmal heart
crises six days later, observed for two months. Neurasthenia? Mild
Graves’ disease?

=Case 143.= (DEJERINE AND GASCUEL, December, 1914.)

An infantryman, 29, was sent to auxiliary hospital No. 274, for heart
trouble, a little thin but looking vigorous enough (typhoid fever at
13 and some diseases of unknown nature and of brief duration while in
military service).

September 24, a large calibre German shell burst and threw him against
a wall, producing no wound or contusion. He was momentarily stunned,
emotionally much affected, and noted at the time extreme palpitation.
He was evacuated to Paris September 30, six days after the shock. His
pulse was 130-134, regular, and the heart seemed not to be anomalous in
any respect.

But there were paroxysmal crises in which the pulse rose to 180 and
in which the patient fell into a state of great anxiety. The mouth
temperature in the midst of such crises would always rise to 38°,
and this temperature would outlast the rest of the seizure. The man
was mentally depressed and apparently indifferent, preoccupied with
his heart and his insomnia, but at the same time emotionally easily
affected. In short, he was a neurasthenic. There was no change in
mental state, tachycardia, or paroxysmal seizures in two months, except
that he gained weight. Walking and climbing stairs produced dyspnoea.
Urine was negative. According to Dejerine, such a case should be
treated by psychotherapy.

Alquier, in discussion, called attention to the slight but distinct
tremor in this case, dermographia, and spells of perspiration. He
suggested that the case might be one of mild Graves’ disease.


Hyperthyroidism three months, following ten months’ service, at times
under protracted shell fire.

=Case 144.= (ROTHACKER, January, 1916.)

A man in service ten months, under strong excitement and at times under
protracted shell fire, complained of palpitation, insomnia, dizziness,
and dyspnoea. Hospital notes showed that the left lobe of the thyroid
was somewhat enlarged. Before the war his neck could not have been
very thick; he had served his year out without difficulty. His mother
is said to have suffered at one time from thick neck. According to the
patient, he had never suffered with heart trouble. Heart not enlarged;
blowing first sound over the apex. Graefe, Stellwag and Möbius signs
negative. Heart rapid, not irregular; pulse strong. There was fine
tremor of the hands, as well as a tremor of the tongue. Knee-jerks
increased.

The patient was at first sleepless and excited, but after three weeks
in bed the heart murmur had disappeared. After three months, he was
ordered to _Ersatz_ with the left side of the neck measuring 20 as
against 18 cm. on the right. There was a soft pulsating swelling of the
thyroid. First sound over apex still impure; heart action now regular;
pulse 64; blood pressure 120 Riva-Rocci; after test exercises, slight
dyspnoea. No cyanosis. The outstretched hands were no longer very
tremulous. The knee-jerks were still increased. The man had begun to
sleep well. His neck was apparently much diminished in girth.

Here then was a case of Graves’ disease of acute development, brought
out by nervous stress and excitement as well as by 10 months of war
work and exposure to shell fire,--with approximate recovery after three
months of rest.


Graves’ disease, forme fruste.

=Case 145.= (BABONNEIX AND CÉLOS, June, 1917.)

A farmer, 31, entered the Rosendael Hospital, Jan. 25, 1917. He had
been two years in active service. The family history was negative
except that one of his sisters had had dyspepsia. The patient denied
venereal disease and alcoholism and had always been well. At the Battle
of the Marne he was slightly wounded in the left knee. January, 1915,
he was exposed to gas bombs and explosive shells. He was several days
in the hospital spitting, or perhaps vomiting blood and was sent on a
long convalescence. On returning to the front, he had to be sent back
to hospital with a note, “not fit for service, nervous troubles and
paroxysmal tachycardia.” In point of view he now showed a number of
symptoms suggestive of Graves’ disease, such as a definite exophthalmia
which, according to the patient, started up a short time after the
shock and a tachycardia (110-120) with circulatory excitement, a
tumultuous heart, neck arteries contracting, almost dancing in their
contractions, together with a systolic murmur maximal in the pulmonary
area, not retaining, variable,--in short, suggestive of an inorganic
murmur. There was also a generalized rapid tremor and a variety of
vasomotor disorders, such as blushing and paling, perspiration,
exaggerated reflexes, emotionality, logorrhea, jactitation. There were
also digestive troubles, regurgitation after meals and the patient had
become thin and weak.

There was, however, no swelling of the thyroid gland nor any eye signs
other than the exophthalmia. In short this case is doubtless one of
the _forme fruste_ of Graves’ disease. It seems to show that Graves’
disease may have a traumatic origin.


Somatic complication in a shell-shock hysteria (Trauma).

=Case 146.= (OPPENHEIM, February, 1915.)

Musketeer. No faulty heredity, but was always somewhat nervous. On
October 26, a shell burst one meter in front of him, burying him under
the anterior wall of the trench. He was dug out and taken to the field
hospital, where he remained unconscious until the next morning. On
October 29, he was taken to the reserve hospital. Severe pain in the
head, entire scalp tender on pressure, especially in the left frontal
region, left side upper lip swollen, bluish and discolored. Left tenth
and sixth ribs broken. Fracture of skull(?). November 10, at eight
o’clock at night, sudden attack of vomiting, and the patient was found
in a faint in the water closet. Almost complete paralysis of speech
and all of the four extremities. Consciousness obscured; no sensory
disturbances. November 11, severe headache and vertigo. Speech somewhat
more intelligible. Pulse, 60 to 68. “Evidently secondary hemorrhage in
the brain.” November 12, to Augusta Hospital. November 20, admission
to nerve hospital. Typical aphonia. Limitation of motion in all four
extremities, but no paralysis--anergy. Reflexes normal. Unable to
stand and walk. Sensibility preserved. Under suggestive treatment,
curative gymnastics, as well as electrotherapeutics, the aphonia
and abasia disappeared in a few days, but the patient continued to
complain of headache and insomnia. December 16, an attack of nausea,
headache, vomiting, loss of consciousness, followed by epistaxis,
marked tachycardia. January 4, in his sleep he felt a prick in his left
upper arm, as if he had pushed a sewing needle into the arm. X-ray
examination showed a needle in the arm. This was extracted under local
anesthesia.



VIII.[5] SCHIZOPHRENOSES

(DEMENTIA PRAECOX GROUP)

    [5] VII. Geriopsychoses (senile-senescent group) not
    represented in war cases (see page).


The Sister’s ear boxed for blow to a German soldier’s pride: Diagnosis
PSYCHOPATHIC CONSTITUTION! A true psychosis develops: hate of Prussia
and the Junkertum: Diagnosis, DEMENTIA PRAECOX!!

=Case 147.= (BONHOEFFER.)

A sick soldier in a military hospital kept complaining of being waked
up too early, and of poor food. His reactions looked like the irritable
weakness of a psychopath. One day he went into a room where a woman
was being examined, without knocking. When ordered out, he boxed the
Sister’s ear.

He said himself, on transfer to the psychiatric clinic, that he had
always been quarrelsome as a child with his brothers and sisters,
subject to fainting spells, and poor and stubborn in military
service,--all of which seemed to clinch the diagnosis of psychopathic
constitution.

But he seemed to show a decided lack of autocritique. About boxing
the Sister’s ear on her saying “Please go out,”--his idea was that he
could not let a thing like that happen to him,--a German soldier and
a patient! Moreover, “It should not be thought that perhaps I had a
love affair with her! There was a cynicism about her.” The Sister had
a strong sex impulse, he could see that by her nose: she was, so to
speak, “hypochondriacal.” Both in speech and writing he used stilted
phrases. The ego at last swelled to the point of his saying that he was
an inhabitant of the World and hated Prussia and Prussian _Junkertum_.

Then came unmotivated states of excitement, with pressure of speech
and motion, and eventually negativism. Accordingly, the diagnosis
hebephrenia finally replaced that of psychopathic constitution.


Dementia praecox, arrested as spy.

=Case 148.= (KASTAN, January, 1916.)

A German private, called to the colors, was supposed to take his
civilian clothes to the post office along with his comrades on March
21, 1915. He did not get his package ready in time and was ordered to
go with another troop. At an opportune moment, he left the barracks
with the package of clothing. When later arrested, he said that he had
gone by railroad to Dirschau; then he had visited Berlin. After this,
he had walked to Bromberg, Schneidemühl, and Landsberg.

At last he had ridden back to Küstrin. At Küstrin some children told
a railway official that the man was making drawings. There was a
petroleum tank near by. Accordingly, he was arrested as a possible spy.
He claimed that he was not a soldier.

In the clinic, he looked dull and smiled a good deal. It seems that,
before being called to the colors, he had been very angry with his
wife and had even threatened her. He now explained this anger as his
wife’s fault. She had attacked him, he said. He said that he sometimes
had attacks of weakness, which used to last two days at a time, but
they had recently lasted for a shorter time. He said that his thoughts
always wanted to be somewhere else. In fact, he had not performed
military duty. His uniform had been gotten for him, but he had had no
further orders. Sometimes in a fever or dream his head seemed to be as
big as a room, as if there were no space for it. There was an itching
in his legs, he said, which often fell asleep so he could not stand on
them. He had had syphilis seven years before, after which he had been
hoarse, forgetful, and anxious.

Examination showed perceptive power and knowledge to be good. He played
the violin, but always the same tunes. He said that he had not worked
in Berlin during the winter of 1914. He spoke as if he had been in
another sanitarium, where he did nothing but dream by himself, taking
no interest in things, and lying indifferently, with a blanket over
him.

He said that when he received the uniform he had a longing for clean
underclothes. Requested to explain the meaning of the uniform, he
remarked: “Why, many have these things on.”

_Re_ dementia praecox, Lépine states that in the French army instances
of dementia praecox have been numerous in the interior, both at the
time of mobilization and at the time of calling out sundry new classes.
He notes that the courtmartial and invaliding experts have neither the
leisure nor the experience necessary to keep these men from going into
the army. The somewhat frequent remissions in dementia praecox make the
task all the more difficult. To be sure, the stuporous and catatonic
cases are not very much in evidence in the army; when such cases do
occur, it is easy enough to evacuate the patients to a hospital for
observation. Far more troublesome are cases of a less advanced or
milder nature. Here are cases in which judgment is deficient, and in
which quite unsystematic, incoherent, and transient delusional ideas
occur. The patient looks quite normal to the non-psychiatric expert.
Something odd happens which quite suddenly reveals the delusional
ideas. For example, there is a fugue, or else the soldier goes to his
superior and aggressively chides him for having troubled him the night
before. These particular psychopaths are among the most dangerous to be
found in the army.


Fugue, catatonic.

=Case 149.= (BOUCHEROT, 1915-6.)

A gunner, aged 23, enlisted on the expiration of his regular period of
service and was a good soldier, in excellent health, up to June, 1915.
He then began to have a few vague ideas of persecution. In a short
time these became more definite and he caused talk by requesting to
go into another corps because his comrades did not like him. He told
his brigadier that the soldiers were frightening him by magnetism. He
had hallucinations of hearing people say, “He will get it.” He kept by
himself, would not eat and stood motionless for long periods of time
before his mess-tin. He was often found in a dreamy state of apathy.
One day he left the cantonment without leave, wandered through fields,
had coffee in a village and then started off in no special direction.
The police took him without resistance the next day. He said, “My
comrades are in politics; they are going to cheat me.” He was brought
to Fismes and the ambulance surgeon said that he found he did not know
what he was about. He was amnestic for the fugue, explaining that he
went because he was frightened. It was hard to get him to eat.

July 14, he was evacuated to Fleury protesting arrogantly, but this
phase of excitement passed and he became absolutely indifferent and
disoriented. He became untidy in his person and in no way could his
attention be attracted whether by mentioning his family or the war. He
sometimes made ape-like grimaces and sometimes laughed causelessly. He
was occasionally negativistic, but in general was perfectly compliant
with the requirements of the hospital. Now and then he started off
impulsively to escape but was brought back quite indifferent. Now
and then he went into bizarre contortions on a medical visit or
aped gestures of bystanders. He began then to go into stereotypical
attitudes. This case is the only catatonic one found by Boucherot in
his war group.


Desertion: Schizophrenic-looking behavior. Adjudged responsible.

=Case 150.= (CONSIGLIO, 1915.)

An Italian private in the artillery, a telephone operator at the front,
came up for desertion in the face of the enemy. It seems that he had
often left his post, going off for a number of hours and drinking.
At last he lost his position in the battery, went off and got drunk
again, and was removed to a hospital and held as a neurasthenic and
psychopathic patient. At the territorial hospital he was regarded as
a melancholic. He still showed signs of alcoholism, was hallucinated,
did a number of peculiar things, was impatient of medical examination,
and was given a furlough of two months for convalescence. He apparently
grew somewhat better in his father’s home, but went to a physician
there and presented his certificate as a mental case. His behavior was
so peculiar on subsequent arrest that he was sent for observation to
Consiglio.

It appeared that he had been in military service from August, 1912, and
had been imprisoned for a space of eight weeks for disobedience when
he had been in military service for six months. He had been punished
in the army nine times, once being given 70 days for lying. He was
regarded as an undisciplined soldier but not as a nervous or mental
case.

At hospital he was in a semi-stupor, claimed that he was forgetful,
was apathetic concerning home and relatives, complained of pain in
the head, and altogether preserved a strange and stolid attitude with
occasional gestures, mimicry, and stereotyped reactions. As he had come
to be operated upon, he looked about for the cannon that was to be used
in the operation. Accordingly the question of dementia praecox might
well be raised.

His indifference turned out actually to be assumed and pretentious. He
preserved throughout an arrogant tone, and there were features in his
voice that strongly suggested simulation.

According to Consiglio, we are dealing with an epileptic degenerate,
addicted to alcohol, lying, and immorality. The question concerning
responsibility was settled in the affirmative. Of course, it might be
thought that the case was one of pathological intoxication, in which
case, the man might be regarded as only semi-responsible. However,
the phenomena of simulation, not merely in the observation hospital
but also in the period of apparent depression and strange conduct
immediately following his arrest for desertion, led to the decision
that the man, despite his nervous abnormality, was responsible for his
act. He was condemned to 20 years in prison.

_Re_ dementia praecox, Buscaino and Coppola found a number of cases
of dementia praecox amongst soldiers admitted to hospital during the
period of mobilization; cases amongst men who had not yet been at the
front. These mobilization cases, in fact, were as a rule either cases
of dementia praecox, cases of a psychopathic constitution, or cases of
alcoholism.


A disciplinary case: Schizophrenia, alcoholism.

=Case 151.= (KASTAN, January, 1916.)

In October, 1914, a German soldier returned to his barracks late from
a drinking bout. He insolently called for order, brandishing his
arms, and when the captain rebuked him, he kept a cigar in his mouth.
Examined in hospital (Allenberg), he was very reticent at first but
wrote his name up over the bed with the additional word “_Dead_.” He
answered, “I don’t know” to most questions. Although it was December,
he said the season was summer. He was to be shot for disrespect, he
said, but showed more disrespect at every remonstrance. “What is your
regiment?” “I am no soldier at all, you know. I have already been
discharged as unfit for service.” “Have you been in prison?” “I don’t
know. My father often thrashed me.” Then suddenly, after a moment, “I
was in prison five, seven, and two years, and my father was in prison
four, six, and three years.” He said that he had drunk ether and urged
the physician to try it, as one saw all sorts of beautiful pictures and
figures and heard music.

Upon investigation, it was found that the man had been in a provincial
sanatorium for some form of degenerative mental disease with
excitement. He, at this time, had given a number of fantastic stories
concerning his wanderings. For example, he said he had come from
Australia, where he had eaten snipes and crows; that he was on his way
home and would get there in half an hour (real distance 10 hours). Or
again, he would roll his eyes, assume a false name and say that he
had come from Morocco, or that he was the emperor and would not play
soldier. When asked to repeat digits, he habitually omitted the last
digit. He had been a poor scholar, and of a tricky and treacherous
character.

Despite this history, he had behaved well in the army at first, though
insolent to superiors. On July 5 he had a heavy drinking bout, and
wrote next day to his mother that he was going to commit suicide.
At this time he had been put for safe keeping in a cell, where he
saw foxes making as if to bite him. He also said that he was a rich
nobleman, a cavalry captain with a servant (asked to be given his
pressed clothes and his cigarettes), and was being pursued. He rode
his pillow as if it were his horse, and hid it in the horse’s stable,
namely, the bed. He ate nothing, as he thought everything was poisoned;
smeared himself with faeces and drank urine as “strawberry punch.”

We are evidently here dealing with a psychopath of schizophrenic
tendencies, strongly colored, however, by alcoholism. The patient’s
father was a drunkard, and a brother and sister were insane.

_Re_ schizophrenia in the German army, Saenger remarks that like
paresis, so also latent dementia praecox becomes acute under war
conditions. E. Meyer states that amongst 1126 officers admitted to his
hospital, August 1, 1915, there were 352 that had either psychoses or
neuroses, amongst which were 148 psychogenic cases (either psychopathic
or hysterical), 128 with what he terms a congenital psychopathic
diathesis, and 76 with traumatic neuroses. The cases of congenital
diathesis were somewhat difficult to diagnose, since but 44 of these
were clearly psychopathic and in the remainder the question of dementia
praecox or of cyclothymic conditions arose.

Stier gives statistics for 1905 and 1906 in the German army, namely 35
per cent of dementia praecox cases. Under war conditions the army has
developed far fewer cases: Bonhoeffer, 7 per cent; Meyer, 7.5 per cent;
Hahn, 13 per cent. But although dementia praecox figures so much less
frequently in the mobilized army than in the army of peace times (manic
depressive psychosis is also less in evidence under war conditions),
the psychopathic constitutions, hysterias, traumatic neuroses, and
the like, run from 17.5 per cent (Stier, 1905-1906) to 54 per cent
(Bonhoeffer), 37.5 (Meyer), 43 per cent (Hahn).


Schizophrenic symptoms. Aggravation by service.

=Case 152.= (DE LA MOTTE, August, 1915.)

A Landsturm recruit, 20, and somewhat peculiar in early life, got
whipped by his comrades for getting back too late from leave. The next
day he was commanded to carry a machine gun. He threw the gun down and
made for the barracks. He was put under psychiatric observation, as
he said he did not know what he was doing. His conduct seemed normal
at first and he explained that he had heard noises and singing in his
head,--pointing to the left ear where there was an otitis media. His
skill, knowledge, and general experience seemed well in hand. However,
he was not very communicative. Eventually a series of schizophrenic
symptoms came to light. He had been hearing threatening voices of
varying intensity for two years, sometimes a veil seemed to be before
his eyes, sometimes he heard his thoughts, and felt that his whole
personality was changing. He began to think that his facial traits were
gradually turning into those of the physician. The hallucinations were
so insistent that sometimes he did not know what he should do. He was
evidently unfit for military service, and the decision was also made
that the mental disease had been aggravated by service.

_Re_ schizophrenia in the service, most authors point out that there
was either patent or latent schizophrenia before mobilization. E. Meyer
attempted to make a study of the influence of the war on psychopaths.
He found that the ego of the psychopath remained relatively unaffected
by the war. Naturally, the paretics and the seniles were unaffected.
The grandiosity and self-centredness of the alcoholics remained as
prominent as ever. Seventeen schizophrenic cases were studied, and some
of these yielded entire apathy with respect to the war; others had the
content of their delusions somewhat affected. Saaler remarks on the
military tinge which dementia praecox assumes under war conditions.
Dementia praecox and manic-depressive psychosis alike show war changes.


Shot himself in hand. Delusions.

=Case 153.= (ROUGE, 1915.)

An infantryman, 26, left for the front August, 1914, was slightly
wounded, recovered, went back to the front, and then is said, in March,
1915, to have shot himself in the hand. When up for military review a
delusional state set in. It seems that he had been interned in several
hospitals for examination, but escaped four or five times because
physicians wanted to poison him and had partially succeeded.

He came to the Lemioux Custodial Institution, July 12, 1915. His
brother, 15, was a _voyou_; his sister, 16, was an imbecile. The
patient told about his military history and how he had shot himself in
the left hand, to be with a certain woman, how attempts had been made
to poison him, especially a certain man in Bordeaux, who wanted to
possess the woman in the case. In point of fact, the physicians could
not save him from this enemy.

The patient now became calm and indifferent, lived secluded and almost
immobile. In November, however, he began to sit down and eat like
others, making low, timorous answers, vague and confused. He smiled
cheerfully on questioning, but had many sad ideas. He would smilingly
say that he was going to die soon.

_Re_ schizophrenia in the French army, Boucherot found eight cases
amongst 107 soldiers admitted to Loiret in the first year of the war.
He remarks upon the fact that the schizophrenic cases were often
disciplinary. The group is a disciplinary group. Damaye remarks upon
the difficulty of diagnosis betwixt feeblemindedness and dementia
praecox as observed in the French army.


Volunteer: Dementia praecox.

=Case 154.= (HAURY, 1915.)

N. enlisted voluntarily for three years in the Infantry, September
10, 1912, and immediately gave indications of abnormal mentality by
his conduct. He made mistakes all day long. At reveille he had to be
called several times, and when his corporal objected, he said, “It is
cold; I don’t see why I must get up; I am free to remain in bed until 8
o’clock.” In reply to his corporal’s remonstrance about his continued
latenesses, he once said, “I can’t get ready; I have no mirror to
wash before.” This was rather surprising conduct from an intelligent
printer-engraver, who had lived and gone to school in the town of
Lyons. He was unable to make his own bed or to perform the simplest of
exercises in the manual of arms. He was violent on several occasions,
once attacking a comrade who had given him an order, and again when
another had taken his place in the line. His reasoning faculties were
those of a young child. He continued doing these strange things, and
was finally discharged.

_Re_ dementia praecox amongst American troops, Edgar King, before the
war, concluded that some 5 to 8 per cent of the American cases of
mental disease in the army belonged to the paranoid form of dementia
praecox. King lays special emphasis upon dementia praecox, finding
that more than one-half of the army admissions for mental disease
belong to this group. He calls attention to the number of desertions
and undesirables in the group. He found that 70 per cent of the cases
showed some heredity.


Hysteria versus catatonia.

=Case 155.= (BONHOEFFER, 1916.)

A reservist, 31, was in the hospital about Christmas, 1914, for
rheumatism, when suddenly he became excited and was sent to the Charité
Psychiatric Clinic. He was restless all night, moving about in bed,
grinding his teeth, and continually getting up. He had a blank and
astonished expression; his breathing was rapid and forced. There were
no pyramidal tract symptoms, but muscular power was diminished,--more
on the right than on the left. While the knee-jerks were being tested,
the legs moved (seemingly psychogenic). Irregular hypalgetic zones
were found, and pain was less well felt on the right side than on the
left. Answers to questions on mental examination were made with the
appearance of effort, the patient breathing deeply and rapidly, head
drooping, forehead wrinkling, and eyes glancing about in an astonished
way. “How many legs has a horse?” After long cogitation, the man
counted slowly,--1, 2, 3, 4. “What’s your wife’s name?” “Marie--Marie,
I think.”

In the interpretation of this case, the functional paresis and
hypalgesia of the right side, the functional pseudoclonus obtained
during the knee-jerk test, the mental situation,--rather suggestive
of a hysterical pseudodementia or a “Ganser” dazed state,--make the
probable diagnosis at first sight psychogenic. Left to himself,
however, the patient assumed a stereotyped unchanging posture; he would
suddenly cry out, without particular emotion, that he was to be shot
or executed; there was a tendency to rhythmic repetition of certain
answers to questions, with the suggestion of perseveration.

After a time, pronounced rhythmic, and then stereotyped, movements
started in. Suddenly negativistic phenomena, with refusal of food and
self-accusatory ideas set in; speech stopped altogether. Information
from his relatives showed that he had been peculiar for some time and
had for years occasionally said that he was going to be shot.

Here then, instead of a hysterical pseudodementia, was a case
of hebephrenia or perhaps catatonia. Possibly there had been no
pseudodementia, but actually an elementary disorder in the associative
process. Possibly the defects which the patient early showed, in his
responses, for example, were really genuine schizophrenic blocking.

According to Lewandowsky, almost all cases of neurasthenia, of
hysteria, and of the so-called traumatic neuroses, stand out very
clearly as functional. Bonhoeffer is far less certain that the
diagnosis can be made readily in all cases. Antebellum conditions have
not been continued in wartime; hysteria was a female affair antebellum,
but under war conditions, it is found necessary to draw many
differential diagnoses in the male betwixt schizophrenics, epileptics,
and psychotics, on the one hand, and hysterics on the other.

_Re_ the so-called Ganser symptom, Hesnard has dealt especially with
the value of what he calls the symptom of “absurd answers,” finding
the differential diagnosis between dementia praecox and simulation
particularly difficult. Hesnard states that incoherence is very hard to
simulate. The answers of the Ganser patient are not always incorrect,
and not always absurd. The patient strikes one as intact except for the
absurd answers; intimidation and other external conditions affect the
symptom greatly. Drugs are refused by the Ganser patient.


“Hysteria”--actually dementia praecox.

=Case 156.= (HOVEN, HENRI, 1917.)

A shell burst about twenty-five meters away from a soldier, 21, but he
continued in the military service thereafter for one month, having only
one symptom, a trembling of the arm. This persisting, he was evacuated
to Calais, then to Dury to the hospital for the insane where he stayed
six months. He was transferred from Dury to the Belgian Hospital for
the Insane at Chateaugiron on August 20, 1915. He remembered nothing
of his stay at Dury, Calais, or of anything that happened after the
shell-shock. He had no complaint and wanted to go back to the front.
He was well oriented for time and space and had no disorders of
association or perception. Besides the persistent, retrograde amnesia,
he showed certain neurological disorders, occasional slight vertigo,
a generalized tremor especially affecting the arms but disappearing
almost completely at rest, lively tendon reflexes, intense dermographia
and cardiac erethism. Diagnosis was made of acute, convulsional
psychosis with agitation, convalescent phase.

During March he was quiet and worked about the hospital. In April
the patient had a number of seizures of an hysterical nature. In
June it was possible to evacuate him to full convalescence. He went
back to the front and stayed there, but shortly developed catatonic
signs with visual hallucinations and delusions of persecution of a
non-systematized nature, such as poisoning, being magnetized, etc.
He was at this time poorly oriented for time, assumed bizarre and
theatrical attitudes, showed Ganser’s symptom, was oversuggestible and
agitated and sleepless. Diagnosis of dementia praecox was now clear.

Hoven remarks that this case is important in that it suggests that a
diagnosis of hysteria may easily be mistaken.


Influence of war experience on the content of hallucinations and
delusions.

=Case 157.= (GERVER, 1915.)

In one of the divisional field hospitals Gerver examined a patient
with a very vivid paranoic condition. The following were some of his
hallucinations and delusions:

The patient asserted that everyone considered him a spy. Voices
continually told him: “You are a spy.” “What? Spy? Caught? What?” “You
will be shot by the Germans for espionage.” About three months before
his present trouble, the patient had been wounded in left shoulder by a
fragment of a large projectile. The wound healed and examination showed
a big scar with attachments to the bone. The patient asserted that now
he could not touch anything with his left hand, as there immediately go
from it “some currents” to the Germans in the trenches and they at once
begin shooting at the Russian position. Later, the patient could not
even look in the direction of the German front, for all he had to do
was to throw a glance in that direction and the Germans would at once
begin a bombardment.

All these phenomena he explained as being due to the fact that the
fragments of the large projectile which entered his shoulder were
poisoned and charmed. Through these fragments there went currents from
his hands to the Germans. The patient always supported his left hand
with his right, in order not to touch anything with it. He slept only
on his right side, so as not to touch the bed or floor with his left
hand. During the examination and conversation the patient tried always
to look downwards, so as not to throw a chance look in the direction of
the German front and call out their fire.


An Iron Cross winner had a hysterical-looking attack (reminiscence of
a bayoneted Gurkha). Later he begins to talk of “this damned war that
is so vulgar” and of “atrocities, concrete and abstract”: Shortly the
diagnosis, hebephrenia, had to be made.

=Case 158.= (BONHOEFFER, 1915.)

An Iron Cross winner, 21, in the field from August, 1914, to the middle
of March, 1915, at first in France, later in Russia, finally went to
hospital for rheumatism and sciatica. Three months later he had to be
transferred to the Charité in a state of delirious excitement.

The attack began suddenly. He thought he was in the field telephoning
with his captain, trembled, threatened to injure people about him,
said he could not hold the position with the few men he had, and
the like. Next day he quieted down and became oriented for time and
place. He explained that he had seen a Gurkha coming upon him with a
mallet, by way of revenge upon him because he had stuck his bayonet in
the Gurkha’s breast. Behind a little hill he had seen Frenchmen and
Englishmen, from which he drew the conclusion there was going to be an
attack that night. A little cloud of dust he thought was enemy cavalry.
In point of fact, he said he had once on patrol stuck a Gurkha through
and the Gurkha’s eyes had since followed him in his mind. He had seen
him crawling along the ground one evening and heard his step. The
patient had imperfect insight into these hallucinations when questioned
about them during the daytime, and still talked somewhat as if the
experience was a real one.

At first the situation seemed probably one of hysterical delusion,
for which the Gurkha experience served as material. In point of fact,
further observation in the clinic showed that the diagnosis of hysteria
was wrong. He was induced to write out his experience in a style
quite like his conversation; and there was a queer tendency in his
writing to the use of foreign words, somewhat improperly used. After
a time he began to sit about dully and at times to run about and throw
himself into and out of bed, or strike rhythmically with his shoes on
the floor, or draw his shoulders together, making grimaces, rolling
his eyes and breathing deeply. He said he had to make these movements
involuntarily if he were in some way excited. But the peculiar conduct
also often occurred without any emotional prod. His emotions were
variable, but on the whole indifferent and not always quite suitable.

He frequently said he wanted to get into the field again, giving vent
to superficial phrases, such as “atrocities, concrete and abstract,”
and “this damned war that is so vulgar.” Yet a few minutes later he
would say he wanted to go to war at Amsterdam as Amsterdam had pleased
him very much. He said he now had a good many thoughts and ideas which
formerly he had not had. He had not been promoted, he said, because he
had once angered an officer in another company.

His field hospital history told of certain oddities, such as his lying
stiffly in bed heedless of what was going on about him, falling into
causeless depression, failing to sleep, and wandering about.

As to previous life, only his own data were available. He had been a
moderate scholar, had been rather irritable and thought a peculiar
character. In the ward, he showed baseless antipathy to certain
patients and said they were well. He seemed to have no insight into his
condition, yet wrote in a letter that the insane state in which he was
had very much “augmented his mental organism.” The diagnosis of early
hebephrenic disorder could now be considered established.


Occipital trauma. Mystical visual hallucinations and explanatory
delusions.

=Case 159.= (CLAUDE, LHERMITTE, VIGOUROUX, 1917.)

A soldier, 33, single, was wounded in the right occipital region by a
shell burst September 25, 1915. There was no sign of focal lesion, but
a trephining operation was done, which healed perfectly. No disturbance
of vision ensued. The soldier was sent to convalesce two months after
having been examined by P. Marie at the Salpêtrière. He went back to
his regimental station and was put into the auxiliary service April 26,
1916.

In the early days of September, that is to say, a year after his
injury, he had a vision. Above the church cross at Chantenay, where he
then was, he saw a rainbow-colored bird, passing slowly in the sky. He
lowered his eyes and the apparition followed and was projected on the
white walls around him. After some time it disappeared. The soldier
himself wondered whether his brain injury might not have something to
do with the vision, but none of his comrades wounded in the head had
had any such vision. So then he thought of tobacco, of which he was a
moderate user, and stopped smoking, but the vision returned in the same
intensity four months later. On examining the bird’s face carefully, he
found that it was the Holy Virgin’s. In dreams he also had analogous
visions and in the dreams the Holy Virgin spoke to him, but what she
said he did not remember. The bird’s head did not speak to him. The
soldier was now convinced that it really was the Holy Virgin who had
visited him in the form of a bird. He remembered that he had asked
Notre Dame de Lourdes to protect him on the day when he was injured.
He had, in fact, eaten a bit of cheese that day upon which he had
inscribed a prayer to the Holy Virgin.

Sometimes he saw a red globe shining like a church lamp; sometimes
white or black ladies descending from the sky; sometimes other visions.
Now the Holy Virgin was to direct all the soldier’s life, but why
should he be specially favored? Was he not to be called sooner or
later to hold a high rank? He confessed, in fact, that he was to be
the King of France, and, like Joan of Arc, was to save his country.
Now the soldier began to understand the hidden significance of his
surroundings. Everything around him was symbolic, thus, white, of
purity, order and royalty; red, of anarchy, disorder and atheism. Some
white ship which he saw outstripping some darker ship showed him how
the kingdom of France was arriving once more. In fact, there was a
symbolism in the whites and yolks of eggs, and the proportion of yolk
to white was as one to five. He made talismans to exorcise bad spirits.

Were there auditory hallucinations? If so, they were only episodic and
took no part in either the construction or the fixation of the man’s
delusional system. Thus, a voice once said to him, “All is not lost.
You will be ----.” May 25, 1917, he entered the neurological center at
Bourges.

As to the interpretation of this case, it seems that the patient’s
mother had crises of depression which at one time caused her to be
interned in the Charité. The contributors of this case do not believe
that there can be any causal link set up between the mystical delusions
and the brain injury.

As an auxiliary the soldier has a right to twenty per cent compensation
for his head wound with loss of substance without bulging of the
dura mater. Of course, as an insane person he must be retired. The
aggravating or accelerating part played by fatigue, emotion and cranial
trauma must, from the standpoint of compensation, be taken into
account.


Shell-shock dementia praecox.

=Case 160.= (WEYGANDT, 1915.)

A subaltern who had been in the service since 1909 was on patrol
under shell fire from the enemy, but shortly thereafter came with his
detachment into the zone of the German fire. Six men, two steps away
from him, were killed by a shell. The officer remained stationary with
the rest of his detachment until darkness set in, then returned, made
his report in due order, but thereafter tremors set in over his whole
body and he lost consciousness. He was carried to the hospital and on
the way met his best friend whom he did not recognize. Arrived at the
hospital he was unable to give answers to questions or obey requests
for two or three hours. He thought he was hearing calls, commands and
a dull _dröhnen_. If an automobile passed he was frightened and cried,
“Auto! Auto!” He remained subject to inhibition, anxiety and insomnia
for a long time; pulse accelerated; visual fields somewhat contracted
for red. Face asymmetrically innervated and dermatographia. Sent to the
reserve hospital, he was still apprehensive, especially at night, but
in the course of a few days became perfectly tranquil. Only if he took
part in the singing of war songs did he feel transient sensations in
his knees.

Here is a case of psychic shock with many traits, such as inhibition
and hallucinations, suggestive of dementia praecox. The Abderhalden
reactions (cortex, white matter, testes, not thyroid) all, according to
Weygandt, are suggestive also of dementia praecox.


Shell-shock dementia praecox.

=Case 161.= (DUPUOY, 1916.)

A machine gunner, 23, was the sole survivor, March 18, 1915, of the
explosion of a large calibre shell in a block house containing ten men.
He worked himself out of the débris and came to Dupuoy’s attention in
September, when an extension of leave was asked for him.

There were two groups of symptoms; persistent headache, painful
hyperacousia, vertigo, tremulous walk, cervical spinal column stiff and
painful both spontaneously and to pressure, muscular weakness, tremor
of hands, hypesthesia of extremities especially upper, exaggeration of
tendon and bone reflexes with tendency to ankle clonus and patellar
clonus, sterno sign lively, frequent nosebleeds (two to four times a
week), profound sweating, unequal pupils.

On the mental side it was clear that the man’s character had changed,
according to information supplied by the mother. Aprosexia, impairment
of memory, recollective and retentive, inability to give age, birth
date and similar data. Words came with difficulty. Some disorder of
comprehension; stereotyped replies; negativism; indifference; he would
sit hours in a chair or on a bed silent and inactive. Fixed attitudes;
dull glance; eyelids half closed. In short, it seemed as if this
patient was a case of catatonic dementia praecox.

_Re_ dementia praecox and shell-shock, Stansfield remarks upon the
similarity of certain symptoms found in Shell-shock to those of
dementia praecox; for example, apathy, retardation, amnesia and speech
defect. According to Stansfield, one often gets the impression in a
Shell-shock case as though the trench and shell fire stress had merely
brought out a latent dementia praecox.

_Re_ his new “sterno” sign (sternomastoid contraction on percussion
of neck at level of third dorsal vertebra), Dupouy claims it negative
in normal subjects, positive in concussion, meningitis, and general
paresis.


Shell-shock; fatigue; fugue; delusions. Recovery.

=Case 162.= (ROUGE, 1915.)

A sergeant, 40, had had nineteen years of service and had been married
five months when he was recalled to the colors when war broke out,
and sent to the front. March, 1915, he was exposed to bomb explosions
during a very intense bombardment. He then got into the way of saying
that he was akin to everybody. April 20, he was evacuated on the score
of general fatigue, rejoined the company May 17, left his comrades
at the end of June, and was taken up as a deserter by the police,
who, observing his state, brought him to a hospital. He there showed
“cerebral overexcitement” with “incoherence and nervousness.” In two or
three days he was much better. He was evacuated on the sixth day to the
hospital at Vichy.

There was amnesia for the fugue and he could remember no further back
than the extraction of a tooth at the Vichy hospital. In fact, he
attributed the fugue to this dental operation. His wife took him home,
but he soon threatened her with a revolver; got better in the night
and next day went about apparently normal, buying things, however,
extravagantly. His delusional state began once more, and two days later
he was brought to Limoux. It seems that, while in Mauretania, he had
formerly shown signs of mental disorder, having a mania for wireless
and airplane inventions and the like. A cousin-german had also been
in a hospital for the insane twice, recovering each time. There was a
lingual and manual tremor. The man had not been recently alcoholic. He
was a little irritable and showed a little megalomania, but worked hard
and made himself useful. He went out, recovered, November 12, 1915.

Analysis indicated that this sergeant received a moral shock as a
consequence of his fatigue and the shell fire, which emerged in a spell
of confusion. It may be that his predisposition had something to do
also with this spell and the fatigue. In any event, it seems as if the
latter phenomena were not all assignable to war stress.



IX. CYCLOTHYMOSES

(THE MANIC-DEPRESSIVE GROUP)


A maniacal volunteer.

=Case 163.= (BOUCHEROT, 1915-6.)

An Alsatian became the object of much attention when he enlisted at
the outbreak of the war in the infantry at the age of 59. He was
interviewed and soon became more than naturally exuberant. The peculiar
things he did soon brought him to Fleury in a gay and expansive mood,
singing and talking as hail fellow with everyone he met.

The next day he grew more excited, disrobed and threw his things out
of the window, filled his bed with excrement and wanted to smear the
orderly therewith. He took other attendants for old friends and wanted
to kiss them. His language and ideas were incoherent. He broke glass.

This situation of alternate joy and anger lasted one month, leaving
him in an excitable, unruly state. He wrote many prolix letters to
the prefects and the ministers, insisting on the discharge of certain
patients and offering plans for the defense of France. He got better
and finally, in October, 1914, was invalided home still slightly
exalted.

_Re_ the cyclothymias, Montembault remarks that manias have been less
numerous than melancholias in the present war, whereas in 1870, manias
were more common than melancholias. Morselli likewise remarks upon the
rarity of manias amongst the Italian soldiers. Butenko reports upon the
maniacal cases amongst the Russians and how the men wish to enter the
ranks, the women the nurse corps. E. Meyer, for Germany, found 4 per
cent manic-depressives. Birnbaum quotes from Bonhoeffer (3 per cent)
and Hahn (2 per cent) for war times as against Stier’s 9.5 per cent of
cyclothymic cases in the antebellum period, 1905-1906.


Fugue: melancholia.

=Case 164.= (LOGRE, 1916.)

Logre classifies as a melancholic fugue the adventures of a man who had
been depressed for some days, had stopped talking and eating, and ran
away suddenly in the middle of an attack of anxious agitation. He was
very anxious over the health of his daughter, whom he thought to be
severely ill. It was, in fact, to go to Paimpol that he deserted, but
he deserted with his arms and without any money. He went off on foot
“in the Brittany direction.” He had gone 50 kilometers, the next day,
and was picked up near Chateau-Thierry by two gendarmes, who fell upon
him, seeing his regalia, and cried, “Give yourself up!” He replied in
a firm voice, “No, I shall not give myself up!” and seizing his gun he
made at one of the gendarmes. There was a fight. The gendarme declared
in his report that he judged it opportune to retreat behind a tree. The
soldier, knowing his trench lore very well, barricaded himself behind
a pile of beets. There he would have held the gendarmes in check for
some time if another had not succeeded by a détour through some woods,
in catching him. He gave himself up after firing several ineffective
shots, but not without getting a bullet in his left thigh himself.
With the charge of desertion and attempt to murder, he was handed
over for mental examination. He was, in fact, a melancholic patient,
subject to attacks of anxiety, and requiring long observation at a
neuropsychiatric center for diagnosis.

Chavigny observed numerous victims of melancholia characterized by
war terror. He remarks a somewhat curious fact that, whereas the
melancholics were numerous and their mental states related to the
war, on the other hand, the paretics were rather apt to be maniacal
than melancholic. Soukhanoff, however, remarks on the occurrence of
depression in a great number of types of psychosis, as was found
in the Russo-Japanese war. Soukhanoff found frequent instances of
schizophrenia, wherein the melancholia tends to conceal the actual
dementia praecox. Soukhanoff predicted that depression will figure
largely in the war.


Apples in No-Man’s-Land.

=Case 165.= (WEYGANDT, 1915.)

A soldier in November, 1914, suddenly climbed out of the trench and
began to pick apples from an apple-tree between the firing lines. The
idea was to get a bag of apples for his comrades, but he began to pelt
the French trenches with apples. He was called back and on account of
his strange conduct sent to hospital. Here he was at times given to
pressure of speech and restlessness; he would climb the posts of the
sleeping room and then loudly declare he wanted to get back to the
trenches; he did not want to go back to Germany alive; did not want to
live over to-morrow; was guilty of a sin; had a spot of sin, _Schand_,
on his heart. Sometimes he refused food and said anything else tasted
better. It seemed he had formerly talked about the Iron Cross.

After being transported to Germany, he was at first a little
negativistic and apparently blocked. He talked about his experiences
and said he wanted to go to Russia. He explained the episode of the
apples on the basis that they were all really hungry and that he had
sought to encourage his comrades who were unused to war. He had noticed
the French all shot too high.

Physically there was a somewhat uneven innervation of the face,
unilateral epicanthus and an areflexia of pharynx. Now and then the man
was very irritable, but in general he was in an elevated frame of mind.

Weygandt interprets this case as one of hypomania, remarking that
war influences may serve to bring out preëxisting manic depressive
tendencies.

_Re_ differential development of mania and depression, see remarks
under Cases 163 (Boucherot) and 164 (Logre).


Four months in trenches: Depression; war hallucinations,
arteriosclerosis (aged 38).

=Case 166.= (GERVER, 1915.)

A Russian reservist, a private, 38, went into the trenches, March,
1915. Without taking part in any battles or sustaining any injury,
he four months later became depressed and had to be evacuated to a
hospital and thence to the interior, little changed for the better.

He was an ill-nourished man, of middle height, with pallid skin and
membranes; arteries sclerotic; face, eyelids, and tongue finely
tremulous; hands tremulous; slight dermatographia; exaggerated tendon
reflexes; pulse 100.

He seemed disoriented for time and place; looked weary; walked with
back bent over; spoke in whispers, and appeared somewhat unclear.
Thinking was slow and difficult.

He occasionally shuddered and looked to one side, said he was afraid,
and was constantly troubled by thoughts of fire. The Germans were
pursuing him; he could hear their voices and footsteps. He himself
was doomed, and his family also; he felt he was the cause of all the
domestic woe. His own heart was dying away; he had fits of anguish and
causeless fear, and was under the constant expectation of death.

One day, he escaped from the hospital and went to the chief physician’s
tent, where he lay on the ground. When he was found and asked why he
was there, he begged the physician to save him from the Germans. The
man was not alcoholic and had no previous history of mental disease.

_Re_ early arteriosclerosis, Maitland in the second interim report of
the British Association Committee on Fatigue in Warfare, speaks of the
many Serbians, who, after six years of nearly continuous Balkan war,
show a marked arteriosclerosis. Maitland remarks that the line officers
were already showing (1916) a growing delicacy of perception as to the
“breaking point.” Men that do not break may return from the lines,
pale, with low blood pressure, and a _faiblesse irritable_, shown by
restlessness of hands and feet.


War stress: Manic-depressive psychosis.

=Case 167.= (DUMESNIL, 1915-6.)

A naval officer, 22, transferred from sea service, went into Belgium,
November, 1914, in a Fusilleur brigade of marines and there greatly
distinguished himself, growing very weary and enervated, however,
about the middle of April, 1915. His attitude to the men altered:
he sometimes struck them; gently, though, according to his account.
They must do in ten seconds what they really could not do under ten
minutes. The officer, in fact, had lost all notion of time. He went
about agitatedly, contradicted his superior officers and was troubled
because, as he said, they often were men of inexperience as compared to
himself. He grew irritated, too, because there were Free Masons in the
army and when he was sent to the asylum in July, 1915, said it was the
doing of the Free Masons. He did not seem to have any hallucinations.
His ideas and sentiments were very labile, and a bit confused, and not
all his interpretations dealt with Free Masons and occultism. August
5, however, the phase of calmness was again followed by agitation;
he broke things and laughed explosively. August 10, another attack
occurred, with destructiveness. During the next few days there were
alternate phases of depression and excitation. He was negativistic,
resistive and struck attendants.

_Re_ war stress and psychoses, Morselli finds the acute cases on
psychopathic soil. First in the list, he places the neurasthenias and
psychasthenias, and second, the hysterias, two groups which, more than
the remainder, may be said to constitute the so-called Shell-shock
group. Third, he found depressions ranging over into a delusional
state with suicidal ideas; fourth, a species of stupor, occasionally
catatonic, recalling dementia praecox; fifth, transient hallucinatory
states; sixth, confusions (Meynert’s amentia?); last, manias.

The above case of Dumesnil appears to be a pure case of
manic-depressive psychosis developing on the war basis, but perhaps
merely comes from a latent cyclothymia.


Predisposition; war stress: Melancholia.

=Case 168.= (DUMESNIL, 1915-6.)

A farmer, 30, was mobilized August 2, 1914, and was wounded in the
hand September 27. He went back to his dépôt in December and stayed
there until March, 1915, when he was sent to Dunkirk. Before leaving
the dépôt he said that he had heard soldiers declaring that he was not
doing his duty, that he was going to be court-martialed, that life was
at an end for him. At Dunkirk he said these same soldiers continued to
say the same things about him, forming a band about him, led off by a
subaltern officer who meant to frighten him and to make him talk. One
night sulphur was thrown at him for poisoning purposes; he complained
of this to a sergeant and declared he did not understand why he should
be thus pursued. After the bombardment of Dunkirk the hallucinations
grew more intense. He was sent to hospital and was so harried by the
voices that he wanted to throw himself down a staircase but was caught
in time. At the hospital for the insane he complained that his thoughts
were being heard and loudly repeated; he was made to make incoördinate
movements; was treated as a spy. He thought he must be a German or they
would not treat him so. He waited for death as he wanted to be executed
at once.

This man’s father was alcoholic. He himself at the age of fourteen had
had a period of neurasthenia with some sort of nervous seizure for a
period of five months. At 28 he had a rheumatic seizure which kept him
in bed fifty days. A daughter born to his wife had died a few days
after birth.

Dumesnil’s analysis is melancholia with delusions of persecution, due
to war stress in a predisposed person.

_Re_ melancholia and the war stress, see remarks under Case 167. _Re_
manic-depressive psychosis in the Russians, Khoroshko found 9.4 per
cent of manic-depressive cases, the same percentage of epilepsies, 10
per cent of paretics, and 20.4 per cent of schizophrenic cases amongst
a group of 318 neuro-psychiatric cases. Almost all his manic-depressive
cases had been patently so antebellum.


Depression; low blood pressure. Pituitrin.

=Case 169.= (GREEN, 1917.)

A private, 22, was sent back from Germany as insane. He had been in the
asylum at Giessen seven months, and a prisoner in all fifteen months.

August 16, 1916, he was admitted to Mott’s wards at Maudsley in a
markedly depressed and lethargic condition. He had improved somewhat
in October, but still had periods of depression. He was put on thyroid
extract (Green’s treatment was in doses measuring from gr. ¼ to gr.
1, t.d.s.; according to Green, the effect of thyroid extract is more
rapid when coupled with pituitrin). In December he was given pituitrin
extract gr. 2, t.d.s. In January, 1917, he was no longer depressed or
lethargic. He complained of pain in his back, found to be due to a
bullet. This was removed.

_Re_ prisoners, Imboden found amongst 20,000 French soldiers taken
prisoner at Verdun after the severest drum fire and strain, only
five neurotic cases (data of Mörchen), and Wilmanns found but five
neurotic cases amongst 80,000 prisoners. Lust reviewed 20,000 war
prisoners in Germany and found singularly few instances of neurosis.
Shunkoff notes, however, that there are a number of psychotic cases
amongst the prisoners because the _mentally_ diseased who do not
disturb the military routine are kept in the line. Bonhoeffer found
amongst Serbians taken prisoners by Germany, emaciation, atrophy,
heart disease, and frequently tuberculosis. (See Case 166.) Bonhoeffer
noted the absence of psychoses amongst these Serbians, drawing the
general conclusion that campaign stress was unable to bring out
psychoses. But, although the exhaustion psychoses are not found,
there are exhaustion neuroses or states of acute nervous exhaustion,
characterized by somnolence and depression, followed by a mild degree
of overemotionality. vum Busch states that interned German civilians
have gone into psychosis frequently. It is said that one in 10,000
war prisoners in Germany has committed suicide. Bishop Bury found at
Ruhleben 60 or 70 cases of psychosis.



X. PSYCHONEUROSES


Hallucination in the field (surprise by _BOCHES_); scalp wound: Three
psychopathic phases--(_a_) over-emotionality, (_b_) obsessions, (_c_)
loss of feeling of reality (victim a “constitutional _intimiste_”).

=Case 170.= (LAIGNEL-LAVASTINE and COURBON, July, 1917.)

A cashier, 31 (of rather weak constitution but without hereditary
or acquired mental taint--a religious man and for religious reasons
chaste, always given to metaphysical speculation and introspection, but
on the other hand, much interested in sports and very sympathetic with
English manners), was about to go to live in the country on the advice
of his physician when the war broke out. He was called to the colors
and shortly lost his tendency to bronchitis, put on flesh, and felt
delighted with his situation.

After almost two years of effective service, June 2, 1916, when his
troop was cautiously advancing into a trench at the end of which they
might be taken by surprise, suddenly the officer cried, “_Sauve qui
peut!_ _The Boches are on us!_” The patient remembered seeing Germans
emerge from every side, remembered his fear, how he had turned about
and crossed over a palisade, and then no more until he found a scalp
wound being staunched by his comrades in the trench. He put on his own
dressing and followed his comrades on foot.

He quickly got well of his scalp-wound but remained in hospital,
very weak, extremely impressionable, jumping at every noise. He got
somewhat better with the rest in bed, though even a month after his
hallucination, he had a spell of insomnia, thinking about his future
and the possibility of a relapse, and having war dreams from which he
would awake in a sweat. Once on awaking, he distinctly heard a voice
saying, “_Well, Charles?_” This hallucination occurred five times,
under exactly the same circumstances, except that once it was in the
daylight. Adrenalin was given, 1:1000, 10 drops the first day, 20 the
second, 30 the third, and a like amount on the following days. After
three days of such treatment, the patient said he felt much better.
Later he had a period in which he had lost self-control and could no
longer take any initiative. Thus, if he wanted to reply to his mother,
it seemed to him that some one not himself was ordering him to write.
He now asked himself if he were not really dreaming. He would not be
sure of his actual existence unless something happened to prove it,
such as the nurse’s bringing him a plate.

In short as the first phase of diffuse over-emotionality had been
succeeded by a second of obsessions, so the obsessive phase was
succeeded by a third phase of mild loss of the feeling of reality.
The first phase following the wound was one of disorder of attention,
of memory, and in fact of all the mental functions, associated with
tremors, tachycardia and dizziness. The second phase seemed, as it
were, to crystallize intellectually the anxious apprehensiveness of the
first phase. There were fears that the ceiling would fall; there were
scruples concerning the past; there were fearful premonitions for the
future (such as, that any bomb he might pick up would burst). According
to Laignel-Lavastine and Courbon, there may have been a predisposition
in the vegetative system of this subject, or even a basis in his
tuberculosis, of which, in fact, the X-ray showed still some slight
evidences. The obsessions appeared at night, at a time, namely, when
the vital rhythm is passing from a sympathotonic period over into a
vagotonic period, at a time when the organic sensations are apt to swim
to the fore. According to this analysis, these somatic sensations,
precisely those that the battlefield had also brought out, brought out
again the other emotions which he had felt on service. It was always
the emotions first developed in military service that were revived in
the disease. In the third phase, the physical condition of the patient
had grown much better _pari passu_ with disappearance of the obsessions
and the onset of the personality disorder. The adrenalin raised
arterial tension, and going down to the sympathetic caused the anxiety
and war emotions linked therewith to disappear; but the adrenalin
treatment, according to Laignel-Lavastine and Courbon, disturbed the
organic sensations so suddenly that there was a break between the new
conscious status and the old. In consequence, the patient felt that
these new sensations no longer really belonged to him but were of a
xenic character, imposed upon him from without in such wise that he
continually asked himself whether he was really dreaming or no. This
man was a constitutional _intimiste_; a psychasthenic _en herbe_.

_Re_ neurasthenia, Lépine notes that there are transient and relatively
permanent cases. The term is often used to cover graver disorders,
such as various melancholias and anxieties. As a rule, in France, the
neurasthenics are evacuated for fatigue. There have been a number of
cases in officers, who find themselves unable to make decisions on
the minute and to remember military facts, or perhaps are unable to
make any physical or intelligent effort whatever. A true neurasthenic,
however, ought not to be a confused person. He is a man with a rather
unusual clarity of view as to his situation; and his trouble appears
to him to be somatic rather than as of the nature of a depression. He
feels that, if he could only rest, he could be cured. Neurasthenia,
according to Lépine’s war experience, is practically always the
disease of a highly cultivated nervous system, and appears in men
who have undertaken responsibilities. There is a group of young men
who have never been physically strong, bowled over at last by some
small event, such as a diarrhoea, and unable to carry on. Such men,
perhaps, are likely to have some traces of an old tuberculosis, an
adrenal insufficiency, or insufficient hepatic function. Martinet has
found them hypotensive and rather poorly aerated. There is another
group of neurasthenics (Maurice of Fleury) that are old arthritics,
with increased tension. These cases are not found at the front because
conditions there rather tend to reduce the trouble; but they are
found doing office work in the interior. Besides these cases of the
“cultivated” group, Lépine also finds a number of neurasthenics amongst
the peasants, in whom anxious ideas may lead to hypochondria.


Fugue, hysterical.

=Case 171.= (MILIAN, May, 1915.)

The fugue of an adjutant who left his regimental relief post at
Palameix Farm and was found several days later with his family at
Castelsarrasin, was reconstructed from partial records as follows:

November 27, 1914, after a night in the trenches, when two shells burst
near him, the adjutant turned up at the relief post with wild eyes
and a complaint of fatigue, and of an old wound and headaches. The
wound he had gotten in a fight which gained him his grade of adjutant.
The physician prescribed rest. He sat down by the stove, silent and
dejected, and at about four o’clock, in the presence of the medical
assistant, made preparations to go, leaving sack and saber behind, but
taking outer garments and revolver case. On the way from the farm, he
met comrades and told them he had been evacuated to his dépôt on the
colonel’s order, and walked with them, Indian file, in the midst of
falling shells, the others talking but the adjutant himself silent.
At nightfall, he said, “Good evening,” and parted from them. Of his
further course to his home, all recollection was lost by the adjutant;
in fact, he did not remember anything beyond the Palameix Farm, where
he had seen a comrade wounded in the head. He got home November 29th,
at eight in the morning. He had most of his money with him, having
traveled by train some distance without a ticket; moreover, without
asking for a ticket, and without having eaten. When the ticketman in
his home town asked him whether he was back from the war, he looked
at him vaguely and went out without replying; nor did he reply to a
newspaper man on the road home. This was the more strange as he was
ordinarily an affable person.

He had a convulsive crisis at home, after which he was exhausted and
apparently unable to move or reply. A physician said that he had had
a cerebral shock. When the police arrived, two hours later, he was
apparently delirious, saying such things as, “_The Christians want
to shoot me but I know the rules! Come, boys, stay in the trenches!_”
“_There are two more dead ones!_” etc. During the day he recovered
consciousness and was greatly disturbed at his military crime.

In point of fact, he had had, at the age of 17, analogous crises, as
was certified by Régis, who had cared for him from 1907 to 1909 for
hysteria with sudden somnambulistic attacks and amnesia.

While in prison after his arrest, he also had hysterical crises with
agitation, flushed face, hard attempts to vomit, respiratory disorder
due to interference in the throat (globus hystericus), and delirious
phenomena (“Germans had followed him home”).

After his birth his mother had had two miscarriages and a stillborn
child. The adjutant was declared irresponsible and acquitted. This is
apparently an instance of hysteria without stigmata.


Hysterical Adventist.

=Case 172.= (DE LA MOTTE, August, 1915.)

An engineer, 31, in the Landwehr at the outset of the campaign, was
first put on sentry service in Berlin on the ground that he was
an Adventist. He was later put into the military service and had
difficulty because he did not want to serve on Sunday. He was shoved
from one company to another. He refused to be inoculated and was
arrested therefor. In the prison, he began to hear God’s voice calling
to him distinctly to tell his fellow-men that the end of this was going
to be the end of all things. Back in the barracks, he again heard a
voice--“_Come forth!_”--“_Go!_” He went! He had his revelations then
published in the form of tracts, and held Bible readings day and night
among his friends in Bremen--looking for the signs of the times in the
Bible sayings. One of his fellow Adventists finally warned the police,
and the military authorities put him under psychiatric observation. He
proved to have numerous stigmata of hysteria. He talked freely about
his visions, and was aware that he was punishable.

Here, then, was a case of hysterical psychosis, liberated by military
service.


Fugue, psychoneurotic.

=Case 173.= (LOGRE.)

The question, Is this escape really a fugue? is brought up not only
in epileptic, alcoholic, and melancholic cases, but also in cases
suggestive of psychoneurosis. A son of an insane person was subject
to what may be called a phobic or obsessive fugue. The case may be
called one of morbid cowardice and was observed in a soldier in the
trenches. In point of fact, the man had always been an anxious and
fearsome person, given to phobias. He had night terrors and fear of
diseases and death. He was agoraphobic in adolescence, and had to have
a policeman or passerby go with him through a public place. He had had
also suicidal and homicidal obsessions, and periods of psychoneurotic
anxiety.

This man’s sojourn at the front put his morbid personality to a cruel
test. He was soon known by all in the trenches as a _froussard_. He had
a terrible fear of the guns, jumped, grew pale, trembled, complained
of palpitations, lumps in the throat, etc. He was the laughing-stock
of his comrades; but according to the patient himself, he was more
afraid of his own emotion than of the shells, although his comrades
couldn’t understand it. He was employed as a kitchenman, in a post not
much exposed. A more resolute comrade helped him to escape, escaping
also himself, thus bringing up the problem of _fugue á deux_. Limited
responsibility was decided for the case, although the fugue had been
aided by his morbid anxiety. Of course, his place was not in the
trenches at all. He was condemned to two years in prison. After his
sentence, he was given a chance to rehabilitate himself by sending him
again to the trenches, but he had to be evacuated a few weeks later on
account of his increasing emotionality.


Shell-shy; war bride pregnant: Fugue with amnesia and mutism.

=Case 174.= (MYERS, January, 1916.)

A rifleman, 30 years old, was brought to a casualty clearing
station, looking like an imbecile, with a history of having wandered
about aimlessly, not knowing where he was or what he was doing. On
questioning, he remained absolutely speechless and terrified. Four days
later, in conversation with Major Myers, he was got to speak in a faint
voice about his wife, home, and occupation, saying that the month was
October (when it was actually August) and that he had been in France
two months, when it was actually twelve. He described emotionally
certain trench scenes, and then thought of his wife sewing.

Hypnotized, he remembered going into a dug-out after running away from
shells; he was made to talk in a loud voice. Next day, during hypnosis,
proper orientation for time reappeared. He was got to write an ordinary
soldier’s letter to his wife. The following day he was active, making
beds, but was mute (there was a case of mutism in the same ward). Under
hypnosis speech returned. He had gone to a horse show, and upon his
return, something hit his back; shells had begun to fall. Found hiding
in a shack, he was carried to a hospital in an ambulance. After this
hypnotic treatment, the power of speech was maintained, although his
voice became faint or failed whenever he was asked about the incidents
described above. Next day he waked speaking normally, nudging his
neighbor and asking, “Is it me that’s talking?” He had before appeared
dull and depressed, but now appeared an intelligent, agreeable, and
garrulous fellow. It appears that his wife was a war bride and he had
heard some months since that she was pregnant. He had been troubled,
thinking she was in money difficulties and kept thinking about a friend
whose wife had lost her first baby. Recovery appears to be complete
except for occasional headaches, and the patient is now serving in his
reserve battalion.


A neurasthenic volunteer.

=Case 175.= (E. SMITH, June, 1916.)

A man who volunteered for service at the outbreak of the war (he had
recently been an inmate of a sanatorium) was sent back to England as
neurasthenic after three trying months at the front. The case sheet
read that he was subject to dazed conditions. In hospital he suffered
from insomnia, and before his slight periods of sleep he constantly had
visions of two comrades who had been terribly lacerated at his side.
These hallucinations in their reality aroused in him a fear that he was
insane.

There were also terrifying dreams, beginning with episodes at the front
and ending with sex experiences. These dreams were ended by seminal
emissions. These formed a second cause for the patient’s belief that
he was insane, as he said he remembered literature read as a boy
concerning spermatorrhoea.

In the treatment of this case the writings of psychologists who
had studied hypnagogic experiences were used and the absence of
hallucinations during waking hours was stressed. The remembered
literature regarding spermatorrhoea was discounted by the rational
explanation of his state.

He seemed to be getting on well when a trivial accident caused a
relapse. While he was saying goodby to his wife, who had visited him,
she was taken ill, and he went home with her. He was punished for being
late in returning to the hospital. Although no moral stigma attaches
to confinements in barracks in most soldiers’ minds, in this man a
depression was produced and suicidal talk followed. It seems that his
father had been sent to jail when he was a child, and he felt he had
been tainted by his father in such wise that his “criming” was due
to heredity. With the removal of this misconception he became more
rational and immensely improved.


Five months’ war experience: Neurasthenia in subject without heredity
or soil.

=Case 176.= (JOLLY, January, 1916.)

A 38-year old soldier is Jolly’s example of a neurasthenia produced in
a person without previous neurasthenic traits or hereditary factors.
This soldier had been a moderately good student and never ill. He
went into the battle line in December, 1914, and came out in May,
1915, on account of exhaustion. The case is not wholly convincing
since the patient had a shrapnel injury of the skull, described as of
so inconsiderable a degree that he was not put on the sick list on
its account. The patient finally arrived at the Nuremberg Hospital,
complaining of pressure in the head, as if there was a band around
the head, and dizziness. He wept a good deal saying that the sight
of the dead had frightened him. Sleep was restless and there were
unpleasant dreams of the battle field. Intelligence was not in any
degree disturbed. The supra-orbital points were sensitive to pressure.
The tongue showed a marked tremor and was coated; the mechanical
excitability of the muscles was increased; and there was reddening of
the skin on stroking. There was a fine tremor of the extended fingers,
less tremor of the head and of the body at large. Knee-jerks normal.
Nutrition well preserved. Partial recovery in the hospital.


Importance of arterial hypotension in the diagnosis of psychasthenia.

=Case 177.= (CROUZON, March, 1915.)

A man of 32 (never well, with general weakness, ideas of consumption
and vacuous thinking following a good recovery from bronchitis at 28,
unsuccessful in business, subject to weaknesses) had had eighteen
months antebellum of what might be called psychasthenia. There were
spells of loss of consciousness without convulsions, and probably of
hysterical nature. There had been for two years insomnia and a general
hypobulic slowing down of work.

In military service the crises became more frequent, coming two or
three times a week. Tuberculosis could not be shown, nor was there any
organic lesion of the nervous system. The arterial tension (Potain
sphygmomanometer) stood at 11.

According to Crouzon, arterial hypotension is an objective sign
tending to assure the organic nature of a psychasthenia. Whereas
simple neurasthenics are hypertensive, others have long been
recognized as hypotensive; but heart experts have recognized this
asthenic hypotension more than psychiatrists or neurologists. In
differential diagnosis it is necessary to consider and exclude the
early hypotensions of pulmonary tuberculosis and those of Addison’s
disease. This hypotension is most frequently observed in constitutional
neurasthenics and psychasthenics. Hypertensive drugs, adrenalin,
tincture of colchicum, have produced a transitory improvement in a
number of cases, but the amelioration has halted with the stoppage of
the drugs.

_Re_ hypotensive and hypertensive cases, see remarks of Lépine under
Case 176. See also Case 169, illustrating some contentions of Green,
from Mott’s clinic.


Service in France and Salonica: Psychasthenia.

=Case 178.= (EDER, March, 1916.)

A man, 29, after some months’ service (three months in France and
later in Salonica) was invalided for backache, insomnia, and enuresis.
It seems that this married man had never done any work after leaving
school at 18, having substantial private means. He had been married
for 3½ years, had a son, and was, according to Eder, perhaps morbidly
attached to his wife and child. He had been a sportsman and was
selected for sniping work in France. The son of a shipbuilder, he had
always planned all kinds of ships and engines, never to be used. After
seeing the world, he was about to enter his father’s business when he
had to take care of his father in a nervous breakdown. After a second
attack, the man never entered business.

February 6, 1916, wide-spread patchy analgesia and lumbar hyperesthesia
were found. He thought sluggishly, being restless and holding attention
poorly. He began twenty letters, destroying each after finishing a
few lines. He was shy and felt that everybody was looking at him. He
became speechless if he had to address his commanding officer. He had
an obsession to mark each flagstone and touch each post, and various
counting and arranging obsessions.

The _Horme_ (Jung) was elusive. A dream: “I was in a cargo boat in
the river; we were steering straight into ferry and harbor. The pilot
rang down ‘Full speed to stern’; I pushed him out of the way, and rang
down ‘Full speed ahead, two points to starboard.’ We went straight
past ferry and harbor without accident.” Again, a few days later, “In
a motor car, came to some rocks which sprang up in front of me. The
machine broke down. I abandoned it and clambered over the rocks. It was
tough work. My object was a ship. I got to the ship, took hold of the
wrench, and signalled ‘Let go.’” Herein, according to Eder, are certain
obvious symbolic conversions.


Antebellum attacks, with dizziness: Fainting on horseback. Neurasthenia.

=Case 179.= (BINSWANGER, July, 1915.)

A harness-maker, 37, a corporal, was called to the colors on the second
day of mobilization. He was attacked by a slight dizziness in the
evening (see previous history below). He went into the field on August
7 and had repeated attacks of dizziness, despite which he took part in
several skirmishes. He could not ride on horseback, since dizziness,
ringing in the ears, headaches, and trembling of the whole body would
develop. October 27 a severe fainting attack came while he was sitting
on a horse. He woke ten hours later, vomited several times and felt
dazed. Two weeks later hearing in the right ear began to be impaired.
During several transfers from hospital to hospital near the East front,
there were two more severe attacks of dizziness and vomiting. Brought
back to Germany, the patient finally came to the Jena Hospital, May 20.

The estimate of this case depends somewhat on the previous history. He
appears to have come from a healthy family, was married, and had two
healthy children. His bodily and mental development had been normal;
he had been an unusually good scholar, but he stammered from his tenth
year without apparent reason. He had had treatment in an institution
for stammerers at 17, achieving a complete cure in six weeks. His
military service was as a cavalryman, 1897-1900, after which he had
married. There was no excess in alcohol; he was not a smoker. From his
own account, he had always been somewhat nervous, had trembled easily,
and had fallen to stammering when excited. In 1913 there had occurred,
after physical exertion, three violent attacks of fainting, with
dizziness, vomiting, and excessive perspiration, each attack lasting
from two to three hours. However, from that time to just before the
war, he had been free from attacks.

On examination at the Jena Hospital, the patient complained of general
weariness, a feeling of pressure in the back of his head, a hammering
all over the head, ringing in the right ear, impairment of hearing in
this ear, a feeling of dizziness on raising the head, palpitation of
heart, especially at night, occasional trembling of the whole body, and
absolute inability to walk.

The man was slenderly built, of medium height, in moderate
nutrition; pale of face and mucosae; pulse small, regular, and 114.
Neurologically, the deep reflexes were generally increased, and the
skin reflexes decreased. Percussion on the back of the head elicited
marked pain. There were no pressure points. The movements of the arms
were free; there was a marked tremor of both hands, more marked on the
right. The left grasp was 45, the right, 20, by the dynamometer.

When lying upon his back, the patient could move his legs, but he
moved them only slowly and with tremor. The heel-to-knee test was
successfully executed despite the tremor; nor could it be demonstrated
that there was a genuine ataxia. Placed upon his feet, he would
collapse, nor could he be made to walk at all. With trunk supported,
he was able to make only a few unsuccessful attempts to drag the feet
forward.

Associated with this apparent paralysis, the sensitiveness to touch
had entirely ceased in the legs, as well as sensitiveness to pain. The
zone of analgesia, however, was more extensive than the anesthesia,
spreading upwards three or four cm. farther in front. Ticking of the
watch could not be heard even at the meatus of the right ear, although
hearing of the left ear was entirely normal; bone transmission on the
left side. Whispers could be heard close to the meatus. On speaking,
the patient stammered in starting sentences.

He looked extremely anxious during the first few days in the Jena
wards, claiming that he could not raise himself. When his trunk was
raised, he would let himself sink feebly back into dorsal decubitus.
However, when believing himself unobserved, he was found to be able
to move himself in bed somewhat quickly. He was able to get a box
from beneath the bed, to open the drawer of the night-stand, and to
take remarkable care of his moustachios. He complained more and more
of headache, though his appetite and sleep were good. He was often
irritable.

Treatment at first consisted of cold packs of the legs twice a day,
salt-water baths, active and passive exercises of the legs in the
position of dorsal decubitus. The patient declaimed against this
treatment. There was slight improvement after a week of treatment. He
was then able to raise himself in bed, seat himself on the edge of
the bed, and stand without support, all the time, however, groaning
and moaning. After a few moments, he would fall back on the bed,
complaining of violent headache and dizziness. While standing, both
legs trembled.


Antityphoid inoculation: Neurasthenia.

=Case 180.= (CONSIGLIO, 1917.)

A corporal, 39, began to be sleepless and weary, with headache, pains
in the back, and dizziness. He was homesick. Upon hospital examination
he was very variable in mood, rather hostile in attitude, and at the
same time suggestible. He was so confident of being sent home that he
anticipated the diagnosis by sending his belongings back to Sicily at
the time he was transferred to hospital from his regiment.

After a month’s rest and psychotherapy, the man’s general condition
was greatly improved; he was no longer sleepless and had no longer any
sign of neurotic disorder. He still maintained that his memory was
weak, although in point of fact his memory was very good and quick. He
could narrate all the facts about his neurasthenic state. The man’s
complaints were out of all proportion to any demonstrable somatic
disorder. He was discharged, cured, to be put to work at shoemaking,
with the diagnosis, neurasthenia. This neurasthenic state developed
after antityphoid injection.

_Re_ the occasional curious effects of antityphoid injection, see Case
65.


Neurasthenia (monosymptomatic: Sympathy with the enemy).

=Case 181.= (STEINER, October, 1915.)

A non-commissioned reserve officer, 26, in civil life a merchant, had a
strong hereditary taint, having been also in peace times very nervous
and on that account obliged to give up his studies. At the age of 14,
he had seen a man fall down from a roof and was much excited about it.

At the beginning of mobilization he suffered a functional aphonia for
a few days. He could not let his men shoot at the enemy because of an
idea that occurred forcibly to him: that the enemy’s soldiers had wives
and children! He felt badly on this account. Later he had a constant
taste of blood in his mouth and a smell of corpses in his nose. Toward
nightfall all these symptoms would change for the worse, and the
symptoms would become especially bad whenever he had anything to do
with the wounded. He tended to weep much and was easily frightened and
had also various physical symptoms of neurasthenia.

_Re_ the amazing sympathy with the enemy, see Case 229 (Binswanger) and
Case 554 (Arinstein), in which chloroform lifted from a German and a
Russian consciousness respectively opposite emotional tendencies.


Shell-shock CLAUSTROPHOBIA: Preferred shell exposure to shell-proof
tunnel.

=Case 182.= (STEINER, October, 1915.)

A colleague of Steiner, an army physician, 35 years of age, with strong
hereditary taint, having two sick sisters (one dementia praecox), had
been incapacitated for work through a neurasthenia a few months before
mobilization. However, at first he felt very well, marching through
Belgium and into Northern France.

On the night of the 17th of October, 1914, a shell struck the house
next where he was and startled him up out of sleep. After that,
especially at nightfall, upon entering a cellar he would have the
feeling of the ceiling falling down, and he would go restlessly from
one space to another. Afterwards, any closed room, however secure or
distant from the front and free from shells, would give him the feeling
of the ceiling about to fall down. He could no longer sit quietly
anywhere, but walked about and avoided the company of others.

A characteristic observation is the following as described by the
physician himself: There was an absolutely shell-proof tunnel running
to the position at the front where he was on duty. It took about 25
minutes to go through the tunnel, but on account of his feelings
he could not bring himself to use this tunnel but walked over the
exposed hill which was frequently shelled. Curiously enough, after the
appearance of the first symptoms, a shell exploded nearby without any
marked psychical effect. This happened about noon. The obsessions were
stronger in the evening. Objectively, there were neurasthenic symptoms
of a bodily nature; there was vasomotor excitability. He was depressed,
wept easily, and showed lack of decision; he had tormenting thoughts
that he had not fulfilled his duty.



XI. PSYCHOPATHOSES

(GROUP OF VARIOUS PSYCHOPATHIAS)


A case of Pathological Lying occurring in a soldier.

=Case 183.= (HENDERSON, July, 1917.)

No. 27369, a private, attached to the 15th Battalion Durham Light
Infantry, was admitted Oct. 14, 1916, to Lord Derby War Hospital from
Netley.

September 11, 1916, he had been admitted to Number 3 General Hospital,
France, in a noisy, excited, insolent state: said he saw spirits of
the dead; heard his sister urging him to lead a better life. Admitted
to Netley early in October, 1916: now said he was a spiritualist, a
Frenchman, had a quarrel with parents and enlisted in British Army,
in army service; went to France August 12, 1914, was wounded at Loos,
September, 1915, returned to front in February, 1916, “shell-shocked”
June 1, 1916; lost consciousness after this--did not know where he was
until July 22, 1916, when he had been arrested as deserter.

Admitted to Lord Derby Hospital October 14, 1916,--quiet, orderly,
coöperative: desired to return to his regiment. He now gave a history:
Enlisted British Army 1908, went to France, August, 1914, wounded
February, 1915, at Neuve Chapelle; recovered; then attached to 45th
Durham Light Infantry; blown up July 22, 1916, came to August 5,
1916, in hospital in Boulogne; then back to his regiment--but month
later left without leave to pay off old score on a former comrade
who had insulted his sister--arrested later by military police; put
under observation in 65th Field Ambulance. No deterioration noted,
school knowledge fairly well retained; no hallucinations or delusions
(maintained he was a spiritualist, also that following shell-shock
had suffered from insomnia and seemed to hear sister’s voice).
Physically--small, well nourished, effeminate looking.

Oct. 23, 1916, he broke parole, but a month later returned to hospital
under arrest. The police reported he had been masquerading as wounded
French soldier attached to British army as interpreter; imposed on
people; had two leaden types in his possession: “Interpreter R. le
Auldere, attached to 1st Division.”

Story in hospital on return:--Born in France, did well in school,
entered military academy at Paris. Quarreled with father--ran away
to sea. Adopted by a French lady at Pembroke Dock. On account of
drunken habits, quarreled again; joined army at Bristol, 1908. Went
to France in August, 1914; January, 1915, invalided home because of
“trench feet”--discharged as unfit. Reënlisted June, 1915, in Durham
Light Infantry. January, 1916, again ordered to France. Blown up on
Somme, July, 1916, by shell--remembered nothing until brought to No. 3
General Hospital. He remembers being accused of desertion but sentence
was not passed, as he was held by the medical officer to have been
irresponsible (as a matter of fact he was, at that time, considered to
be a case of dementia praecox.)

Said that during twenty-five days, due to drunkenness, his friends had
taken him to Manchester with them; arrested by police as he attempted
to get back to hospital. He was now accused of wilfully lying and,
confronted with his police record, at first denied it, but later gave
following approximately true story:

Born, England, 1890; early life of a roving disposition, good at
school, liked books of adventure. Drank early. Ran away at sixteen; was
returned home. Ran away again--convicted of drunkenness. Three-year
sentence to reformatory in 1910 for stealing: escaped. Rearrested for
stealing in 1911: released in 1913, enlisted in army and deserted.
Arrested in January, 1914, for stealing; sentenced to three years:
released to rejoin army in June, 1915. Arrested as deserter: imprisoned
but released in January, 1916; left for France. August, 1916,
“shell-shocked,” sent to Field Ambulance No. 3, General Hospital,
Netley, and Lord Derby War Hospital. Court-martialed for desertion:
nothing came of it on account of medical evidence.

After breaking his hospital parole, he masqueraded in district as “R.
le Auldere,” “Le Marchal” and imposed on various persons.


Psychopath almost Bolshevik.

=Case 184.= (HOVEN, 1917.)

A sergeant, accountant in civil life (father insane, mother pulmonary,
grandfather alcoholic, cousin insane; patient himself anemic as a
boy, victim of chronic gastritis and gonorrhea), was evacuated from
the front to Chateaugiron in March, 1916. It appeared that instead
of watching over his men as a sergeant should, he gave utterance to
baroque theories of the divine right, the influence of the grace of
God on man, and the end of the war. He went so far as to ask leave to
transmit to the Inventions Bureau of the War Ministry an invention
with respect to the problem of locomotion, and he sent to the King of
Belgium a manuscript to the effect that he had received from heaven
a mission to reëstablish the world’s balance. He was, in fact, the
victim of delusions of a mystical nature with visual hallucinations. To
explain his mission, he wrote, “It was my duty to take supreme command
of war operations.… I have the power, the right and the duty to give
the following order … general armistice … peace will be symbolized
by the house undivided and will be constituted by general Christian
religious unity … as a consequence of what we shall say they will give
up our territory to us of their own accord.”

This case of paranoia apparently took its coloring in part from the war
situation itself.


Hysterical mutism: Persistent delusional psychosis.

=Case 185.= (DUMESNIL, 1915.)

A sergeant, aged 23, evacuated from the front to a hospital for the
insane, had been mute, though not deaf, since February 28, 1915. If
asked to cry out he grew black in the face and could utter only a
raucous scream which made everyone jump. He wrote very frequently,
stating in February that as he was still a sergeant and had no hope
of advancement, he cared nothing more for life. “The idea of death
got anchored in my head.” In this state of mind, on the afternoon of
the 27th two bombs came. “I saw the first one coming and cried out
a warning. Coming back I saw the second one. The bombs were coming
rather softly. From this moment on and up to the time when they burst,
I thought I had gone, that I had been carried off and crushed. I was
quite astounded at finding myself covered with earth and stones … but
I could not talk any more, I could just say in a low voice ‘Papa,’ and
the next day in an ambulance I could not talk at all.”

There was complete pharyngeal anesthesia. The man had been a foundling
and was clearly a degenerate. He had always been of a depressed
disposition and given to thoughts about his misfortunes. Over and
above the mutism gradually ideas of persecution and revindication
developed (such as that he merited adjutant’s rank and was being mocked
and treated as a simulator). He drew up a long letter to the War
Ministry in which he stated his desire to be sent back to the front.
He complained to the police about a hospital sergeant and offered a
duel in an elaborate and inflammatory style, “with whatever weapons
shall please you, either sabre of 1845, revolver of 1902 or bayonet of
1886 or the _chassepot_. One of us two must disappear.” He had become
dangerous enough to be interned and in hospital remained mute with the
same ideas of persecution and revindication, the same alternate phases
of calmness and excitation. According to Dumesnil: hysterical mutism
with persecutory delusional psychosis.


A peasant’s psychopathic inferiority brought out by the war.

=Case 186.= (BENNATI, October, 1916.)

An Italian peasant began to feel sick on being called to arms.
Antebellum he had been an even-tempered, good-natured man, according
to his own story, satisfied even with stale food, and always enjoying
his sleep. He had been in the war about a month, doing construction
work, sentry duty, and chores. Though he lived in the trenches under
damp conditions, there had really not been much excessive war strain.
He shortly developed migraine and war-weariness, as well as middle-ear
disease.

A number of times he heard shooting nearby, and was subject in his
sentry duty to a good deal of anxiety and painful associations. On
sentry duty he had digestive disorder, vomited, and became intolerably
weary; in point of fact, a fever, regarded as malarial, then developed,
together with diarrhea.

Upon hospital observation, he was found fatigued, given to terrible
dreams, tremulous in the fingers, with skin reflexes a little
excessive, and the Moebius phenomenon. The thyroid was somewhat
swollen. The pulse stood at 80. The Mannkopf sign was well marked, as
well as that of Thomayer (80-120), and Erben (120-87). The oculocardiac
reflex was prominent.


Psychopathic episodes.

=Case 187.= (PELLACANI, April, 1917.)

A Neapolitan, 26 (neuropathic stock: mother epileptic, brother
psychopathic; patient had previous criminal record; married and then
appeared to behave himself for several years; had always been excitable
and of violent temper), after but one severe day in the trenches, woke
and found his night clothes soaked in urine. Another time, his comrade
had awakened him because he was gnashing his teeth in his sleep. Again,
his grief became very violent at learning of his wife’s infidelity, and
during the night he bit his finger. He thereafter suffered from severe
headaches, dizziness and vertigo though without falling. He was granted
a furlough, but the condition was aggravated on account of his wife’s
abandonment of him, and one day, finding her with her lover, he threw
himself at them, wounding her severely in the face: he did not remember
this impulse later. Many hours later, on awakening in prison with his
wounded hand, he recalled the entire episode. He showed a confused and
excited condition, which, however, quickly diminished. He became lucid
and tranquil, though easily aroused. He cried at the thought of his
daughter, whom he wanted to save. Insomnia, instability of reaction,
habitual migraine, and dizziness. Tremors of the fingers and of the
eyelids. Exaggerated reflexes. Very striking cutaneous analgesia.


Maniacal and hysterical delinquent.

=Case 188.= (BUSCAINO AND COPPOLA, January, 1916.)

An Italian soldier, 25, a foundling, was always off and on in a
military prison. At a tavern one night the man unsheathed his sword and
threw three bottles at the host. Bystanders overpowered him and carried
him to the local police station. Handcuffs were put on to stop the
mania. His pupils were dilated and he was sweating profusely. Alcohol
could absolutely be excluded from the history of this incident.

Observed in clinic, the patient was rather silent, but on the whole
normal and without delusions or hallucinations. It seems that he had
committed a number of crimes in the army that were always excused on
account of his mental state. He had been strongly alcoholic, although
not at the time of the incident mentioned. He was covered with
tattooings of an obscene and violent nature.

He showed pharyngeal and conjunctival anesthesia and concentric
limitation of the visual fields of unusual degree, and a remarkable
hypalgesia. The knee-jerks were lively. The man was, in point of fact,
sent back to military service, with, however, the suggestion of reform
school.


Psychopathic delinquent.

=Case 189.= (BUSCAINO AND COPPOLA, January, 1916.)

An Italian, 20 (family history negative), was described by officers as
of an odd disposition, at times thoughtful and again chattering and
presumptuous, and often very vulgar in talk and manner. He had tried
several trades, with little success.

While in the army he discharged his gun three times, claiming to
have heard noises in a nearby field. On account of the inopportune
repeated discharges, he was condemned to the barracks for ten days. The
following day, instead of returning to the barracks, he abandoned his
musket, cartridge box and uniform, and, returning to town, left for
Leghorn. Being sent to prison, he began to scream that he was thirsty.
He tore his jacket into strips with his teeth, and making a noose of
it, attempted to hang himself.

On being transferred to the military hospital, he was often very
restless, screaming and making a great uproar. On being questioned,
he answered indifferently and had a vacant stare. During his stay at
the clinic, patient was always quiet. Once, however, he had a spell of
intense psycho-motor agitation, brought on without any known cause and
followed by a short period of bewilderment, lasting altogether half an
hour.

Patient had insomnia and his visual fields showed concentric
contraction for white. He was sent to a military convalescent hospital.


Psychopathic excitement.

=Case 190.= (BUSCAINO AND COPPOLA, January, 1916.)

An Italian soldier, 22 (father and brother both committed to insane
asylums), since his enlistment had been conducting himself strangely,
being impulsive, undisciplined and unbalanced. He had been in Libia
from January to August, 1913, and was returned to Italy on account
of persistent severe headaches. A month later he was returned to a
regiment in camp.

September 23, 1914, the patient, who had been reproved by a superior
officer to whom he had given a disrespectful answer, began to be
excitable. He was calm during the day, but acted in a sullen and gloomy
way and kept entirely to himself, avoiding even his most intimate
friends. When, however, he suddenly recalled his punishment of the
morning, he began to race around the yard and finally threw himself
upon the ground, remaining there in a cowering and squatting position.
At the beginning of the attack he was possessed of a paroxysm of fury,
which made a great impression upon those present: eyes agape, face
swollen and distorted. He resisted being transferred to the hospital
and a furious struggle followed. He tried to bite and scratch everyone.
It required ten persons to carry him by his hands and feet safely to
the hospital, where he arrived in a state of great excitement and rage.

At the clinic, during the period of observation, he was always
tranquil, rather silent, gloomy, somewhat hostile; said he did not
remember why he was brought there. Often he was not able to sleep,
especially during the first few days of his stay. Has had painful
headaches and feeling of dizziness. Several times he showed a
tendency to be untruthful. Bodily examination revealed the absence of
conjunctival and pharyngeal reflexes. W. R. of serum was negative.

Patient was sent to an interior hospital for convalescence.


Desertion: Dromomania.

=Case 191.= (CONSIGLIO, 1917.)

An Italian private, 19, came up for desertion in the face of the enemy.
He had had a good record during a year of military service and his army
conduct in the war was regarded as very good.

He felt sad and preoccupied for a number of days, but all of a sudden
“some indomitable force” thrust the idea into him to go out into the
country a distance of some 20 kilometers from the front, with the
definite object of praying in a certain church. It seems that this same
impulse had occurred to him several times before but not so forcibly.
These prayers were to be said in memory of some sad events in his life.

Upon examination he was found in a sad and self-accusatory state, much
discouraged with ideas of his guilt, unworthiness, and ruin. He had a
variety of gloomy fears and obsessions, all of which contributed to the
dromomania that culminated in desertion.

As to his previous history, he had had a depressive psychosis two years
before, but the delusions at that time were of persecution. He had also
suffered from typhoid fever a few weeks thereafter.


Suppressed homosexuality.

=Case 192.= (R. P. SMITH, October, 1916.)

A man, 32 years, of high intellectual attainments and unblemished moral
character--a teacher--enlisted as a private. He apparently found his
associates in camp very uncongenial and undesirable. He grew physically
tired, then mentally tired and unable to concentrate attention. He
began to neglect his uniform, could not keep his equipment in order,
became introspective and depressed. The drums he heard seemed to point
to his funeral. There was but one thing to do in his opinion: that was
to humiliate himself by committing sodomy. He thought of committing
suicide.

Upon discharge from military duty, he began to show improvement. Smith
regards this case as one of suppressed homosexuality.

Of the cases in which change or excessive work is the precipitating
cause, four out of six of Smith’s cases were men.

_Re_ homosexuality in the Italian army, Lattes has made a special
study. The effeminate homosexual is decidedly unfit for the army, being
unable to stand the war stress. Homosexuals diminish army morale.
The cases of functional effeminacy with normal physique are likewise
unfortunate for the morale of active units, though they may be employed
in garrison duty and office work. The medical decision in these cases
may prove difficult unless a broad interpretation of the concept
“psychopathic” is allowed to prevail.


Psychopathic: suicidal, then self-mutilative.

=Case 193.= (MACCURDY, July, 1917.)

An English soldier as a child had night terrors and fear of the dark;
as a youth wanted to throw himself down from heights; took delight
in seeing animals killed; was shy with both sexes; was never able to
run great distances; was taken from school at the age of fifteen for
weakness, and had always been subject to headaches, somewhat improved
by lenses.

During training sharp pains appeared in the left groin that grew
better when the man lay down. These pains were regarded as hysterical.
Thereafter began shortness of breath, pain above the heart, with
palpitations and occasional attacks of dizziness. After a short sick
leave he insisted upon going to the front, though his superior officer
thought it unwise, and, after a period of seventeen months training,
was finally sent to France in September, 1916.

He was at first somewhat afraid of shells and, though he soon got
used to the shells, the horror of the war grew on him, with pity for
the Germans as much as for the British. He became depressed over his
weakness and when his commanding officer committed suicide got obsessed
with the idea of committing suicide himself. He went so far as to drive
a knife into his upper lip and to smash a looking-glass to avoid seeing
himself. After a long spell of trench duty he had to be sent home
incapacitated.

In hospital in England he was depressed and suicidal. He began to want
to mutilate himself, yet found that a slight pain and the drawing of
blood was all that he really craved. Of course, he had been a failure,
but now he rationalized the failure by a comfortable conviction that
he should never have been sent to the front. He complained of memory
and attention disorder, insisted that he was physically incapable of
outdoor exercise, complained of headache if he stayed indoors. He said
he wanted to go back to the front; knew, however, that he could not,
and even refused to consider the possibility of getting well to work
at home. At the time of report he argued there was nothing left but
suicide.


Bombardment: Psychasthenia?

=Case 194.= (LAIGNEL-LAVASTINE AND COURBON, July, 1917.)

A twenty-year old engineering student of high grade and without
hereditary taint, a scientific and non-introspective man of a brilliant
and gay disposition, not very religious, without special sexual
abnormality, was mobilized in class 1914, was put into the artillery,
and was soon appointed _maréchal des logis_. He left for the front
April, 1915, yet had to be evacuated in November. One afternoon, at the
end of a bombardment, he rose from a recumbent attitude and immediately
felt a dreamy, bizarre feeling, as if a fog lay between him and his
surroundings. Next day, after a good night, he woke in the same state.
Everything was bizarre and novel despite the fact that he recognized
men and things. A physician ordered rest and after a few days evacuated
him.

He was cared for in various hospitals, but the psychasthenia increased.
He felt a terrible and causeless anguish, with precordial constriction.
He felt as if he were about to be executed. His fears appeared after
seeing some turning object, such as a wheel or a cane twirling.
Gradually this fear was transformed into a genital excitation, though
lascivious pictures did not excite him. Seeing anything turning gave
him a voluptuous feeling in proportion to the speed of the rotation.
It seems that all sexual interest had been at a standstill for several
months in the early part of his disease, when suddenly this new
aberration appeared. It seems that a portion of the man’s work in the
artillery caused him to use screws and cogwheels every day. Attacks
of vertigo occurred, with the appearance of an infinity of small,
colorless spheres turning over one another, the whole forming a sort
of animated system of rotation. In the night this system was luminous
and somewhat like what one feels on compressing the globes of the eye.
There was a retraction of the visual field. The man would be found
in the dream state, especially after waking in the morning or when
some novel kind of act was being performed. He got somewhat better
and did not wish to go on leave, because he feared the recurrence of
these psychasthenic paroxysms. However, he took a leave July 14th.
In the first part of his journey he had some vertigo and some of the
voluptuous sensations, but in the next two days he was much better. He
returned to hospital without trouble.

The authors somewhat doubtfully term this case one of a quiet
psychasthenia, but in discussion still further talk arose as to the
diagnosis.

_Re_ psychasthenics, Lépine notes that the lack of any out-standing
symptoms in many psychasthenics allows them to stay in the army longer
than would epileptics or hysterics of the same degree of disease. The
line officers tend to consider them exaggerators or simulators. The
fact that they besiege the line officers and the physicians with their
troubles may add to the impression of falsification. The basis of the
psychasthenia is often also, genuinely enough, a fear. Lépine divides
the military cases into anxiety neuroses and hypochondrias. The anxiety
cases are hypotensive and given to tachycardia. They have very labile
vasomotors. When it comes to the necessary exclusion of malingering, it
is the history, with its hereditary and collateral taint, that tells
the tale. A history in the patient himself of alcoholism, typhoid
fever, syphilis, or especially cranial trauma may play a part. An
agoraphobic may actually be in general a courageous man except for his
crises of anxiety about open spaces.

As to the hypochondriacs, fear of syphilis must be noted. Akin to the
syphilophobics are a group of pseudo genitourinary cases that fear
effects of an old gonorrhoea. See Case 195 (Colin and Lautier) below.


Gonorrhoea: NOSOPHOBIA, depression, suicidal attempt. Recovery,
thirteen months.

=Case 195.= (COLIN and LAUTIER, July, 1917.)

A munition worker came to Villejuif, December 6, 1915, with cord marks
on his neck and conjunctival ecchymoses. He had tried to hang himself.

Non-alcoholic, he had, however, long since shown signs of imbalance;
his father had died insane, in an institution. When the man came in,
he wept and groaned and made vague complaints of having contracted a
venereal disease, insisting that his genital organs were purple.

After a few days, he grew less anxious and told how he was married and
how his wife had made life a hell for him, giving herself up to drink
and becoming a sloven; how several months since he had contracted
gonorrhoea; how though told that the condition was cured, he had found
filaments in the urine and had tried a variety of drugs, spending most
of his money; how he found more and more filaments, thought himself
incurable and unable to live with his wife; how at last, desperate, he
had tried to hang himself.

He got well quickly, though his convalescence was interrupted by
several periods of depression a few days in duration, with anxiety and
tears. February, 1916, he was discharged well.

He returned four months later; he was still occupied with his disease,
still going to physicians and buying drugs. It took six months more
before the man could be discharged from the service, at the end of 1916.

This man appears to be a hereditarily predisposed subject, who simply
affixed his delusional ideas to a disease which had begun some time
before the mental trouble itself. The family plight is important and
practically constant in this group of cases. The fear lest the disease
shall be revealed by the physician to the family is deep-grounded and
impossible to overcome by mere statements concerning professional
secrecy. The impulse to suicide is extraordinarily keen.


A soldier (neuropathic taint) after hardships for two days stumbles
over a corpse; unconsciousness: Stupor; episodes of fright with war
hallucinations; look of premature old age; paresis; anesthesia.

=Case 196.= (LATTES and GORIA, 1917.)

An Italian soldier (a shoemaker with an epileptic mother and two
nervous brothers; himself always irritable and for long periods
melancholic; at 15 condemned to nine years in prison for homicide in
a quarrel) took part in a number of attacks at the beginning of the
war. His company was heavily engaged in October, 1915, and there was no
sleep two nights, and only a bit of cold food. He was dazed.

October 24, the company had to advance at night in the rain and under a
heavy rifle fire. The shoemaker stumbled over a corpse, fell, and lost
consciousness for a time that he thought was very long. He woke up in a
camp hospital, remembering all the experiences he had undergone up to
the time of losing consciousness. He now fell into a state of torpor,
occasionally jumping out of bed and shouting with fear, hurling himself
at non-existent persons, assuming a position of defence, and suddenly
awaking in anxiety.

October 29, he was transferred to a second hospital, and October 30,
in a third hospital, was examined and found well and strongly built,
but looking prematurely old. He was inactive, depressed, and stuporous
looking. He fell to weeping often and rarely gave any answer to
questions. Sometimes he refused food. There was a slight paresis of the
left arm, and the left pupil was smaller than the right; both pupils
reacted poorly to light. The larynx and cornea did not respond to
stimulation. Skin reflexes were poor, and the plantar reflex lacking.
The left side about the shoulder and hip showed large patches of
anesthesia to touch, pain and heat; but deep sensibility was present in
these areas. He slept well at night. Status unchanged for two weeks.
He was experimentally sent to the guardhouse, but was soon back in
hospital with the same symptoms as ever.



B. SHELL-SHOCK: NATURE AND CAUSES.

              --la buia campagna
      tremò sì forte, che dello spavento
      la mente di sudore ancor mi bagna

    La terra lagrimosa diede vento,
      che balenò una luce vermiglia,
      la qual mi vinse ciascun sentimento;

    E caddi, come l’uom, cui sonno piglia.

            --the dusky plain
      trembled so violently, that the remembrance
      of my terror bathes me still with sweat.

    The tearful ground gave out wind
      which flashed forth a crimson light
      that conquered all my senses;

    And I fell, like one who is seized with sleep.

                      Inferno, Canto III, 130-136.


Bombardment; shell explosion nearby: Mania; death in 24 hours. The
AUTOPSY showed superficial punctate hemorrhages of brain and congestion
of pia mater. CAUSE OF DEATH--small bulbar hemorrhage, congestion
of veins, and nerve-cell changes of a local and differential nature
(chromatolysis of vago-accessorius nucleus). SHELL-SHOCK SYMPTOMS due
to capillary anemia and chromatolysis of various regions.

=Case 197.= (MOTT, November, 1917.)

A soldier became rather nervous at the Somme, and later underwent
intense bombardment for some four hours, February 22, 4 to 8 P.M.
Although he said he “could not stand it much longer” he carried on
for twelve hours more when perhaps six shells went over, February 23.
One of the shells burst about ten feet away, just behind the dugout.
The first day of the bombardment he was tremulous and depressed;
later coarsely tremulous in the limbs. February 23 there was crying
and inability to walk or do any sort of work. Questions were not
answered. The pupils were dilated. The evening of February 23 the man
was admitted to the field ambulance in acute mania, shouting: “Keep
them back! Keep them back!” He was quieted with morphine and chloroform
and slept well during the night. There were at least two hypodermic
injections of morphine in the ambulance. He woke up the morning of
February 24 apparently well, but suddenly died.

The autopsy showed small scratches on the anterior chest wall, but
otherwise no sign of external violence. Both lungs were edematous;
the left lower lobe showed a considerable hemorrhage. The heart was
enlarged and the right side dilated. The liver was somewhat congested.
The kidneys were small, but otherwise showed no gross change (urine
without sugar or albumin).

                                CHART 7

                   EFFECTS OF HIGH EXPLOSIVE SHELLS

    EMOTIONAL

    COMMOTIONAL

    LESIONAL

                                           After Vincent and others

                                CHART 8

    SHELL-SHOCK
         ^
         |
    +----+-----------------------------+
    |                                  |
    |                                  |
    |        SUGGESTION                |    ESSENTIAL!
    |  (AUTO-, HETERO-, MEDICAL)       |    (Babinski)
    |                                  |
    |                                  |   SOMETIMES SOLE
    |                                  |      FACTOR?
    +----------------------------------+
        ^            |        ^
        |            |        |
        |            |        |
    +------------+   |    +------------+
    |            |   |    |            |     INTRABELLUM
    |            |   |    |            |       FACTORS
    |            |   |    |            |       USUALLY
    |   EMOTION  |   |    |   SHOCK    |       ONE OR
    |            |   |    |            |        BOTH
    |            |   |    |            |
    |            |   |    |            |
    +------------+   |    +------------+
           ^         |          ^
    -------|--------------------|----------------------------
           |                    |
    +------------------------------------+
    |                                    |
    |               SOIL                 |      FREQUENT BUT
    |       (ACQUIRED, ANTEBELLUM)       |      NON-ESSENTIAL
    |                                    |
    +------------------------------------+
                      ^
                      |
    ------------------|--------------------------------------
                      |
    +-------------------------------------+
    |                                     |
    |               TAINT                 |    FREQUENT BUT
    |            (HEREDITARY)             |    NON-ESSENTIAL
    |                                     |
    +-------------------------------------+

The scalp showed a slight frontal bruise. The brain was extremely
congested. On each side of every superficial vessel there was an
ecchymosis. A number of minute punctate hemorrhages was found on the
surface of the brain in connection with very small vessels. The brain
substance was soft, but not markedly edematous. The cerebrospinal fluid
was tinged with blood. On each side of the great sinuses of the skull
there was considerable ecchymosis. This examination was made by Capt.
A. Stokes, R.A.M.C., in the mobile laboratory. There were no areas
of large hemorrhage anywhere in the brain substance and no smaller
petechiae, except the superficial ones above noted.

Microscopically Mott confirmed the pial congestion and macroscopic
subpial hemorrhages described in the gross. He found besides congestion
also actual hemorrhage in the vascular sheaths of the corpus callosum,
internal capsule, pons and bulb. Now and then blood corpuscles were
found extravasated into the nervous tissue.

The microscopic examination showed a generalized early chromatolysis
in the nerve cells of varying intensity, especially affecting the
small cells. The Nissl granules of the larger cells were also somewhat
abnormal, being smaller and packed rather loosely together.

The small cells of the bulb and pons were slightly swollen and their
nuclei large and clear. As to the larger cells of the bulb and pons,
there was less evidence of this swelling and nuclear change.

According to Mott, this chromatolysis may perhaps be regarded as a sign
of loss of biochemical neuropotential. The chromatolysis indicates a
relative degree of exhaustion of the kinetoplasm. Mott assumes that
the cells of this victim of shell-shock are in a state of beginning
nervous exhaustion. He remarks that the cells of the vago-accessorius
nucleus show more signs of this nervous exhaustion than others. With
respect to cerebellar findings Mott remarks that the changes found are
very similar to those described by Crile in the case of an exhausted
and wounded soldier. Mott correlates the mania shown on the evening of
February 23 with the venous congestion of the cortex, the small subpial
hemorrhages and evidence of scattered arterio-capillary collapse.

                HISTOPATHOLOGY OF CASE OF SHELL-SHOCK,
                        BURIAL, GAS POISONING?
                             (F. W. MOTT)

    [Illustration: Punctate hæmorrhages in corpus callosum from a
    case of shell-shock and burial; very probably accompanied by
    gas poisoning while lying unconscious and buried. Observe the
    small white area in the centre of the hæmorrhage, in the middle
    of which is a small vessel which, under a higher magnification,
    will be seen to contain a hyaline thrombus. (× 20.)]

    [Illustration: Hyaline thrombus of vessel in centre of a
    punctate hæmorrhage. The thrombus was stained brown by
    dissolved pigment. Around the blocked vessel is a white area of
    brown substance containing numbers of leucocytes; outside this
    is the hæmorrhage, not very distinctly seen. The specimen was
    prepared from the subcortical white matter of the frontal lobe.
    (× 345.)]

    [Illustration: Leash of small perforating optostriate arteries
    filled with pigment granules. Two of the arterioles show
    miliary aneurisms. (× 350.)]

    [Illustration: Three punctate hæmorrhages showing optostriate
    arterioles filled with pigment granules. (× 30.)]

                     HISTOPATHOLOGY OF SHELL-SHOCK
                             (F. W. MOTT)

    NOTE THAT THE CHANGES IN CELLS OF FIG. 3 ARE DIFFERENTIAL FOR
    NUCLEUS AMBIGUUS: CELLS NEARBY PROVED NORMAL

    [Illustration: FIG. 1.--Photomicrograph of section of corpus
    callosum from case of shell-shock showing the capillary
    punctate hæmorrhages. In several a small white area is seen of
    brain tissue in the centre of which is a small artery or vein.
    (Magnification 20 diameters.)]

    [Illustration: FIG. 2.--Section of medulla oblongata from case
    of gas poisoning, stained by Nissl method, showing the swollen
    cells of the nucleus ambiguus. Observe the enlarged, clear,
    eccentric nucleus; the surrounding cytoplasm shows an absence
    of Nissl granules. In not a single cell is the nucleus seen in
    the centre as it should be. (Magnification 450.)]

    [Illustration: FIG. 3.--Section of medulla oblongata from
    case of shell-shock with burial, stained by Nissl method,
    showing the swollen cells of the nucleus ambiguus. Observe the
    enlarged, clear, eccentric nucleus; the surrounding cytoplasm
    shows an absence of Nissl granules. In not a single cell is
    the nucleus seen in the centre as it should be. (Magnification
    450.)]

    [Illustration: FIG. 4.--Section of third cervical segment of
    spinal cord from case of concussion, stained by Nissl method,
    showing the medium group of anterior horn cells corresponding
    to the nucleus diaphragmaticus. They show certain amount of
    perinuclear chromatolysis. But all the cells exhibit the Nissl
    granules. Even at the seat of concussion, the fourth segment,
    an external group of cells remains showing Nissl granules.
    Concussion therefore does not destroy the Nissl granules.
    Probably the cells of the nucleus diaphragmaticus show a
    certain amount of chromatolysis because they were continually
    discharging impulses along the phrenic nerves, and the few
    cells that were left of the nucleus had therefore much more
    work to do. (Magnification 300.)]

Mott suggests that the sudden death of the case may be due to a
hemorrhage into a sheath of a fair-sized vessel in the median raphe
of the bulb; the general venous congestion; and the almost complete
chromatolysis of the vago-accessorius nucleus (adjacent hypoglossal
nucleus normal).

According to Mott, also, many Shell-shock symptoms, _e.g._, headache,
giddiness, amnesia (anterograde and retrograde), dizzy feelings, lack
of power of attention, and fatigue, stupor, inertia, mental confusion,
terrifying dreams, are to be explained on the basis of capillary anemia
and chromatolytic changes.


Mine explosion. Ecchymoses; no bone or visceral consequences seen at
AUTOPSY (third day after explosion) except SUBDURAL HEMORRHAGE and
PUNCTATE HEMORRHAGES OF BRAIN.

=Case 198.= (CHAVIGNY, January, 1916.)

A sergeant in a Chasseur Battalion was in a mine explosion and
entered hospital June 19, 1915, so agitated that he had to be tied to
the stretcher during transfer from the railway. There were remains
of epistaxis and blood in the right ear, not proved to be due to
otorrhagia; blue-black ecchymoses of both eyelids; and small ecchymoses
of the bulbar conjunctiva of the right eye. No other sign of trauma
or fracture. The explosion had probably taken place on June 17 or
18. Patient was but semiconscious and irresponsive; rolled upon the
mattress, beating the air with arms and legs, assuming fighting
postures and uttering cries. Urinary incontinence. No fever.

There was doubt as to the diagnosis, which lay between fracture and
concussion. The persistent agitation and oniric delirium pointed rather
to concussion. Without further sign, however, the patient died on the
night of June 20.

The autopsy was extremely careful and showed no sign of cranial
fracture of vault or base. The cerebrospinal fluid was strongly
bloodstained. The inner surface of the dura mater had a thin sheet
of hemorrhage, hardly 1 mm. thick, covering both hemispheres and the
cerebellum and spreading over the bulb. There was no distension of the
lateral ventricles. Serial sections of the brain showed no lesions of
the substance, except for slight hemorrhagic points.

According to Chavigny, so slight a meningeal hemorrhage is incapable
of producing a mechanical disturbance of the brain and the cause of
death could not be said to be meningeal hemorrhage. Massive multiple
gas embolism through sudden decompression is not a suitable explanation
of a case with death delayed, as in this instance, even if Arnoux’s
explanation is suitable for cases of immediate death.


Mine explosion: no skin, bone, or visceral consequences seen at AUTOPSY
(death in seven days) except slight LOCALIZED MENINGEAL HEMORRHAGE.

=Case 199.= (ROUSSY AND BOISSEAU, August, 1916.)

A soldier entered Val-de-Grâce February 27, 1915, in a state
of confusion following mine explosion the night before. He was
delirious, thought himself on leave, and had spells of excitement.
Lumbar puncture, February 29, showed a slightly darkened fluid, with
approximately normal amount of albumin, one or two lymphocytes and rare
red blood cells.

A brief period of slight improvement followed, but the restlessness
and delirium increased once more, became particularly severe March 3,
and the patient died on the night of the third, seven days after the
explosion.

The autopsy showed slightly congested lungs; no other lesion except a
sharply defined hemorrhage in the cervical spinal meninges and over the
meninges of the temporal and occipital lobes. Microscopic section of
the brain failed to show any hemorrhages within the brain substance.

Here is a case of death following explosion without external wound.
The meningeal hemorrhages are hardly enough to explain the death. The
explanation of the death must probably be made after histological
examination.

Concussion of spinal cord from shell burst--WITHOUT spinal fracture,
WITHOUT penetration of splinters of shell or bone into canal or cord
substance: Microscopic demonstration of intraspinal AREAS OF SOFTENING
with classical secondary degenerations. Such a case forms a link in the
argument that serious lesions of the nervous system may develop as a
result of VIOLENCE directly TRANSMITTED through investing tissues EN
BLOC.

=Case 200.= (CLAUDE and LHERMITTE, October, 1915.)

A man, 23, was struck in the left thorax and shoulder, in both thighs
and the neck, by fragments from a bursting shell March 27, 1915. One
fragment was imbedded near the vertebral column.

Twenty days later there was an absolute, flaccid paraplegia, yet
the legs occasionally gave spontaneous, jerky movements. Tactile
anesthesia reached the fourth dorsal root-level, except that the
perineoscrotal region and the penis were somewhat sensitive. There was
anesthesia to pain and heat, as well as in bones and joints, along
with the tactile anesthesia. There was a hyperesthetic region on the
right side, corresponding with the distribution of the fourth dorsal
root. All the cutaneous reflexes up to the abdominals were gone; but
defense reflexes could be brought out in foot and leg by skin, bone
or joint stimulation. The deep reflexes of the legs were also lost,
whereas those of the arms were increased. Retention of urine without
incontinence; no retention of feces. Sacral, trochanteric and heel
decubitus had developed in the course of the three weeks following
injury. A lymphangitis ran all the way up the right thigh from one of
the sores, with a corresponding hyperpyrexia.

Surgical intervention was indicated from the evidence of spinal
compression at a definite level, but the lymphangitis grew worse.
Oniric delirium, and finally a stuporous state, set in, with death May
6, forty days after the wound, a death due to septicemia, without
special alteration in the paraplegia itself or in the sensory and
reflex situation.

At autopsy the spine and dura mater proved normal; but microscopically
serial sections through the fourth and fifth dorsal segments showed
softening of the right anterior horn and posterior columns, with
cavitation in the radicular zones, and the white matter of the fifth
dorsal segment was in a state of acute degeneration. There were also
ependymal changes, namely, at the fifth dorsal level a dilatation with
deposit of albumin; in the lumbar region, breakage of the ependymal
wall, with cellular gliosis. The dilated ependyma was surrounded by
an area of fibrillary gliosis which had proliferated in the form
of a septum in the interior of the canal. (According to Claude and
Lhermitte, these data concerning hydromyelia, which they regard as
secondary to trauma, are an argument in favor of the traumatic origin
of certain syringomyelias. They regard the breakage of the ependymal
wall as due to hypertension of the spinal fluid due to mechanical
lesions.) Their interpretation of such acute degeneration as was found
in the fifth segment is that this degeneration, as well as that of the
posterior roots, is due to the direct impact of the cerebrospinal fluid
upon the cord structure. As for the softenings with cavitation, they
regard them as surely due to spinal concussion and as very possibly due
to an ischemic necrosis, suggesting that older work by Duret and Michel
on concussion of the brain indicates the possibility of a temporary
ischemia of the spinal cord from the violent impact of the spinal
fluid upon the cord due to shock of the spinal column. The transient
hypertension of the spinal fluid might well induce, they believe, a
vascular spasm with anemia, to which the gray matter is well known to
be especially sensitive. In the present case, a period of somewhat less
than six weeks had sufficed to produce secondary degenerations above
and below the fifth dorsal segment, of a quite classical sort.

Accordingly, we here deal with a severe form of spinal concussion due
to a shellburst, in which intraspinal lesions were produced without
spinal fracture or penetration either of bone or of shell fragments
into the spinal cord or the spinal fluid.


Shell explosion (1 meter distant) kills a soldier by bursting both
lungs within the intact thoracic cage.

=Case 201.= (SENCERT, January, 1915.)

A man of the 26th Regiment of Infantry was brought October 26, 1914,
to Ambulance No. 6 of the Twentieth Army Corps at the Chateau d’Henu.
Weakly and jerkily the man was able to tell how, as he was going
forward, a large calibre shell fell less than a meter in front of him
and exploded. He fell back and lost consciousness, was picked up in the
evening and carried to the relief post and then to the ambulance, where
he arrived ten hours after the fall. There were signs of a considerable
shakeup, with pale and anxious face, nose pinched, hollow eyes, rapid
superficial respiration, small pulse, 120, and a feeble voice. There
were small skin wounds of the right arm, a finger, and ear, but there
was otherwise no wound. The thorax and abdomen were somewhat painful
all over, but there was no especial point of pain. The chest showed
a slight dulness at the bases. Examination of the abdomen produced
defensive movements and the man vomited blood during examination. He
was put on his back, kept warm, given artificial serum, hypodermic
injections of camphorated oil and caffeine, and carefully watched. In
the night he had another bloody vomiting, his pulse became smaller and
smaller, dyspnea became more and more intense, and he died late in the
night.

The autopsy showed that the abdomen was free of lesions and that all
the organs were of a normal appearance and color. There was no sign
of perforation or of peritonitis. The stomach itself was filled with
blood and there was a generalized ecchymotic appearance of the mucosa,
with small, submucous hematomata and a number of tears in the pyloric
portion.

The pleurae were found filled with blood, almost a quart in each
cavity. The right lung showed a large tear at the level of the middle
lobe, 15 cm. long. An orange-size, black bit of lung protruded through
the tear. There was no sign of rib fracture opposite this tear, and no
subpleural, intercostal or subcutaneous contusion. The thorax wall was
perfectly normal.

The left lung showed, in the middle portion of the upper lobe, a
somewhat analogous pleural tear, almost as big as that on the right,
with another large hernia of black lung. Bits of the herniated lung
sank in water. The thorax wall was intact. The pericardium was free
from blood. There was nothing else abnormal about the body.

_Re_ effects of an explosion upon structures with intervening objects
left intact, Fauntleroy notes that a shell bursting three yards from
an aneroid barometer may force its levers into an abnormal position.
A further fact will indicate how permanent is the physical state into
which the levers are forced; for when the barometer with its levers
placed right was placed under a bell-jar and the pressure therein was
reduced to 410 mm., the levers resumed the position into which the
explosion of the big shell had thrown them.

_Re_ windage and internal effects in the human body, Ravaut recalls the
fact that the internal and intraneural hemorrhages of Caisson disease
(“bends”) are well known. The external hemorrhages of aeronauts and
mountain climbers belong in the same physical class. Dynamite exploded
in a pond kills fish. Dynamite may break pillars inside a building
without damaging its front. Cases like Chavigny’s (198), Roussy and
Boisseau’s (199), Claude and Lhermitte’s (200), as well as Ravaut’s own
case (202) are in point.


Shell explosion near by: Paraplegia, interpreted as due to windage. Two
foci of HEMORRHAGE (SPINAL CANAL, BLADDER) clinically proved to exist
in a case without external sign of injury.

=Case 202.= (RAVAUT, February, 1915.)

An infantry sergeant was brought to the ambulance, one day in November,
1914, with a paralysis which had set in immediately upon the explosion
of a large shell a short distance away. Both legs were paralyzed and
there was anesthesia to the navel. He could not urinate. It was early
in the war, and Ravaut thought he would find an injury to the vertebral
column, but on undressing the soldier there was no wound. The skin was
intact, and there was not even an ecchymosis. The patient was suffering
not at all, but said that after the shell exploded he felt a forcible
shock, was stunned for a moment, and when he wanted to rise, found
that his legs were inert. His state did not change during the day and
he did not urinate. Catheterization showed a urine full of blood. This
indicated a lumbar puncture, and a bloody fluid emerged under great
pressure. Thus two foci of hemorrhage were proven to exist in this
patient despite the fact that there was no external lesion.

_Re_ windage effects, see suggestions of Ravaut under Case 201. Ravaut
also suggests that certain cases of emotional jaundice may be similarly
explained on the basis of internal lesion due to windage. Sundry cases
of gastro-intestinal disorder and of hemoptysis fall into the same
class; possibly the cases of death in a fixed posture belong there,
too. Ravaut thinks, despite the look of hysteria about the shell-shock
cases of paraplegia, deafness, mutism, and the like, that the cases
are actually ones in which there has been at the beginning a slight or
severe hemorrhage, clearing up in a few days. He states that there is a
pretty definite parallelism between the course of the clinical symptoms
and the chemical characteristics of the spinal fluid.


Shell-explosion in confined space; paraplegia after fifteen minutes;
slight hemorrhage and LYMPHOCYTOSIS of spinal fluid; Hematomyelia.

=Case 203.= (FROMENT, July, 1915.)

A Sergeant lying down in a small dugout space, 2 × 1 m. high, had a
77 shell burst behind his head and between his head and the back of
the dugout. The patient was not moved by the explosion, but was buried
in a small amount of earth and stones to a depth of about 20 cm. He
was not wounded and showed no ecchymoses either then or later. Aided
by stretcher bearers, he was able to walk to the relief post about
400 meters from the trench. He did not lose consciousness, and got
to the relief post about a quarter of an hour after the shell burst.
Thereafter, however, he was unable to move his legs. The accident
happened February 6 at 4 o’clock. He was examined 24 hours after the
trauma. The accompanying diagrams show the variations in sensory
disorder at intervals during six months.

A lumbar puncture, February 8, 1915, showed hypertensive clear fluid
without macroscopic clot on centrifuging, but showing a number of red
blood cells and lymphocytes--3 or 4 to the microscopic field. There
was a slight hyperalbuminosis. The development of the muscular atrophy
and hypo-excitability of the left lower extremity, the exaggeration of
the left knee-jerk, together with the spinal fluid appearances, seemed
to prove the organic nature of the paraplegia. There was an intense
rhachialgia, with radiation along the sciatic nerve. This outlasted
all other symptoms. Thermo-analgesia was the most prominent sensory
disorder. There were no sphincter disorders.

During the first days, the anesthesia was of a pure segmentary type,
with nothing about it to suggest that it was later to be supplanted
by a radicular type of disorder. Hematomyelia was, years ago,
thought--according to Froment--to tend to yield sensory disorders
of a segmentary nature. At the outset this anesthesia was total,
though there was a vague, poorly localized feeling on intense
painful excitations,--as with energetic pricking or burning. Thus the
protopathic sensibility of Head had remained, whereas the epicritic
sensibility had disappeared.

Detailed examination of this case showed extreme errors in the position
sense. For example, pricking the foot might be localized as pinching
above the knee. The cremaster reflex was extremely marked and would
appear upon even slight excitation of any part of the lower extremity,
even at times when the patient declared he felt nothing. These
phenomena at the beginning early gave place to a syringomyelic type of
anesthesia.

At the time of report, July 29, 1915, Froment regarded this case as
analogous to hematomyelias of divers, although there is not such a
degree of decompression; the suddenness of the decompression is more
marked in these Shell-shock cases than in divers.


Shell explosion; bowled over; loss of consciousness: Hemiplegia
with reflex signs thought to be organic; hypertensive spinal fluid;
LYMPHOCYTOSIS.

=Case 204.= (GUILLAIN, August, 1915.)

A corporal in the engineers was going the night of June 7th to a
creneau of mitrailleuses, when he was bowled over by a bursting
shell. He lost consciousness and was carried to the cantonment by
his comrades. Next morning he complained of headache and pain in the
back; had a convulsion; and proved on examination to have a left-sided
hemiplegia. He was given the diagnosis of hysterical hemiplegia.

He was sent to the 6th Army neurological center, and there showed a
complete left-sided hemiplegia with tendency to contracture. The left
knee-jerk and arm reflexes were exaggerated, and there was ankle and
patella clonus with Babinski sign. There was a dysesthesia on the
left side, with wrong interpretation and poor localization of painful
stimuli, and non-recognition of cold and heat sensations. Muscle sense
and stereognosis were impaired. There was a slight dysarthria. Lumbar
puncture yielded a clear hypertensive fluid with a slight lymphocytosis.

The situation remained without change for a month, when the patient
was evacuated to the rear. Thus, a shell-burst can produce destructive
nerve lesions without evidence of external injury.

_Re_ hypertensive spinal fluid, Sollier and Chartier cite Dejerine as
having brought the proof of hypertension in the cerebrospinal fluid in
Shell-shock cases. They also believe that the Shell-shock hysteria is
built up on a physical basis, more or less after the model of Charcot’s
hysterotraumatism. Shock, windage, and gas may bring about the same
kind of result. They rely especially on the cases of Sencert (201)
and Ravaut (202) for their argument (1915). They recall the fact that
Charcot found a hysteria due to lightning stroke and to high tension
electric accidents. They quote Lermoyez as attributing like results in
ear cases to labyrinthine shock, tympanic rupture, and ear hemorrhages.


Shell-shock: Hemiparesis, amnesia. Lumbar punctures early (but here as
late as one month after shock and after disappearance of hemiparesis)
showed PLEOCYTOSIS and hyperalbuminosis.

=Case 205.= (SOUQUES, MEGEVAND and DONNET, October, 1915.)

A French sergeant, a machine gunner, was the victim of shell-burst
September 25, 1915, was evacuated with a diagnosis of commotio cerebri,
and, when examined at Paul-Brousse October 5, showed a right-sided
hemiparesis, clouding of consciousness and somnolence, the hemiparesis
involving the face, with deviation of tongue to right, Babinski reflex
right, cremasteric and abdominal reflexes abolished on right. Normal
respiration and pulse.

Lumbar puncture October 7, that is, thirteen days after the injury,
yielded a clear fluid with an excess of albumin, 144 small lymphocytes
(some degenerate) and a single endothelial cell.

October 12, the knee-jerk was a little less lively on the right side.
The plantar reflex varied between extension and flexion on the right
side. The cremasteric reflex had been weakly regained on the right side.

The patient was now less stupid and could tell how he jumped when
the shell burst, and how he had been in the air ten minutes (!) and
fell, getting up at once, with nothing wrong except nosebleed. After a
half-hour he felt weaker and was ordered to leave the post, whereupon,
on the road, his weakness increased and he tended to fall to the right,
but reached the ambulance on foot.

October 23, there was no longer any evidence of hemiparesis, the
Babinski reflex had entirely disappeared; there was no complaint except
of dizziness and headaches. He got back his autocritique on the matter
of remaining in the air ten minutes, but there was still an amnesia for
the ten day period between the shock and his arrival at Paul-Brousse.
He forgot that he had had a lumbar puncture October 7.

Another puncture, October 25, yielded some 14 or 15 lymphocytes to the
cmm. There was still an excess of albumin. The lymphocytes decreased
further according to a puncture November 2. Had this patient been
examined some weeks after the shock there would have been no signs of
an organic paresis, no special modification of the spinal fluid, and no
reason for regarding the man as other than an hysteric. Early spinal
puncture is, accordingly, important.

Of course, the question whether the lymphocytes and hyperalbuminosis
of the fluid might not be syphilitic must be raised. At the Hospital
Medical Society meeting, October 29, 1915, Souques states that
Ravaut and Guillain believe that simple shell-shock often produces
“syphilitic” chemical, physical or cytological changes in the spinal
fluid. Roussy is cited as thinking such changes rare.


Shell-shock; burial: Coma and semicoma; BLOOD-STAINED SPINAL FLUID.
Improvement on puncture. Persistent astasia abasia with spasticity.

=Case 206.= (LERICHE, September, 1915.)

A man was buried March 15, 1915, following the bursting of a large
calibre shell. He is said to have had hemoptysis and arrived at
hospital March 17 in coma. He kept moaning while asleep. March 18, he
was still stupid and as if stunned. He did not talk or understand what
was said, but was able to write a few words. The knee-jerks were a
little exaggerated. There was a slight spasticity of the limbs, which
was exaggerated on emotion into a sort of spasmodic crisis.

Lumbar puncture gave a reddish fluid under strong tension. After lumbar
puncture the man came out of coma and the next day, after another
puncture (fluid slightly yellowish), there was further improvement and
the patient spoke. The third puncture, March 20, yielded yellow fluid.
The spastic phenomena still persisted, however. The patient could not
walk or stand. Every time he touched the ground he had a clonic crisis.
He was evacuated to a neurological center.

_Re_ astasia-abasia, Nonne found these cases heading a group of 63
cases of war hysteria treated in a twelvemonth. Figures as follows:

    Astasia-abasia                   14
    Generalized tremor               12
    Brachial monoplegia              11
    Isolated contracture              6
    Crural paraplegia                 5
    Mutism                            5
    Isolated tic                      4
    Hemiplegia                        3
    Isolated respiratory convulsions  2
    Isolated sensory disorder         1

Fifty-one of the 63 cases were freed by therapy from their main
symptoms (twenty-eight cases cured in one or two hypnotic sittings).


Prolonged bombardment; shell explosion (nearby?): Depression; suicidal
attempt; hypertensive spinal fluid.

=Case 207.= (LERICHE, September, 1915.)

A patient entered an evacuation hospital June 27, having come from
an ambulance with a ticket reading, “Melancholic depression, with
stupor--attempt at suicide (threw himself into a pond)--sprained
ankle--to be evacuated, lying down, on a milk diet.” The patient was
depressed, indifferent to surroundings, irresponsive, and did not even
look at an interlocutor. There was no other somatic sign except a pulse
of 62. He did not eat, and remained lying down, without movement.
Lumbar puncture in a sitting posture yielded a clear liquid under
pressure of 34. June 30, another lumbar puncture yielded clear fluid of
a dichroic appearance when looked at from above. 25 c.c. were removed.
July 1, there had been a good deal of improvement. The patient said he
was better and began to take a little milk. July 2, there was still
some improvement. Pulse 60. He said that his condition had lasted a
month and that it followed a violent and prolonged bombardment for ten
days in his sector. July 3, he was much better, began to look about,
talk, and eat a little. July 4, lumbar puncture yielded a clear fluid
with a pressure of 30, reduced to 22 after withdrawal of 20 c.c.

According to Leriche, explosion of large calibre shells or of a mine
can produce cerebral or spinal symptoms, some of which are removed
by lumbar puncture. The fluid is red shortly after the explosion and
under hypertension for some days. Such hypertension may be found even
in shell cases that have no other sign of cerebral condition. This
particular melancholy patient had a relapse and another depression with
fugue.


Example of HEMATOMYELIA, indirect result of bullet wound. Partial
recovery.

=Case 208.= (MENDELSSOHN, January, 1916.)

An infantry subaltern, 23 years old, was injured September 24, 1914,
by a rifle bullet, which entered above the left clavicle and emerged
between the right scapula and the vertebral column. The patient
leaped into the air when he was struck, but fell at once and found
that his legs were paralyzed. A feeling of cold crept up from the
feet to the region of the umbilicus. Consciousness was preserved.
There was hemoptysis because of the bullet’s passing through the left
lung. The wounds all healed quickly. There was retention, followed by
incontinence, of urine and feces; and the situation was complicated by
eschars in the gluteal and trochanteric region.

For three months there was no change in the paraplegia, except that at
the beginning of the third month the patient could move his fingers a
little and raise his knees slightly. He was transferred back through
three hospital units, with a diagnosis of spinal cord lesion or
fracture due to a vertebral column lesion at the second and third
dorsal vertebrae.

Seven months after injury, he reached a Russian hospital for a
laminectomy, incapable of standing or walking without support,
although able to sit and rise with extreme difficulty. He could now
very slightly flex and extend the knees, and very slightly flex and
rotate the ankle, and weakly move the toes. Passive movements could be
carried out without much difficulty, though there was a slight joint
and muscle stiffness. Both quadriceps muscles were markedly atrophied.
There was slight amyotrophy of the lower legs. Tendon reflexes were
exaggerated, and there was a marked ankle clonus, a Babinski reflex,
and an abolition of the abdominal and cremasteric reflexes.

There was a sensory disorder of an incomplete syringomyelic pattern,
with diminished sensibility to heat and complete abolition of pain
sensibility. Touch and electric sensations were somewhat delayed.
There was a diminution in the faradic and galvanic excitability of
the legs and feet; vasomotor disturbance (slight hyperidrosis) of
the paralyzed limbs. Two of the eschars had not yet cicatrized. The
sphincteric disturbances had diminished. For the rest the patient
was normal. The second and third vertebrae showed deformity and were
painful to pressure and percussion of spinous processes.

The patient was treated by galvanization of the spine, with a current
descending at first and then ascending, and by faradization of the
paralyzed muscles. There was progressive improvement, irregular but
constant. At the time of report, July 1, 1915, he was perfectly well,
able to take long walks, and without sphincter or sensory disturbance.
The tendon reflexes were still exaggerated, and there was still a
slight ankle clonus and Babinski. The abdominal and cremasteric
reflexes were still abolished. The last of the seven eschars had not
yet healed over.

For the organic nature of this lesion, the numerous early eschars, the
persistent sphincter disturbances, the limited paresis of the legs,
the reflex disorders, and the dissociation of sensations seem abundant
evidence. It is probable that there was no fracture of the vertebrae
(X-ray confirmation), and it is probable that there was a meningeal
hemorrhage, together with some hemorrhagic foci in the spinal cord
substance, especially in the gray matter. A good deal remains doubtful:
Mendelssohn remarks that the sphincter disturbances ought to be related
to disorder of the fourth and fifth sacral segments, and the knee-jerk
and Achilles jerk absence with disorder of the lower lumbar, and sacral
region; the abdominal reflex disorder with the low thoracic lesion;
the distribution of the anesthesia ought to indicate a lesion in the
lower part of the spinal cord. Was not the hemorrhage therefore lower
down than the spot where the vertebrae were displaced? It is surely of
prognostic note that the eschars did not necessarily foretell a fatal
outcome; in fact, the patient had become functionally well before the
seventh eschar was healed over.


Shell explosion with subject lying down applied to machine-gun; no
contusion: HEMATOMYELIA. Partial recovery.

=Case 209.= (BABINSKI, June, 1915.)

A veterinary student, six months captive in Germany, wrote out for
Babinski the following:

    “September 1, 1914, I was about to operate a machine gun when
    a shrapnel shell exploded very near me,--probably about two or
    three metres overhead. I base this estimate on comparisons made
    with shells I saw exploded beside me before this one.

    “Just after the explosion, which deafened me and at the same
    time took my breath away a little, from the powder, I felt a
    rather severe pain in the kidney region,--a pain which then
    persisted without interruption. I moved my left arm, to find
    the effect produced by a bullet which I heard whistle by my ear
    and which struck the upper part of the left shoulder without
    entering. At the same time, I tried to turn to see what had
    become of my legs, and had a feeling that they had vanished.
    Almost immediately I felt little prickings, not very painful,
    in the lumbar region and in the upper part of the thighs. Just
    then, seeing my comrades going away I tried to imitate them,
    but could not. All these feelings passed very rapidly.

    “A comrade then came near to tell me to go back. I told him
    that I could not move and that I must have been wounded in the
    lumbar region. He looked at my kit and my coat and said there
    was no trace of shot or tear. Not wanting to leave me, he
    lifted me by the armpits and knees. I could not help him get
    me up, and my legs hung flexed and inert. After a few steps he
    had to put me down, and tried to stand me up. I immediately
    crumpled. I had no sensation of my feet touching the ground. I
    sent my comrade back, asking him to tell my brother, who was
    in my squad. I did not lose consciousness or any feeling of my
    situation, or of the danger being run by my comrade.”

The man remained four days on the battle field without food. He
was on the edge of a stream. He did not defecate, nor for two days
did he urinate. Eventually the bladder and rectal functions were
re-established, though they remained irregular. Catheterization was
never resorted to. The lumbar pains were diffuse, fixing themselves a
few days after the accident in the region below the umbilicus. There
were pains at the waist predominating on the left side. The paralysis
of the lower extremities grew rapidly better. Movements in the right
leg reappeared, and 27 days after the accident the man was able to
stand and walk around his bed. Still further movement followed (left
leg weaker).

At the time of the report, May 28, 1915, the patient could walk without
a cane, but he could get about only slowly. The left toes would rub
against the ground, and he could not support himself for any length of
time on his legs. The knee-jerks were exaggerated, especially the left.
The Achilles jerks were increased. There was a Babinski reflex on the
left side and an abduction of the fifth toe on plantar stimulation. The
same reflexes were found on the right side, but less marked. Abdominal
reflexes absent, except the right superior reflex, which was distinctly
present. Cremasteric reflexes absent. Anal reflexes preserved. The
defense reflexes were exaggerated, but more markedly on the left side.
The zone from which the defense reflexes could be elicited on the left
side included the whole lower extremity and rose as far as 2 or 3 cm.
above the nipple. Stimulation of the lateral parts of the left lower
extremity would even produce defense reflex movements on both sides
of the body. On the right side, however, the defense reflex movements
could only be tried out by scratching the anterior surface of the
ankle, which was then followed by a flexion of the foot.

Sensibility to touch and deep sensibility were preserved; but
sensibility to temperature and pain, normal on the left,--_i.e._,
paralyzed--side, was weak in the right leg. There was a marked sudation
on the left side, limited by the white line, the inguinal fold, the
iliac spines, and a horizontal line passing through the umbilicus.

Here, then, paralysis followed a shell explosion while the subject was
lying down. No contusion therefore was possible. According to Babinski,
we are dealing probably with a hematomyelia, the result of shell
explosion.


Struck by missile in back; unconsciousness; no wound: Hysterical
paraplegia? HERPES and SEGMENTARY Hyperalgesia suggest radicular and
spinal injury. Recovery.

=Case 210.= (ELLIOT, December, 1914.)

November 1, 1914, a sergeant in the 20th Hussars, with other dismounted
cavalrymen, was chasing Germans with a bayonet, over turnip fields
pitted by shells. Several hours later, he found himself in a house in
a nearby village, to which he had been carried unconscious. Probably
he had been struck by some missile in the back, as the bottom of his
haversack had been torn off. His face was blackened with smoke, and his
clothes were muddy. He had no wound. His left arm was weak and his legs
powerless and numb. The passing of water was painful, but there was no
blood in the water and no hemoptysis.

Five days later, he was examined at a base hospital and found to be
paralyzed and numb in the legs. The knee-jerk and ankle-jerk were
retained upon the right side only. Pain occurred on passive movements
of the legs, which were flaccid; there was a hyperalgesia about
Poupart’s ligament, more marked on the left side. Lower abdominal
reflexes were weak on the left side; pain in lower abdomen with bladder
full and at outset of micturition. Pain and paresis also affected the
left arm, but there was no numbness. Pain on pressure over lumbar and
cervical vertebral spines. There was no evidence of bruising.

The physicians were inclined to regard the phenomena as hysterical.
Three days later, the arm movements became much freer, and after
another three days, the arm movements were fairly powerful, and the
legs much stronger, although the patient could not yet stand or walk.
He still had pain if his bladder was full.

                                CHART 9

                         CAUSES OF SHELL-SHOCK

    HEAD INJURY

    ATMOSPHERIC CONCUSSION

    MENTAL STRAIN

    NON-NERVOUS TRAUMA

    NEUROPATHIC HEREDITY

                                                      After Ballard

As against the diagnosis of hysteria, three herpetic clusters appeared
on the skin of the left thigh, from three to six inches above the
knee. Elliot regards it as certain that the posterior root ganglia
were injured. He regards the case as one of injury to the spinal nerve
roots. The hyperalgesia about the body of course suggested damage to
the spinal cord. According to Elliot, therefore, this case is one of
organic disease; whether of the roots or of the cord was uncertain. At
any rate the cases of this type, though not functional, recovered.


Mine-explosion; burial; labyrinthine lesions and head bruises, more
marked on left side: Focal canities (WHITE HAIR developing OVERNIGHT)
on left side.

=Case 211.= (LEBAR, June, 1915.)

A soldier, 23, in the Argonne was blown up by a mine in a trench, fell,
and was covered by a mass of earth, from which he extricated himself.
He immediately became deaf from what was medically determined to be a
double hemorrhagic labyrinthitis. There were also superficial powder
burns of the face, as well as several bruises on the head, especially
on the left side.

The next day, at the English hospital at Arc-en-Barrois, the patient
noticed tufts of white hair on the left side of the head. There were
four islets of gray hair in the left fronto-parieto-occipital region,
separated from one another by normal hairs. The gray hairs were gray
completely from the roots to the ends of the hair. The longest hairs
were as white as the shortest. There was not a brown hair amongst them.
The gray hairs were solidly implanted, and could be pulled out only by
strong traction. There was a discoloration also of the bulbar swelling
of the hair. The rest of the head hair was dark brown. His hair was
described in the military description: “deep chestnut brown.” There was
no other symptom aside from an incessant twitching of the left eyelids.
The place of whitening was apparently determined by the region of the
scalp injured. Not only were the bruises on the left side of the head
and face, but the labyrinthine lesions were more marked on this side
and the twitching of the eye-lids was confined to the left side.


Shrapnel wound of skull; focal canities over wound; shell-shock and
shrapnel wound of right leg. Head tremors and contractions, changing in
relation to posture; glove anesthesia and local anesthesia of trunk.

=Case 212.= (ARINSTEIN, September, 1915.)

A Russian private, 24, was wounded twice: once in the head by a bullet,
and at another time by a bit of shrapnel that imbedded itself in the
skull. The hair over the injured spot became gray.

Later, September 16, 1915, the soldier was subjected to shell-shock,
and at the same time wounded by shrapnel fragment in the right leg
(operated next day).

Upon examination at Petrograd, the hearing was found diminished and the
eardrum was pulled in. At first the patient could not speak or open
his eyes, and made incessant lateral movements of the head, jerking
backwards and to the right. The right half of the face gave convulsive
movements, which began at the lip and spread upwards. During sleep,
there was an entire cessation of these head shakings and jerks. In
the lying posture, the head shook at a rate of 100 to 120 per minute.
The jerking movements became more marked when the patient sat up or
walked. He carried his head bent toward the right shoulder. When he sat
down, the side-shaking movements disappeared, only to reappear when he
lay down. The swallowing reflexes were absent. The sensitiveness to
touch, pain, and temperature was lost in the upper part of the trunk
including the neck, to the level of the tenth dorsal vertebra. There
was anesthesia of the arms as far as the elbow on the right, and as far
as the shoulder on the left. The mucosae of the mouth were anesthetic.
Dermatographia was strongly marked.


Shell explosion; burial: Hemiplegia, probably organic.

=Case 213.= (MARIE and LEVY, January, 1917.)

A soldier was blown up by a shell and then buried at Vaux, March 29,
1916, and entered the Salpêtrière, July, 1916, with a right-sided
hemiplegia and contracture without evidence of wound. He remembered
nothing for the first fortnight after the trauma. When he came to
himself, he was paralyzed and was unable to say more than a few words,
but at the end of a month his aphasia ceased and he began to walk.

The hemiplegia was spastic. There was pronounced contracture. The
arm was extended, hand open, fingers stretched. Finger movements
were diminished, as well as extension of the wrist, but the arm was
otherwise normal. The leg was not so stiff. The great toe was in a
state of continuous extension. The toes could not be moved, and the
foot scarcely; but the leg could be strongly flexed and extended on the
thigh. The tendon reflexes of the right side were more lively than on
the left. Cloniform movements followed tapping the patellar tendon on
the right side, and a patellar clonus and ankle clonus could also be
demonstrated. Plantar reflex, flexor on the right. Distinct adduction
of the foot. Slight disturbance of tactile sensibility in the paralyzed
limbs; marked disorder of position sense and gross disturbance of
stereognostic sense. Moderate dysarthria.

Ten months after the traumatism, the hemiplegia and spastic walk
remained. The upper limb was now carried in extension back of the
body, with hand supinated, fingers sometimes in extension, sometimes
in flexion, index finger separately from the others. Finger movements
difficult and shoulder movements limited. The leg, however, was almost
normal except that the toes could not be moved. The tendon reflexes
were more lively and cloniform on the right, but there was no longer
patellar or ankle clonus. Stereognosis slow, but finger movements were
naturally difficult. W. R. of blood, negative. Probably this is an
organic case.


Blown up by a shell; no skin or bone lesion: Mixture of organic
(_e.g._, lost knee-jerks) and functional (_e.g._, urinary retention)
disorders.

=Case 214.= (CLAUDE and LHERMITTE, October, 1915.)

A man, 38, was blown up in a trench without sustaining skin or skeletal
lesions, April 5, 1915. He lost consciousness for a half hour and,
coming to, found a crural paraplegia and urinary retention. Examined
July 24, in addition to the paraplegia were found tactile and algesic
hypesthesia of the legs with preservation of deep sensibility. Pains
were felt in the legs, especially in the hips. The knee-jerks were
abolished; the Achilles jerks were preserved, as well as the flexor
plantar reflexes and somewhat weakened cremasteric and abdominal
reflexes. Micturition was difficult. Constipation. Slight paresis of
left arm. Lumbar puncture, July 28, yielded a clear fluid of normal
tension without chemical or cytological changes.

The sphincter disorders gradually disappeared. The knee-jerks
reappeared in a weakened form August 31. The legs could, at the time of
report, be moved somewhat, though not above the level of the bed.

We here deal, presumably, with a mild form of concussion of the spinal
cord, in which, however, some of the transient symptoms are very
possibly merely functional in origin.

_Re_ complicated pictures of organic and functional nature, some
experimental work has been carried out. Mairet and Durante set off
explosives, such as melinite, at a distance of 1 to 1.5 metres, near
rabbits. Some died at intervals from an hour to thirteen days; others
lived. Pulmonary apoplexy was found in the cases dying early. Spinal
cord and root hemorrhages, hemorrhages in the cortical and bulbar gray,
perivascular and ependymal hemorrhages were found, always small and
without diffusion, suggesting rupture by rapid decompression following
the first wave of aerial compression. The functional effects are
thought to be brought about through the anemia of the areas supplied by
the ruptured vessels. Russca of Berne got similar results and notes
direct and contrecoup brain lesions, tympanic perforations, intra- and
extra-ocular hemorrhages, thoracic, cardiac, and splenic hemorrhages,
ruptures of kidney, stomach, intestine, and diaphragm. As in the work
of Mairet and Durante, the lung proved the most sensitive organ.
(Compare also the human case of Sencert [Case 201].) Some experiments
with fishes yielded lesions of the swimming bladder. Persalite and
other explosives were used.


GASSING: Organic-looking picture.

=Case 215.= (NEIDING, May, 1917.)

A German soldier, 21, was a serious case of gassing. He was unconscious
two days (venesection twice). When he came to, he could not walk and
felt as if he were drunk. October 22, 1916, he was incoördinate in
walking and tended to fall forward when standing with eyes closed.
The ataxia of the legs was demonstrable in the position of dorsal
decubitus, and there was also a slight ataxia of the arms. The pupils
were dilated and reacted poorly to light.

December 12, all symptoms had disappeared. The clinical picture in
this case was somewhat like that of a multiple sclerosis. According to
Neiding, the disorder is not a functional one but an organic cerebellar
disorder.

_Re_ the neurology of gas poisoning, Neiding regards the condition as
a new nosological unit. We do not know what the ultimate results of
apparently cured cases will be. Court questions of importance will
doubtless arise with reference to their compensation. Ninety-six
of Neiding’s 274 cases failed to show any nerve symptoms whatever;
forty-six cases showed one symptom only, such as headache, dizziness,
abnormality of reflexes, or abnormality in sensation. One hundred and
thirty-two cases presented a fairly full picture. The picture of a
complete traumatic neurosis not infrequently appears, aided perhaps by
the psychic features of the gas attacks; and possibly some cases are
entirely psychogenic from the beginning. Such symptoms, for example, as
dermatographia, rapid and irregular heart, hyperidrosis, blepharospasm,
mental perturbation, hypochondria, etc., do not necessarily point to
any directly toxic effect of the gases. Thirty-seven of Neiding’s cases
showed pupillary changes, hyperreflexia, and analgesia. Thirty-one
showed analgesia and absence of laryngeal and corneal reflexes.
Twenty-six showed pupillary changes and hyperreflexia, four of these
latter showing also an absence of laryngeal and corneal reflexes. One
case yielded hyperalgesia alone; ten yielded headache, dizziness, and
analgesia.


GASSING: Mutism, tremors, depression, battle dreams.

=Case 216.= (WILTSHIRE, June, 1916.)

An infantryman, aged 27, had been at the front for three months. He was
wounded a month before coming to hospital; but when the wound healed he
went back to the front, quite mute but intelligent and able to write
the following:

    “We were on our way to the trenches, and as we were going
    through the railway cutting they started to shell us, with gas
    shells mostly, and we had not been there more than quarter
    of an hour when I was compelled to lie down from temporary
    blindness and weakness through getting a dose of gas through my
    mouth and eyes. I was lying down for about ten minutes when a
    shell came somewhere near, and was struck by something in the
    face and on my left knee and I remembered no more until I found
    myself in hospital. I was all of a shake and while lying down
    would frequently jump up and wonder where I was.”

The patient had been mute thereafter, depressed, and given to dreams
about fighting and shells. There was a fine tremor controllable by the
will; the knee-jerks were increased. On lateral deviation, there was
difficulty in fixing the eyes. There was a slight deafness due to an
old discharging left ear. According to Wiltshire, Shell-shock is only
exceptionally caused by chemical poisoning from gas.

_Re_ poisoning by certain German asphyxiating gases, Sereysky reports
in 1917 that these gases contained, among other poisons, a nerve
poison. He found that poor heredity was a favorable soil for the action
of this nerve poison. The clinical pictures in the gassed soldiers
rather suggested cerebral arteriosclerosis. He remarks that the logical
distance between the “exogenous” and “endogenous” is greatly reduced
in these gassed cases, as the syndrome of “exogenous” gassing closely
approximates that of various “endogenous” disorders.


Hysterical speech disorder related to mechanical disorder of auditory
apparatus.

=Case 217.= (BINSWANGER, July, 1915.)

Whenever a German officer’s servant, 23 years, was addressed on the
ward in the Jena Nerve Hospital, his hands would tremble and the
muscles of his face would fall into grimacing associated movements. He
had a peculiar infantile type of speech, talking with a fixed glance
and an anxious mien. He would carefully utter, as a rule, separate
words, chiefly only nouns or infinitives. He would gesticulate with
both hands to make what he said understood. Thus (freely translating
the German) runs his description of a battle:

“Well--because--I--we had--no artillery and so many losses--then got
in position again, then we--laid down a long time--perhaps until four
o’clock in the afternoon--five--and--and it happened that--lay in
Rübenfeld--couldn’t go back--then shell near me--fell in and I right
near, how--how far--I don’t know and--grown better. Comrade said--10
meters--don’t know--un--unconscious.”

Long compound German words could not be repeated, since after the first
or second syllable there was a severe emotional excitement; syllable
articulation and phonation ceased. Finally, however, the patient
could be gotten to pronounce the whole word. Reading aloud was very
difficult: syllable sounding and omission of difficult syllables; after
a time, weeping.

The patient was a somewhat small, muscular, well-nourished man, with
a murmur at the apex, a somewhat rapid pulse, increased reflexes,
especially skin reflexes, painful supra- and infra-orbital points,
temples painful to percussion, pressure over spine painful from
second thoracic to third lumbar vertebrae. There was an increased
sensitiveness to touch and pain over the whole body. There was a
bilateral, somewhat marked tremor, more marked on the left side than on
the right. Swaying in Romberg position was slight. Tremor of tongue.

This patient was first brought to Jena November 23, 1914. An
illegitimate child, a moderately good scholar, he had worked as a mason
until he went into the army, in 1912. He worked as a soldier chiefly in
the officers’ casino because he got pains in his legs and knees in long
drills. At the outset of the campaign, however, he withstood the heavy
marching, although with difficulty. He was in his first actual skirmish
September 20. A shell struck nearby and threw him several meters;
whereupon he became unconscious and was carried away by the hospital
corps. When he woke up he could not speak or hear. Ten days later,
however, speech returned, and hearing returned in right ear; October,
deaf in the left ear, and he could not hear a watch tick on the right
side at a distance of 16 centimeters. He was examined at the otological
clinic in Jena October 12, where the drum membranes were both found
opaque, without reflexes or normal contours; hysterical attack on the
caloric test. The next day, on the medical visit, there was a screaming
attack. His plight seemed not so much simulation as one of traumatic
hysteria.

Again, after his stay at the nerve hospital, another hysterical
outburst was produced by a hearing test with vestibular apparatus, in
the ear clinic, February 6, 1915. The diagnosis was nervous deafness
with involvement of left ear.

The insomnia was successfully treated by sodium bicarbonate. There was
a slight improvement in speech. In March body weight had improved, but
there was a marked tremor of the right hand. In the next few months
there was a progressive improvement in general well-being, in speech
disorder, and in tremor. The auditory disorder remained unchanged. The
man now works in his father’s garden.

This case appears to show a combination of psychic and mechanical
injury. There are severe hysterical auditory and speech disorders.
Although the auditory disorder is of mechanical origin, the speech
disorder appears to be of psychogenic nature. It is somewhat remarkable
that the ear tests almost every time produce hysterical attacks in the
form of convulsive crying. Rather unusual is the general cutaneous
hyperalgesia, more marked about the ears.


Shell-shock (distant, neither seen nor heard); left tympanum ruptured;
semicoma eight days: Cerebellar syndrome and hemianesthesia. Recovery,
nine months.

=Case 218.= (PITRES and MARCHAND, November, 1916.)

A lieutenant underwent “shell-shock” either at night or in the early
morning, September, 1915, the shell bursting at a distance. He neither
saw nor heard the shell, lost consciousness and was eight days
semicomatose, failing to recognize his wife.

On recovering his senses, he could not get about, as he had lost his
memory, having to write down his room number and be warned of meal
times. He was led about like a child. He had a continuous headache on
the right side and pains in the occiput and along the spinal column,
as well as in the right leg as far as the heel. These leg pains were
lightning pains. Walking was difficult, staggering, leaning to left.
Weakness of right arm and leg; right-sided hemianalgesia. Complete
insomnia. During November there were frequent urgent desires to urinate
day or night. Evacuated to the oto-rhino-laryngological center in
Bordeaux, December 13, for examination of ears. The right ear was
found normal, but there was a rupture of the left tympanum. There was
at this time a trismus. The jaws were opened with the dilator and the
man had a syncope during this operation. The question of surgical
intervention for a cerebral lesion was raised, but he was first sent to
the neurologists at Bordeaux. There, December 31, he was found with a
facies of anguish, unstable gait, inclination to the left in walking;
no Rombergism; occasional dizzy spells. In walking, the right foot was
pointed outward and on request to direct it forward he complained of
pain in the loins, reaching as far as the scapula. Walking with eyes
closed, he leaned to the left and lost balance. With eyes open, no
disorder of balance. With eyes closed, the body leaned backward. If
requested to go back, he failed to flex his legs to keep balance. If he
was asked to put a foot upon the chair in front of him, he immediately
fell backwards. He could not support his body on the right leg more
than a few moments. He had difficulty in raising both legs from the bed
at one time and he could lift the right leg not so high as the left.
Movements of the legs were performed hesitatingly and slowly and with
greater difficulty with eyes closed.

He could not thread a needle and could hardly dress himself. Eyes
closed, he could with difficulty perform the finger to nose test; eyes
open, with much less difficulty. Adiadochokinesis; muscular strength
less in right than left; plantar reflexes absent; knee-jerks lively;
hemianalgesia, right side. Loss of deep and bony sensibility on right
side and diminution of testicular sensibility. Retraction of visual
field, right; diminution of smell and loss of hearing, right; position
sense absent on this side; stereognostic sense preserved. Mentally,
memory was poor; he was unable to read or do mental work. He slept
little and had bad battle dreams. He was very impressionable and
emotional and constantly complained of occipital pain. He had lost 8
kilos weight.

He grew gradually better. In May he could go out alone. The muscular
strength increased. The adiadochokinesis and synergic disturbances
lessened; the hemianesthesia persisted. In June there was greater
improvement; in fact, there was no sign of disorder left except
irregular sleep.

We here deal with a cerebellar syndrome plus a hemianesthesia.


Mine explosion: Tremors, mutism, hemiplegia. Tremors cleared by
hypnosis. Mutism replaced by stuttering. Persistent hemiplegia,
probably organic.

=Case 219.= (SMYLY, April, 1917.)

A soldier was blown up by a mine and rendered unconscious. Upon
recovery of consciousness, the patient was dumb, unable to work, very
nervous, paralyzed as to left arm and leg. The paralysis improved so
that in the hospital at home the patient became able to get about.
However, he threw his legs about in an unusual fashion. Several months
later the patient was much improved.

Shortly, there was a relapse. Transferred to a hospital for chronic
cases, the patient was unable to walk without assistance on account of
complete paralysis of the leg. There was insomnia, a general tremor,
bad stuttering, and a habit of starting in terror at the slightest
noise.

Hypnotic treatment was followed by almost complete disappearance
of the tremor. The patient began to sleep six or seven hours a
night; nervousness diminished, and the stuttering slowly improved;
but neither the paralysis nor the anesthesia of the left leg was
affected by suggestion. The leg remained cold, livid, anesthetic, and
flaccidly paralyzed to the hip. A slight improvement has followed upon
faradization but the patient still can walk only with assistance.

Smyly regards this case as probably not a true case of Shell-shock,
depending as he states “more on a lesion in the nervous system than in
the psyche.”


Shrapnel bullet WOUND of skull: Unconsciousness (three weeks), followed
by agraphia (three weeks), insomnia (six weeks), amnesia (six to
eight weeks), hemiplegia (twelve weeks), impairment of vision (twelve
to sixteen weeks), dreams (seven months). Recovery save for slight
overfatiguability.

=Case 220.= (BINSWANGER, October, 1917.)

A French tailor, aged 22, of healthy stock, was wounded in the left
frontal bone in August, 1914. The shrapnel bullet, from an unknown
distance, made a penetrative wound. The man was able to remember
how at the moment he was injured he felt a sort of strain in his
brain, felt his head with his hand, found he was bleeding, took out a
bandage from his kit, removed it from its cover and without unfolding
it put it on his head. At this moment he fell unconscious and there
was then complete loss of memory for three weeks. This patient, who
was intellectually keen, distinguished exactly between what he could
himself remember and what he was told by his comrades. One of these had
told him that he had cried out indistinctly that in a matter of fifteen
days he would be well. He estimated the interval between his wound and
the loss of consciousness as about five minutes.

After three weeks, the tailor came to and remembers that the first word
he heard was Munich. Astonished to be in Bavaria he asked for paper and
pen to write to his people, but found he could not write, though still
able to dictate a little to his comrades. Besides agraphia there was
hemiplegia on the right side, marked exhaustion, rapid fatiguability of
vision, power of concentration but slightly diminished, and apathy for
his surroundings; emotions normal.

Three weeks later the power to write returned; after six weeks,
sleep; memory was restored in from six to eight weeks; the paralysis
disappeared in twelve weeks; vision became normal in three or four
months; the dreams ceased after seven months. The mood for the first
two months after regaining consciousness was slightly elevated; for
another two months slightly depressed. The mood then became normal.
There was, then, in this case complete recovery save for slight
overfatiguability in a period of seven months. There were still a few
residuals of hemiplegia. An operation in November, 1916, removed a
shrapnel ball, one centimeter in diameter, from a dural scar.

This is a case of acute reaction psychosis of exogenous origin lasting
three weeks and leading to complete recovery in an after phase of from
four to seven months.


Normal subject, wounded and thrown to ground by shell explosion:
Recurring MEMORIES of battle scene; persistently HYPERESTHETIC healed
shell WOUND, with pupil and pulse changes on pressure of the scar.

=Case 221.= (BENNATI, October, 1916.)

A lieutenant of artillery, student (one of his brothers dead of
meningitis), suffered somewhat from diarrhœa on the battlefield.
He was, however, always able to obtain the best of food. External
conditions did not seriously interfere with sleep. In particular
there was no excessive dampness where he was. He was preoccupied with
having to act as substitute for the commandant of the battery. He was
not afflicted by the thought of his parents far away; their financial
affairs were entirely satisfactory.

This almost normal man was wounded after a day of incessant fighting
five months after going to the front. When firing ceased, he withdrew
with his soldiers to a trench. Here he was followed by an enemy gas
shell which killed some and wounded others. While outside the trench
shifting mutilated soldiers to the rear, he was hit by another shell
of which a chip wounded him in the left thigh. He felt a terrible
spanking blow that threw him to the ground and gave him great pain.
He was carried on a stretcher to the medical post across the zone of
fire; thence to a field hospital and from there to a hospital further
from the front. He had been for almost seven hours in a sector of the
fighting line which had been almost continuously active.

The wound healed in less than a week. But what he had seen and felt
kept tormenting his mind. There remained slight numbness in the wound
where there was to be seen a spot of pigment, the size of a two-cent
coin, with somewhat obscure outlines. The pain was irritated by damp
weather, in certain positions, and by touch, and the pain on pressure
was reflected in the pupils and in the pulse.

No other disturbance, organic or functional, was found.


Wounds; operation: Hysterical FACIAL SPASM.

=Case 222.= (BATTEN, January, 1917.)

A 23-year old soldier was admitted to the National Hospital for the
Paralyzed and Epileptic, June 18, 1915, in the following state: He sat
in bed, gasping, with the left side of the face set in a strong tonic
spasm and jaws tightly set. The contraction of the masseters was such
that his mouth could not be forcibly opened. He himself could separate
his teeth for about a half a centimeter, but the jaws came together
when a spatula was brought for insertion and then failed to relax.
The facial spasm increased as the jaw was clenched more tightly. The
patient said he was unable to breathe excepting when sitting upright,
and when put into dorsal decubitus he breathed violently through his
clenched teeth and held his breath as long as he could, “assuming a
purple tinge,” as Dr. Batten states, “which was apt to be disconcerting
until one was accustomed to it.” Faradism and force permitted the
removal of false teeth but only to the accompaniment of shrieks,
foaming, and violent movements of the arms, lacrimation, and sweating.
During sleep, the face was at rest. The spasm of left face and of
jaw would come on a few seconds after waking, when an observer was
perceived. Attempts to force the mouth open invoked the same procedure
as before in spite of the fact that the patient ate well. In a month he
was virtually normal.

It appears that May 13, about five weeks before, the patient had been
struck by shrapnel on the right hand, forearm, and shoulder, and base
of the nose, while in France. He had been dazed but had not lost
consciousness, and the wounds had completely healed before arrival at
hospital. It was about a week after being wounded that the patient was
operated upon for removal of shrapnel from the face. Upon recovery from
the anesthetic, the patient found himself unable to move the right side
of the face. Unable to remove his teeth, he had been fed by rubber
tube.


Shell-shock: Hyperesthesia and over-reaction.

=Case 223.= (MYERS, March, 1916.)

A stretcher-bearer, 19, who had had 18 months’ service and 6 months’
service in France, sent to Lieut-Col. Myers the day after admission to
a base hospital, showed a remarkable condition of hyperesthesia and
over-reaction.

It appears that four days before, he had been blown up three times by
aero torpedo mortar shells while attending the wounded. One had blown
him into the air, another had blown him into a dug-out, and a third
had knocked him down. Two or three hours later, having finished the
job of carrying wounded to the dressing station, everything seemed to
“go black” in the dug-out where he was resting, and from that time on
he had been shaky. It seemed that he had hardly slept for several days
before he finally gave in.

There were irregular spasmodic movements of the head, arms (especially
the right), and legs (especially the left). There were coarse tremors
and incoördination in moving the arms. With eyes closed, he touched
his nose with uncertainty. Cotton-wool touch on arms or head provoked
lively movements. “I was always ticklish,” he explained, “but
never like this; I can’t stand it, Sir.” Pinpricks produced almost
convulsions. There was perspiration, rigidity of legs, and spasm such
that knee-jerks were unobtainable. Plantar reaction, flexor. There were
also visual hallucinations of bursting shells, and these were also
heard when dozing.

Improvement followed with rest, but about two weeks later, on waking
to find himself being carried back to his tent to avoid a shower, he
was so terrified that a special nurse became necessary. He was still
jumpy the next day, alarmed at footsteps, and afflicted with headache.
He improved further in three days; remained two months in hospital in
England, had one month’s leave, and then returned to light duty.


Shell-shock; thrown against wall; comrades killed; no visible trauma,
or loss of consciousness: Persistent TREMORS, augmented in intentional
movements; CRISES of agitation following noise or emotion.

=Case 224.= (MEIGE, February, 1916.)

A corporal (an expert gunner) and his squad had just entered a mine
shaft on Nouvron Plateau, January 13, 1915, when a shell, bursting
above them, threw him violently against the wall and killed or wounded
several of his comrades. The corporal himself was not wounded, nor is
it clear that consciousness was lost. The man lay waiting on the ground
for some time until a communication trench could be finished and he
could be evacuated without much danger from the mine shaft. He had
already begun to tremble, and trembled still more while going back in
the trench.

He carried on there for a fortnight, always trembling, but not eating
and no longer able to handle a gun. He was evacuated a month later
and sent successively to Villers-Cotterets, to Meaux, to Courneuve
(a month), again to Meaux, and finally to the neurological center at
Villers-Cotterets, where he remained for two months (April 13 to June
15, 1915). Here he was given the diagnosis of hysterical chorea by
Guillain, and showed lively knee-jerks and Achilles jerks and great
emotionality. The tremors were greatly increased when the cannon grew
loud or bombs burst nearby. Lumbar puncture here showed a perfectly
normal spinal fluid. He was then sent to the Salpêtrière, June 19,
1915, and was evacuated July 13 to a civil hospital until September 24,
whence he was sent for convalescence to his home village, October 6 to
December 15, from which he was returned to the Salpêtrière.

Throughout these transfers there had been no change whatever in his
status. For almost a year, as the result of a shell explosion, he had
been trembling in precisely the same way. All four extremities trembled
equally, unless the right arm and the left leg might be thought to
tremble a bit more. The tremor was equally pronounced in dorsal
decubitus as in the sitting or upright postures, but ceased during
sleep. The tremors were worse in the evening and it was hard for the
man to get to sleep. The eyelids and tongue showed a few irregular,
jerking movements, not synchronous with the tremor of the extremities.
The head showed few tremors. The patient was able to diminish the
trembling of the arms somewhat by keeping the elbows flexed at a right
angle and held firmly to his body. If the tremor of the legs got more
energetic, the patient would get up and take a few steps. Any movement,
such as laying hold of an object, carrying a spoon or a glass to the
mouth, led to an exaggeration of the tremors in such wise that the
tremor of multiple sclerosis in its most extreme form was recalled.
It was very hard for the man to eat. If the eyes were closed, the
tremors grew more marked. The emotion caused by sudden noise or sharp
command or memory of his trench life caused motor crises, with coarse,
generalized movements, and even loss of balance. This agitation grew
gradually less marked, but the tremors persisted. An attempt to test
reflexes led to violent generalized contractions. There was no sensory
disorder. The pulse was variable; at rest it stood at 60; if a table
near by was struck suddenly, the pulse would go up to 120.


Sharp gunfire: TREMORS; TREMOPHOBIA. A patient’s (an artist)
description of his feelings.

=Case 225.= (MEIGE, February, 1916.)

One of Meige’s victims of shell-shock tremors was an artist. He stood
the hardest sort of trench life for many months without disorder. Under
particularly sharp fire, “the machine went off the track,” as the
artist said, and he began to tremble. Both arms and head trembled, but
especially the head, which was subject to small sidewise oscillations,
variable in degree, and almost permanent,--a sort of vibration which
the patient could diminish somewhat by stiffening his neck muscles. His
manual tremor was not exaggerated by voluntary movements. Superficially
he resembled a Parkinsonian case. He presented a curious appearance of
combined vibrations and stiffness.

There was no doubt that this tremor had an emotional origin. In fact,
the psychopathic status of the patient was described by the artist
himself. “My nervous state, which I thought ought to last not more
than a fortnight, still persists more than three, or almost four,
months after being evacuated, although the trembling is a little
less. I am calmer and palpitate less, and my hands perspire less when
I am emotional or making an effort. At first, the slightest shock
immediately ran through me, followed by an uncontrollable trembling.
Now there is an appreciable delay between the shock and the trembling;
I can control it for a few seconds but not longer. The subway gate
noises, a flaring light, a locomotive whistle, the barking of a dog,
or some boyish prank is enough to set off the trembling; going to the
theater, listening to music, reading a poem, or being present at a
religious ceremony, acts the same way. Recently when a flag was being
raised at the Invalides, I thought at first that I was going to be
cured by so moving a spectacle, but then I suddenly began to tremble so
violently that I had to cry out, and I had to sit down, weeping like a
child. Sometimes the trembling comes on suddenly without any cause. I
went to a novelty shop to do some errands with my wife. The crowd, the
lights, the rustling of the silk, the colors of the goods--everything
was a delight to me to look upon,--a contrast to our trench misery. I
was happy and chatted merrily, like a schoolboy on a vacation. All of
a sudden I felt that my strength was leaving me. I stopped talking;
I felt a bad sensation in my back; I felt my cheeks hollowing in. I
began to stare, and the trembling came on again, together with a great
feeling of discomfort. If I can lean against something, sit down, or
better, lie down, the trembling gets better and pretty soon stops.
There are three conditions in which I feel well: first, upon waking
after 11 or 12 hours’ sleep; next, after a meal, especially if it is a
good one; and lastly, and above all, when I get the electric douche.
Then, as if by magic, my ideas get clear, cheerful, and regain color; I
feel myself again. That lasts for an hour or so; then I relapse into my
sad state.”

As to the tremophobia, this patient says “In the tramway or in the
subway, I perceive that people are looking at me, and that gives me a
terrible feeling. I feel that I am inspiring pity. Some excellent woman
offers me her seat. I am deeply touched; but if they look at me and say
nothing, what are they thinking of me? This anxiety makes me suffer a
good deal. If I am able to speak it is less painful to me, for then it
is obvious that, despite my trembling, I am not a coward. What a sad
situation this is!”

Meige remarks that therapeutics is not especially successful in these
cases of tremor. Sedative drugs, hyoscyamin, hyoscin, duboisin, and
scopolamin, do not last long and should be used cautiously. Static
electricity works well in some cases. Rest, isolation, and calm.

As for the military prognosis, a period of observation of some three to
four months may be necessary to learn the nature of the tremor. If the
tremor then fails to alter, a convalescent leave for one or two months
may be given. The patient should then be re-observed _by the same
physician_. Upon persistence of tremor, temporary invaliding. Tremors
may be wittingly cultivated for medicolegal purposes (Brissaud’s
sinistrosis.)


Letters of a German soldier about his shell-shock.

=Case 226.= (GAUPP, April, 1915.)

A volunteer, 21, who had been in civil life a lackey, wrote as follows
upon arrival in Gaupp’s clinic:

    “On account of our privations and the various terrible scenes
    that you have to see, my nerves went back on me. Like the rest
    of the front, we too had to suffer terribly heavy artillery
    fire from December 20 onwards. December 29 at eight o’clock
    in the evening, when I was about to mount guard at the camp,
    I was thrown down by a shell that unexpectedly struck near me
    across the earth pushed out into a trench. I ran at once to
    cover as some more shots followed directly. I couldn’t be made
    to do anything on the thirtieth nor can I very clearly remember
    the events of that day. There was a terrific cannonade again,
    then cries of the wounded and the sight of the dead, etc. I was
    told afterwards that I fell down, cried, struck about me, and
    remained lying, dazed. The first that I can remember was that
    I was lying on a floor. I was then carried into another house,
    into a better room. Then I regained consciousness and could
    hear again after the noise in the ears had stopped, but I could
    not talk or walk. I was unconscious for two days. I got into
    the hospital train at R. the next day but had to be carried
    in as I could not walk. Travelling in the train made me quite
    foolish in my head and gave me bad headaches; I could not form
    any clear thoughts.”

It seems that this volunteer had not been quite up to the hardships
of the war from the beginning; always a weakling, he had to be spared
on the marches. In fact, he had been refused by the army at the first
examination as unfit. He had been a nervous, tender, somewhat anxious
fellow since childhood.

At the clinic there was an astasia and an abasia without any signs of
organic disease. The striking feature was mutism. He could understand
things spoken and written, but he was entirely mute, nodding and
shaking his head properly for affirmatives and negatives. He carried
with him a few slips of paper with written requests, like: “Please,
can I have salt; otherwise I can’t eat the soup;” “Are we going to ride
farther, I have such a bad headache. The doctor must not come. The one
who wanted to shoot me if I couldn’t speak. They are all bad.”

Treatment by suggestion (laryngeal faradization, lively verbal
suggestion to pronounce single vowels, syllables, and whole words and
sentences with enunciation of them) removed the mutism in a few days.
At first the man’s speech was low and somewhat retarded, but later it
became entirely normal. Within ten days the abasia cleared up and the
patient became lively and cheerful. He was depressed on finding that he
had lice, but after losing them became happy and childlike again.

February 1, however, on learning that he would be able to do garrison
duty again, he took the news very soberly, and grew more quiet,
trembled and seemed anxious.

February 7, he was sent to the garrison, increasingly excited. His own
account of it in a letter written to a hospital nurse, runs as follows:

     “As you will see, I did not reach Dn. but only got as far
    as here [Another hospital]. I will tell you how it happened.
    Probably I ought to have remained in Tübingen for a while
    longer and perhaps then nothing would have happened to me. You
    will remember that I was more nervous and excited the last days
    than I had been before, and the cause was also known to you. I
    wanted to get home in some way and so I pretended to be as well
    as possible. That crying attack, or whatever it was [an outcry
    in a frightful dream] had not been thought of by the physician
    any further, you know, and so I didn’t think anything about
    it either. Then the head doctor asked me once if I had any
    trouble left. Well, I spoke out everything I had to say, but
    no further attention was paid to that either. Then when I took
    a walk and after walking slowly two hours could hardly stand,
    was trembling all over and had a high pulse and also a violent
    acute pain in the region of the heart, that wasn’t of any
    importance either. Well, then I just got better from day to day
    and so I got what I wanted only too easily because they wanted
    the space and I certainly would have gone home and not to Dn.
    as I should have. [His reserve battalion was at Dn.] I got
    into the wrong train at St. so as to go home. I kept saying to
    myself, ‘You can’t do that, it will be punished.’ Nevertheless
    I couldn’t act any other way because I was really sick from
    longing for home.”

Here he described an episode in a comrade who had lain beside him in
the clinic, had gone off with him and had a hysterical excitement in
Heidelberg so that he had to be detrained.

    “I was so awfully sorry to see him so miserable. I began to
    cry and was startled by every train coming from the opposite
    direction and by every loud noise. I was stared at by everybody
    in Frankfort and I could only cry more. Then a soldier scolded
    me because I was running senselessly up and down. Finally I got
    into the Leipzig train. Another guard questioned me. Everything
    then got more and more confused in me; I heard my mother
    call; then I heard shooting again; and finally I was entirely
    confused. I came to my senses in a room in the station toward
    evening, and was frightened again at a loud noise somewhere
    or a passing train. Then I was told what I had done in the
    train. I had cried out and raved, tried to get out of the car,
    called for my father and mother, wanted to go home, imitated
    shooting; allowed myself to be calmed a little, but began to
    shout again at every loud noise. When I was out of the train
    I bit a soldier and tore his whole coat open, so then I was
    carried to the hospital here in an auto. Up to this time I have
    been able to calm myself very well. The physician said that it
    was quite natural that I should not have very strong nerves
    yet. I must have beaten about and got knocked against things a
    good deal. There are bruises on my head and I am covered with
    black-and-blue spots.”


A British soldier’s account of his shell-shock.

=Case 227.= (BATTEN, January, 1916.)

A British soldier, 22 years, who went out to France in November, 1914,
remained well until March 12, 1915, when after shell explosion, he
became unconscious for half an hour, and on recovery found he was deaf
and dumb. He was able to think of words but could not say them. He
remained dazed and frightened for a time, and still wakes up with a
start at night.

He was admitted to the National Hospital for the Paralyzed and
Epileptic, March 25, 1915, and on March 27 recovered his speech
suddenly and spontaneously. By March 29 he had completely recovered
and talked well. Dr. Batten remarks “how perfect the memory may be
up to the time of concussion, and how complete the mechanism is for
expressing the ideas in written words when that for spoken words is
abolished”; which may be seen from the patient’s own account, as
follows:

    I went out to France on the 3/11/14 and I was two days at Le
    Havre and then we went on to our 1st Batt. When we arrived at
    our destination the regiment was in the trenches so we had to
    go in. It was snowing hard and I felt it very cold. This was at
    Givenchy. We were relieved the following night and we went back
    for a rest. The next place we went to was just opposite Neuve
    Chapelle on the La Bassée Road and it was awful, the trenches
    were up to the knees in mud and water. The first night was
    very quiet, but the following morning about 9 p.m. the Germans
    started shelling and continued all day; the next was the same,
    but about 1 o’clock the Germans were seen to be coming up in
    masses. They got to within a distance of about twenty-five
    yards, then they turned. They commenced shelling us again and
    they had another try about three o’clock but they did not get
    far. One of the men on my left had the half of his face blown
    away and we had about ninety-two killed and wounded. We got
    relieved after being in five days, then we went back for three
    days’ rest. The next place we went to was Rue de l’Epinette
    and we had an awful time there just before Christmas. We went
    into the trenches and we were up to our middle in water and in
    some places it would have taken you over the head. We were in
    these trenches for twenty-four hours. There was nothing unusual
    happened and we got relieved by the Royal North Lancs.; but
    we did not get far away; we had just got into our billets and
    were making some tea when the fall-in went and we were told
    that the Germans had broken through the North Lancs. We went
    away without any great-coats, and into the trenches we went
    for other seventy-two hours, and if the Germans had attacked
    again we could not have fired a shot as we were hardly able to
    stand for the cold and with the wet kilts on our legs it was
    awful. We got nothing to eat except three biscuits that some
    of the men went out and got. When we came out of the trenches
    on Christmas Eve we looked all like old men and a lot of them
    had to be carried. We went back for a rest to (Nervaille?)
    about thirty kilometers from the firing line for a month. When
    we came back again we went to La Bassée and had a pretty hot
    time there. The next place we were at was at that big fight at
    Neuve Chapelle when 472 guns bombarded the German trench for
    thirty-five minutes. At about 7 p.m. the word was passed along
    that we were to charge the German trench in front supported by
    the City of London Territorials. We got the trench all right
    and I got orders about 4 p.m. to go back to our own trench and
    bring along the belt-filling machine belonging to the machine
    gun. There was not a proper communication trench, there was a
    small dry ditch that ran out in the direction of the trench we
    had taken for a distance of 150 yards, the other 100 yards you
    had to come across the open. We got into our trench all right,
    and I got this box on my back and started back to the trench.
    I was just stepping out of the trench when a shell burst just
    over my head and I went down. When I came to my senses I was
    lying in our support trench where I had been carried by two
    of the men of the 4th Black Watch. One of them said something
    but I could not hear him and I tried to tell him so, then I
    discovered that I could not speak.


Shell-shock by windage: Hysterical crural monoplegia, of gradual
development beginning four days after accident. Recovery by suggestion.

=Case 228.= (LÉRI, February, 1915.)

A number of chasseurs were doing the “tortoise-shell” under
bombardment, when the last chasseur in the line was blown forward
above his comrades by a shell bursting about a meter behind him. He
was projected some four or five meters, got up, walked four or five
kilometers, found an automobile, and was carried to Nancy. He passed,
according to his story, red urine three or four times. He was six days
at Nancy, where a slight abrasion of the side was treated. He began to
feel heavy in his left leg on the fourth day. At Vendôme, the paralysis
got worse, and by November 17 he had apparently a complete paralysis
of the left lower extremity, called “spinal contusion.” He walked upon
two canes, dragging left leg behind and had to be carried upstairs on
a stretcher. The reflexes were normal except that there might have
been a very slight excess of the left knee-jerk. There was a slight
hypesthesia of the left leg, sharply limited above.

These phenomena were strikingly modified, at a single sitting, by
verbal suggestion and faradism, but the man was one of those with
_mauvaise volonté_. He did not want to get well so quickly, so that his
complete cure was delayed a while.


NATURE OF SHELL-SHOCK: At the nerve clinic the patient presents,
_e.g._, sundry CONTRACTURES, of such a nature that they may be caused
to DISAPPEAR BY SUGGESTION, _e.g._, by mental influences during
recovery from chloroform narcosis (note battle-dreams). PAINS and
ANESTHESIAS disappear PARI PASSU with the contractures. The history
is of shell explosion so near as to burn patient’s clothing, fall
with nosebleed, eight hours unconsciousness, crural monoplegia with
anesthesia (crawled 3 meters, however).

=Case 229.= (BINSWANGER, July, 1915.)

The treatment of a German private, 22, for contracture of the left
leg and other phenomena, culminated in narcosis. Binswanger lays
stress upon the mental influence to be exerted upon the patient at
the conclusion of narcosis, at the moment in which the patient is
particularly accessible to verbal suggestion. Treatment (see diagnostic
details below) was carried out as follows:

After a few days of essentially suggestive treatment with continued
attempts at passive movements of the contracted joints (knee, ankle,
toe), with steady concentration of the patient’s attention upon the
joints, a slight mobility in the toe joint on passive movement was
obtained.

After a few more days, the ankle became passively mobile to some
degree; the patient exerted a certain resistance to passive flexion
of toes and ankle. A week later, reflex contractions of the toes
could be evoked by deep pin-prick. There had been an analgesia of
both lower thighs and of the soles of the feet, and this analgesia
remained unchanged. At this point, the subjective complaints of the
patient, namely, noises in the head, especially in the left ear, and
other cephalic sensations, tended to disappear and the patient felt
subjectively better; yet there was still an intolerable itching of the
head and spine.

A month after the admission of the patient to the nerve hospital of the
psychiatric clinic in Jena, there had been no essential change in the
immobility and contracture in extension in the left leg. Accordingly,
with the permission of the patient, he was placed in deep chloroform
narcosis, and the knee-joint was bent at a right angle and fixed in
approximately that position with a bandage. This experiment failed
because, while the patient was waking out of his narcosis, the leg
slipped back into extension, breaking the bandage. Accordingly, deeper
narcosis was undertaken, and the leg fixed at a right angle in a
plaster cast.

While the patient was coming out of narcosis, it was evident that he
had been dreaming of battle scenes. In fact, Binswanger remarks that
these dream pictures and the words spoken while going under and coming
out of narcosis, are curiously demonstrative of “_sympathy with the
enemy_,” for while waking out of narcosis, he cried: “Dost see, dost
see the enemy there? Has he a father and mother? Has he a wife? I’ll
not kill him.” At the same time, he cried hard and continually made
trigger-movements with his right forefinger.[6] In point of fact,
throughout his waking treatment, no one was able to learn what was
going on in his mind, his sleep was good and deep, and his emotional
state was entirely quiet and patient.

    [6] Compare sentiments of a Russian in narcosis (Case 319,
    Arinstein.) See also Case 181 (Steiner).

As the patient was coming out of chloroform and regaining consciousness
of his surroundings, he was repeatedly and persistently assured that
the bending of his leg was now accomplished and the cramp removed. All
that he would now have to do was to get back the strength of his leg.

During the next few days he complained of violent pains in his left
knee-joint and in the ankle-joint, but he remained in good spirits and
full of confidence. Accordingly, in five days the plaster was removed
and the contracture in the knee-joint was found to be completely
absent; the knee was easily movable. The ankle-joint was but slightly
movable. He could accomplish slight active flexion of the knee-joint
while lying in bed, and the toe-joint had already, before the narcosis,
been both actively and passively mobile. After a few days, exercises
in walking were begun. The patient had a little difficulty with his
left knee-joint in walking, walking in fact as if with knock-knee. The
foot was not well raised from the ground on account of the persistent
stiffness of the ankle-joint. Walking, however, improved daily. He
walked for three hours, resting at intervals.

A sensory examination showed that the upper limit of the analgesia
had come down five centimeters from its former level, now occupying
the left foot and leg up to the junction of the lower with the middle
third. There was now a zone of anesthesia interposed between the
normal skin of the upper thigh and the anesthetic-and-analgesic skin
of the lower thigh and leg. Upon the posterior aspect of the leg, the
analgesia and anesthesia had disappeared to a point at about the middle
of the upper thigh.

About five weeks after the narcotic experiment, the extended left leg
could be actively raised while lying in bed, up to the full extent,
with slight tremors. The patient described himself as fatigued by the
active movements of this leg. The ankle-joint remained less effective.
There was still a trace of resistance to passive movements. Although
the passive movements of the toes were normal, active movements of
these were weak and hard to execute. There was still a trace of
difficulty at the knee in walking and the gait was awkward, trepidant,
precipitate. He could get about without a cane, however. If unobserved,
his posture was more certain and free. If he exerted himself hard,
severe parietal headache on the right side would develop.

It was then proposed to the patient that another narcosis would rid
him of the stiffness in his ankle-joint. He feared narcosis and was
told that regular and energetic voluntary movements would also rid him
of the stiffness. These will exercises consisted in his directing his
whole attention to his left ankle-joint until he felt it. Then he was
given the command: “Let go the joint”--whereupon he would take his
attention away from the ankle-joint at once. In this way, he was told,
his will would make the ankle-joint mobile. Meantime he was given
twice daily a gram of bromophenacetine for his parietal headache.

The result was a rapid recovery. There were still a few traces of
difficulty at date of report. The zone of sensory loss had retreated to
the ankle, with a cuff-like zone of hypalgesia above the definite zone
of analgesia and anesthesia.

As to the previous nature of this case, although there was neuropathic
heredity on the mother’s side, there had been no sign of any individual
neuropathic disposition. He had been a volunteer since 1911 in a guard
regiment of infantry. His military training had been well borne; in
the war he had fought through 20 battles. On November 11, 1914, in a
storming attack, he had had his breeches burned from the effects of a
shell. He had fallen, unconscious; the unconsciousness lasted about
eight hours. He found on awaking that he had had nosebleed. When he
wanted to get up, he found that his left leg was completely paralyzed
and insensible; in fact, he thought it had been cut away. He crawled
for about three meters to a trench in which there were several wounded.
In the evening he was taken by automobile to a field hospital, and on
the 17th was removed to a reserve hospital at Erfurt. Thence he was
transferred to the Jena Hospital, January 25, 1915.

A strongly built man, with many reflexes increased and a lively
dermatographia. The reflexes of the left, or contractured, leg were
lacking; the mastoid processes were painful, and the occiput and
temples were painful to percussion. The spinous processes of the
vertebral column in the lumbar region were painful. The other phenomena
have been sufficiently indicated above. The head sensations were
peculiar; there were no pains but a peculiar itching. Contraction of
the fingers of the left hand was painful. There was a feeling as if
there were lice under the skin in the left upper thigh. There was
itching in the nose, which the patient described as due to the sulphur
“out there,” meaning shell gases. Sleep and appetite were good. Memory
was imperfect: he could no longer remember the names of the battles,
and of late had had to count on his fingers to find out how much was
2 times 2. As to the curious parietal headache, contralateral to the
contractured leg, Binswanger inquires whether we may not here have to
do with localized vascular phenomena of the brain part which might
conceivably be related with the innervation of the leg. Binswanger
remarks that if the plaster cast be left on too long, it may happen
that hysterical contracture will take place in the new position.

As to the will exercises used in the present case, Binswanger remarks
that the patients must be intelligent and attentive, and naturally they
must desire to get well. Fortunately, many of the war hysterics do want
to get well, since the contrary experience is had in various industrial
cases.


Wound of thigh: Pseudocoxalgic monoplegia with anesthesia. Cure of
anesthesia by faradism at one sitting. Cure of lameness by reëducation
and electricity in one month.

=Case 230.= (ROUSSY and LHERMITTE, 1917.)

An infantryman, observed at Villejuif, February 9, 1915, was
suffering from a right-sided crural monoplegia of a pseudocoxalgic
type, following a wound September 9, 1914. The wound had been a
through-and-through one in the upper right thigh. Every active movement
could be performed as well on the right side as on the left; but the
strength of the movements was less on the right, especially that of
leg-extension. The reflexes were normal, the lameness was slight, with
toeing out; the sole came down flat upon the ground. There was an
absolutely complete anesthesia of the entire right leg and side up to
the umbilicus.

Energetic faradization of the skin caused the anesthesia to disappear
the day the patient was brought to the hospital. The cure of the
lameness required a month of reëducation and electricity.

According to Roussy and Lhermitte, crural monoplegia is less frequent
than brachial monoplegia. The flaccid form is rare, and when it occurs,
complete, though the patient always remains capable of executing
some voluntary movements and can walk with crutches or cane. During
the automatic movements of walking, some muscles may be observed to
contract that remain immobile when the patient is being examined
recumbent. Naturally such a difference in contractions standing and
lying, would be very exceptional in a case of organic monoplegia.


Contusion of thigh: HYSTERICAL right crural MONOPLEGIA. An ORGANIC
CRUTCH PARALYSIS develops in the right arm, unobserved by the patient
whose main concern is his useless leg. Cure of leg by psychotherapy.

=Case 231.= (BABINSKI, 1917.)

A certain lieutenant, following contusion of the right thigh, developed
a crural monoplegia of hysterical nature. In fact, although the
paralysis had lasted several months, the tendon reflexes, the skin
reflexes, and the electrical responses of the muscles, were absolutely
normal. Moreover, the good effects of psychotherapy confirmed the
hypothesis. But besides the hysterical crural monoplegia, there was a
radial paralysis on the right side, clearly organic in nature, due to
the nerve compression by the crutch which the patient had employed on
account of the paralysis of his leg.

Babinski notes that this association of conditions was remarkable
in that it demonstrated that hysteria and simulation should not be
confounded with one another. To be sure, it is difficult to tell
simulation from suggested phenomena, for there are no objective
characters that demarcate the two. Babinski had himself said that
hysteria was a demi-simulation; but a demi-simulation is not a
simulation. The patient was in fact, sincere enough in his belief that
he could not move his leg. To obviate this paralysis, he had in fact
leaned so conscientiously upon his crutch that an organic paralysis
had resulted. In fact the radial palsy had only been discovered
incidentally, and the paradox appeared that a purely imaginary trouble
occupied in the patient’s mind for a long time a much more important
place than the genuine organic trouble which accompanied it.


Bombardment; war strain; gassing?; collapse; arthritis: Hysterical
MONOPLEGIA and ANESTHESIA of leg, interpreted as a “PROTECTIVE”
reaction. Later, monoplegia and anesthesia of arm.

=Case 232.= (MACCURDY, July, 1917.)

A corporal described as normal (“except for some shyness with the
opposite sex”) adapted himself well to training and went to France
in May, 1915, where he was at once thrown into 18 days of almost
continuous bombardment. After some initial fright, he settled down
to work well enough, but, when the weather got bad in September,
1915, grew tired of the situation. Bad dreams began (falling into a
deep hole; being shelled). He thought of suicide, wanted a shell to
incapacitate or kill him, began to have pains in the head, arms and
legs, and was already groggy when a gas attack came. Whether he got a
whiff of the gas or not, he at any rate felt giddy, got a swallow of
water, and when the gas passed got out of his dugout in the open air.
He was fatigued and much relieved when the company was ordered back.
Now, however, he got shaky and fell in a collapse on a pile of straw,
without, however, losing consciousness.

Apparently he had an attack of acute articular rheumatism. There was
a sore throat and a pain in the head, radiating to left shoulder and
to finger tips, with pain also in legs. The pain was worse in the
right leg on moving the knee-joint. These pains lasted for a month in
hospital. The leg had been like a log since the collapse on the pile
of straw. Even after the pains left him a month later, the right leg
was paralyzed and anesthetic. He walked with a crutch and developed a
crutch palsy. After a month a hysterical paralysis of the right arm,
with superficial anesthesia, supervened. During a period of eight
months thereafter improvement was steady under reëducative measures.

According to MacCurdy’s analysis, the acute arthritis led to paralysis
as a protective reaction. The paralyses are disabilities that would
ensure absence from the front.


Lance-thrust in back, rapidly healed. Paralysis of right leg,
disappearing with rest and exercises. Later, psychotic symptoms, with
recovery.

=Case 233.= (BINSWANGER, July, 1915.)

N. H., 21, a laborer, industrious and sober (mother healthy, father
insane and a suicide; patient somewhat sickly in childhood after
pneumonia, a good scholar) volunteered at the outbreak of the war.
Early in November he was on the Eastern front. November 17 to 22 he
was in a number of small reconnoitring skirmishes almost daily, as a
cavalryman. On the 22d, there was a clash with a Cossack patrol of far
superior numbers. Eight German horsemen cut their way through, riding
about 4 kilometers back to their squadron.

While dismounting, N. H. discovered that his back was wet. It occurred
to him at once that he had been wounded. However, he successfully
dismounted and then collapsed, feeling as if his right leg had fallen
asleep. His companions found a wound in his back, which had come from
a lance-thrust. The wound was bandaged. He was transported to Germany
on a peasant’s wagon, the trip occupying six days, and on December 6 he
came to the surgical clinic in Jena. The wound was insignificant and
healed quickly.

The leg remained motionless, and on December 10 the patient was
referred to the nerve hospital. He was a small, slenderly-built man,
with poor nutrition, weighing 108 pounds. The scar, about 1 cm. long,
alongside the thoracic vertebra, was still somewhat red and but
slightly sensitive to pressure. Neurologically, the knee-jerks and
Achilles jerks were greater on the right than on the left, and there
was on the right side a distinct patella and ankle clonus. There was no
Babinski reaction on either side.

The movements of the right leg were not of wide excursion, and flexion
and extension of the knee and ankle-joints, while lying on the back,
were slowly and hesitatingly performed, with an expression of pain, and
with visible effort by the quadriceps muscles. Flexion and extension
of the toes were likewise difficult, and when the toes were stretched
there was a distinct contraction of the tibialis anticus. Electrically
the muscles were normal. On passive motion, there was slight spastic
tension in the musculature of the right leg, and the patient said he
felt marked pain. In walking, the right leg was moved with a limp and
with the evident design of sparing it. The knee was imperfectly bent
and the sole of the foot was dragged along the ground. There were short
out-throwing movements of the lower leg.

Pain sense was normal, or possibly slightly in excess. There were
painful points on pressure on the lower part of the os sacrum and
coccyx and over the right sciatic and tibial nerves. Intelligence
examination showed school knowledge to be extremely poor and
calculation ability poor. Critical judgment and reasoning power were
deficient. Memory and perception were without marked disturbance.
The patient was dull and without interest in his surroundings. He
complained that his right leg was as if dead and that he felt great
pain in any attempt to move it. He also complained of pains at night
in the region of the right shoulder and neck. His nerves, he said, had
been very weak since his trip back from the front, during which trip he
had been very cold and poorly cared for.

Treatment consisted of rest in bed, application of moist packs to
the right leg, active and passive exercises of the right leg. After
ten days he made his first independent attempts to walk, and active
movements of the right leg in dorsal decubitus became unrestricted and
painless. He remained somewhat unsteady in station, showing bilateral
twitchings and movements of the right leg muscles. In walking the right
leg was dragged behind in a spastic-paretic fashion. Appetite improved;
spasms decreased; but at the end of December foot clonus was still
persistent.

Upon January 10 there was an odd mental change. He became seclusive and
suspicious. January 15 he expressed ideas of poisoning; his sister, he
said, wanted to poison him, and others were watching him suspiciously;
his room-mates were talking about him; in fact, he thought one comrade
was an Englishman. Sleep was poor. At the end of January, after a short
period of improvement, he again had ideas of being poisoned, and had
dream-like, unclear thoughts. His actions became incoherent: he would
undress suddenly in the daytime and go to bed, getting up five minutes
later and dressing. Senseless postcards were written.

This condition lasted a few days only, whereupon the mental and bodily
condition greatly improved. Daily walks were then taken in the garden
and in the city without exertion. The ankle-clonus on the right side
was now decidedly weaker but did not entirely disappear. The muscle
power on the right side was somewhat less than on the left.

The patient was very homesick, and on March 14 was sent home.


Shell-shock--six days later, crural monoplegia, cured by suggestion.
“Metatraumatic” hysteria. HYPERSENSITIVE PHASE AFTER SHELL-SHOCK.

=Case 234.= (SCHUSTER, January, 1916.)

On August 13, 1915, a soldier was knocked unconscious by the explosion
of a shell nearby. He woke up several hours later with headache, noises
in the ears, itching, but no trace of paralysis.

Six days later, on August 19, he was released from hospital, still
free from paralysis. On the railway journey he met some people of his
district by whom he sent greetings to his wife, meanwhile becoming
greatly excited. When he tried to get out of the train he noted a
weakness of the left arm and left leg; this weakness somewhat quickly
grew into a severe paralysis, so that when observed in Berlin the left
leg was entirely paralyzed, not a single muscle of which could be
moved when the patient was examined by Schuster one month after the
accident. There was also a hypesthesia on the left side with total
anesthesia of the left leg, which anesthesia was related stocking-wise
to the hypesthesia of the trunk. There was tremor of the hands as well
as generalized increase of reflexes. The plantar reflex, though weak,
was flexor. The pulse rapidly ran up under excitement. In short, the
patient seemed to be suffering from hysterical palsy. Waking suggestion
did so well with the man that after three weeks normal sensibility was
restored to the leg, and he could walk tolerably well without a cane.

The point of interest in this case is that the symptom of greatest
importance, namely paralysis of the left leg, did not arise until six
days after the shell explosion and then only after the man became
excited by thoughts of his home and family through meeting his town
people. The term _metatraumatic_ is suggested by Schuster for cases
of this sort. The emotions and stresses of war may be regarded as
_labilizing_ and _sensibilizing_ the nervous system sometimes for
months.


Wound of left foot: ACROCONTRACTURE. Psychoelectric cure, about seven
months later, at one sitting, except for some residuals that cleared
shortly afterwards.

=Case 235.= (ROUSSY and LHERMITTE, 1917.)

A soldier, 21 years, was observed at the Centre Neuropsychiatrique,
August 30, 1916. He had been wounded in battle, March 16, 1916, near
the left internal malleolus. Infection followed and inguinal adenitis,
for which he was in hospital a month.

Even before the abscess began, the foot had begun to twist inward.
After the abscess had been cured, a contracture set in permanently, and
at entrance to hospital was irreducible. The knee-jerk and Achilles
jerk were more active on the side of the equinovarus contracture. There
was even a slight amyotrophy of the calf. There was no appreciable
vasomotor disorder. The foot and lower part of the leg were a little
warmer on the left side.

Cure followed a single sitting with psychoelectric treatment, at least
so far as the contracture went. Pain and swelling remained in the
evening, followed by fatigue. The patient was discharged cured, October
12, 1916.

Hysterical pes equinovarus shows the foot immobile as if frozen
(_figé_). The foot is extended with the toes lowered and the internal
border incurved, as if revolved about the axis of the leg. The surface
of the sole is directed inwards and much furrowed. The tendon of the
tibialis anticus is very prominent. The internal malleolus is hardly
visible, while the head of the astragalus is easily made out. No
passive movement is possible and the tibiotarsal and mediotarsal joints
are quite out of function. Upon palpation, the excessive contracture of
the anterior muscles of the leg is striking. Upon request to move the
foot, the foot is not moved, but muscles of the lower leg may contract,
and even those of the thigh.

There were no sensory disorders in the present case, though they often
do occur in this form of acrocontracture. It is doubtful whether
the skin changes sometimes seen, such as hypothermia, hyperidrosis,
cyanosis, and glossiness are due to circulatory disorder induced by
the contracture or to the prolonged immobility. It has been proved
by Meige, Benisty and Lévy, that even in a normal subject prolonged
immobility may cause a difference of temperature of several degrees.
Circulatory disorders sometimes cease immediately upon cessation of
the contracture. Roussy and Lhermitte insist upon energetic and early
treatment of these psychoneuropathic acrocontractures, which are apt
to proceed less favorably than the acroparalyses. If not treated
energetically and early, actual nerve, tendon, and bone lesions may
ensue.


Shell-shock; shell-wound; emotion: Hysterical paraplegia. Approximate
recovery.

=Case 236.= (ABRAHAMS, July, 1915.)

A private of the First East Lancs could remember a shell’s bursting and
striking a wagon near him when he was carrying food to the firing-line.
He also thought a spare wagon wheel might have fallen on him. A
period of unconsciousness of four or five days duration elapsed, on
recovery from which he found himself suffering from a shell-wound in
the left buttock, complete paralysis of both legs, and pain in the
back, by the fourth lumbar vertebra. He thought that he had suffered
from sphincteric paralysis for eleven days after the accident; but by
September 25, there was no sign of this. Besides the paraplegia, there
was complete loss of sensation below Poupart’s ligament in the right
leg, reaching as high as the iliac crest behind; and an anesthesia of
the left foot including heel and sole, with anesthesia to light touch
throughout the limb (pin-pricks being appreciated in a normal way as
far as the ankle); and there was an anesthesia to touch and pain in the
ulnar distribution.

April 20, 1915, the patient was found to be a robust, somewhat
microencephalic slowly cerebrating subject. Total flaccid paralysis
of legs; right knee-jerk slightly exaggerated; no plantar response of
any sort was obtainable. Right leg entirely anesthetic; left leg and
both arms showed a diminution of sensibility; suggestion of glove and
stocking anesthesia; trophic changes absent. The scar of the healed
bullet-wound lay over the trunk of the left sciatic nerve.

It seems that the man’s companion had both his legs blown off at
the time the shell burst. It is questionable whether the paraplegic
patient actually saw the legs blown off, or merely heard about the
accident. Another psychic feature lay in the fact that the patient had
a paralyzed sister--a possible financial burden.

April 30, nitrous acid anesthesia. During the temporary rigidity, the
legs were found to stiffen slightly; the legs were flexed. Upon the
return of consciousness, the patient was told that the legs had moved
during anesthesia, and was asked to place them in a more convenient
position. The thighs moved slightly, and throughout the day movements
were encouraged against resistance.

The next day he was gradually raised to the vertical position and
supported upright. But at this stage he had become mentally resistant
and resentful. During the day the upright position was at intervals
resumed, and the patient was made to walk between two attendants. The
next day he walked alone and his mental resistance had broken down.
There was no longer any evidence of exhaustion and effort in the
movements, and the patient began to take pleasure in his recovery.

Improvement was progressive. A pronounced hysterical element persisted,
encouraged by the perpetual attentions of visitors. When discharged,
there was a slight hemi-anesthesia throughout the right side, and a
doubtful patch of anesthesia on the dorsum of the foot, sole, and
plantar surface of the heel.


Shell-shock; burial; flexion of spine: Paraplegia.

=Case 237.= (ELLIOT, December, 1914.)

A reservist, 34, formerly army instructor in gymnastics, a member of
the 1st Battalion King’s Royal Rifles, was subject to injury from
the bursting of a “Black Maria” on his trench. He was sitting with
bent back in his shelter, with legs fully extended. He was in a small
dug-out, a recess excavated under the earth backward from a narrow
trench and not timbered. The “Black Maria” burst and covered him up
to the chin in a heavy clay soil. After building up the breach twenty
minutes later, his comrades dug him out.

He had received on his body the violent impact of the mass of earth
pushed laterally from the crater excavated by the bursting of the
shell. Accordingly his vertebral column was forcibly flexed, its
ligaments were stretched, and hemorrhages were produced in the great
muscles of the back. As the twelfth thoracic vertebra is the weakest
spot in the spine, the roots of the cauda equina opposite this weak
spot were probably injured. Such accidents are met in mines.

The legs were powerless and numb. There was nausea, no vomiting, no
gas, no dizziness or trouble in the head, not even pain in the small
of the back. The accident had occurred at 8 A.M. Upon nightfall, he
was removed on a stretcher to the field hospital, arriving at the base
hospital four days later; and on the fifth day power began to return
to the legs. Knees, ankles, and toes would move slightly November 6,
though passive movements of the legs caused pain in the back. The deep
reflexes were weak, the plantar reflexes flexor. The left cremasteric
reflex was weaker than the right. Impairment of sensation was slight
in both extremities, but the left leg was a little more numb than the
right. The left lower abdominal reflex was lost. A band of hyperalgesia
corresponded with the left eleventh and twelfth thoracic segments
November 12, slight reflex disorders and some degree of paresis of the
legs.


Shell explosion: Paraplegia; sensory symptoms.

=Case 238.= (HURST, January, 1915.)

A lieutenant, 23, came to the ambulance September 15, 1914, having the
morning before been to the firing-line with his company and thrown to
the ground on his back by the explosion of a shell which he had seen
falling behind him. He had not lost consciousness, but was unable to
rise. After a night in the relief post, he was brought by automobile
12 kilometers to the ambulance. He complained of pain in the back,
though no wound or ecchymosis could be found there, nor any painfulness
of spinous processes or irregularity of bone. He had not emptied
the bladder from the time of the shock. Preparations were made to
catheterize on the morning of the 16th, when the patient after effort
became able to micturate. There was crural paraplegia such that he
could not sit or walk even when supported. Lying down, he could move
his legs slightly sidewise. Anesthesia to pin-prick and temperature
was complete to the groin; but tactile anesthesia was found only in
the sacral root territory, namely in the feet, the outer aspect of
the legs, the posterior surface of the thighs, and the scrotum. There
was loss of sense of position for the toes. The plantar reflexes were
abolished; but there were no other reflex disorders; nor was there any
evidence of other disorder.

September 20, the man was evacuated by sanitary train in the same
status as at entry. January 27, 1915, the patient could walk on
crutches, supporting himself in part on the left leg. The lumbar pain
had largely disappeared.

Hurst regarded this case as one of organic origin due to commotio
spinalis.


Wet, cold, heavy marching; leg pains, rheumatic; no other somatic
factor or any emotional factor discoverable: Transient paraplegia; two
months after period of exposure, brachial tremor, hysterical. Recovery
incomplete.

=Case 239.= (BINSWANGER, July, 1915.)

A German soldier, 34 (non-alcoholic; married, father of five healthy
children; on military service 1901-3; regarded as a very good soldier;
father alcoholic), got bad leg pains from wet and cold in West front
trenches September 8-13, 1914. Still he was able to march some 30
kilometers. But two days later (he had lain down in wet clothes in a
barn), his legs became quite immobile. He was in a reserve hospital
from November 3. The rheumatism disappeared, and suddenly, early in the
morning of November 8, when he was washing, a lively tremor and shaking
of the right arm set in.

Examination at Jena January 30, 1915, showed no special physical
disorder. The sense of touch was slightly diminished on the right side;
the pain sense was normal; movements were free. While at rest there was
a continuous shaking tremor of the right arm and hand, which consisted
of very rapid pronations and supinations, and shaking movements of
the upper arm. At times the tremor would completely cease, and when
attention was diverted the tremor became slighter or quite disappeared.
The tremor increased when it was talked about in the man’s presence.
The left grip was stronger than the right.

January 31, after he had been in bed one day and treated with moist
packs, the shaking suddenly ceased. He then complained only of mild
pains in the right shoulder and wanted to get up.

February 23, he was given three days’ home leave, which he stood
very well. He now began to take part in the medical gymnastic work,
but complained afterwards of more pains in right shoulder and arm.
There was a lapse into the shaking tremor, which lasted with varying
intensity for several weeks. Loud noises or calling made it worse.

Hypnotism and suggestive treatment of the tremor were without effect
March 25. March 26, on passive extension of the right arm, patient
complained of pain in shoulder and arm. Next day the tremors were more
marked, but March 29, the tremors suddenly stopped altogether. April 4,
the pains stopped never to return. April 15, he was given leave to go
home for spring farm work.

Four weeks later he returned, sparing his right arm, which he held
stiffly beside his body when walking. If he let the arm hang free in
walking, rhythmical movements in it began. He complained of painful
involuntary contractions in the right arm even when in complete rest.
Nor did the condition afterward essentially change; the patient went
home at the beginning of July.

The remarkable feature of this case is the complete lack of any
emotional shock. The total genesis seems to have consisted in the
prolonged exposure to wet and cold, and the heavy marching. The
tremors, limited to the right upper extremity, occurred without
any demonstrable psychic or bodily trouble, and set in after the
disappearance of the so-called rheumatic disorder. Although there is
no one psychogenic factor to single out, the psychic influencibility
of the case is unmistakable; moreover, the incompleteness of the cure
is doubtless, according to Binswanger, a matter of the imperfect
suggestive therapy employed.


Fever patient watches barrage coming: unconsciousness, paraplegia:
recovery.

=Case 240.= (MANN, June, 1915.)

A lieutenant was lying with fever in a farmhouse in upper Alsace,
watching from his window the shelling of a battery about 400 meters
away. He saw that the enemy was to reach the farm with shell in due
course of time. The shells came nearer, say up to about 100 meters, and
the lieutenant was able to reckon closely when he would be reached. He
was quite defenseless and unable to get to safety. At the very moment,
he thinks, when the shells began to strike the house, the lieutenant
lost consciousness from fear. He was unconscious an hour before
being carried to the cellar. The shelling lasted several hours more.
Immediately upon coming to the patient found that, although he bore no
external wound, both legs and the right arm were paralyzed.

There were never any signs of organic disorder. The patient recovered
completely with purely suggestive treatment.


Incentives to paraplegia.

=Case 241.= (RUSSEL, August, 1917.)

A young Canadian paid $150 to have his teeth repaired to be accepted
for service and then married. The wife became pregnant. He reported
sick after falling out on a route march in a heavy rainstorm. The
medical officer said he had weak feet and ankles. He lay around the
huts, was excused duty, and got worse in the wet and cold. He was
admitted to hospital and came to Russel’s wards on a stretcher showing
paralysis of both legs with slight power of movement at the knee.
Stroking anesthesia to pin prick from the knee down. Reflexes not
abnormal. He walked back upstairs!

According to Russel the wife’s pregnancy had furnished a sufficient
incentive, and the M. O.’s suggestion had fallen on fertile soil.

    [Illustration: CAMPTOCORMIA (MLLE. ROSANOFF-SALOFF)

    WOUNDED SEPTEMBER 3, 1914. THROWN INTO AIR BY SHELL-BURST;
    UNCONSCIOUS. FEBRUARY, 1915: PLASTER JACKET, 3 WEEKS; SECOND
    JACKET, 3 WEEKS. CURED. SENT TO GRAND-PALAIS.]


Bullet wound of back: Hysterical bent-back--camptocormia.

=Case 242.= (SOUQUES, February, 1915.)

A man was wounded September 6, 1914, by a bullet that entered along
the axillary border of the scapula and emerged near the spine. He spat
blood for several days; but the skin wounds quickly healed.

When he got up, his trunk and thighs were found to be in a state of
moderate flexion upon the pelvis, the trunk being bent almost at a
right angle; the legs were flexed somewhat upon the thighs. The man
could not voluntarily extend his trunk, but he could extend his thighs
to a moderate degree. He could bend his trunk still further forward
than its habitual contractured position, being able to pick up an
object from the ground. If the man was put in the ventral position,
the trunk could be straightened to a considerable degree. Curiously
enough, the man felt no pain, nor had there been any pain since the
healing of the wound. No motor, sensory, reflex, trophic, vasomotor,
electrical, visceral, or X-ray disorders could be found. It was evident
that there was a contraction of the muscles of the abdominal wall and
of the iliopsoas, yet it was also clear that these muscles were not
contractured on account of the subject’s ability to flex his trunk and
to extend his thighs.

Here, then, is a vicious attitude crystallized (in the phrase of
Souques) in the form of a pseudocontracture.


Blown up by shell; unconsciousness: Camptocormia (bent-back,
“cintrage”). Cure by corsets.

=Case 243.= (ROUSSY and LHERMITTE, 1917.)

Camptocormia with antero lateral bending is described by Roussy and
Lhermitte in an infantryman observed at Villejuif, February, 1915,
after having been wounded September 3, 1914. The infantryman had been
thrown into the air by the bursting of a shell, had lost consciousness,
and came to with violent pains in the back. The trunk was found to
be bent strongly forward and to the right side, and remained in this
position thereafter. There was no evidence of wound.

In February, 1916, a plaster corset was applied by Souques, which
brought the patient partly to normal station in three weeks. The trunk
was now no longer bent forward, but was still bent to the right. A
second corset was applied for three more weeks, with which the patient
became absolutely straightened out again. He was discharged cured and
sent to the Grand-Palais for the reëducation course.

This condition is a form of trunk contracture in the nature of a
kyphosis (scoliotic and lordotic forms of contracture are also found
in the hysterical group), for which the terms _plicature_ of trunk,
traumatic kyphosis, pseudo-spondylitis, and camptocormia have been
in use. The term camptocormia has been proposed by Souques and
Rosanoff-Saloff. The _poilus_ speak of the condition as _cintrage_
(arching). In these cases the trunk is held almost horizontally,
with the head in hypertension and neck muscles and thyroid cartilage
jutting. The patient looks fixedly straight forward, with eyes wide
open, and carries his legs extended or half flexed. The normal folds
of the abdominal wall are very deeply marked, and at the level of the
groins, the epigastrium and the pubis, there are deep folds. Viewed
from behind, the median lumbar fold has disappeared or is faintly
marked, as are the sacro-lumbar and other masses of spinal muscles.
The whole lumbar region is elongated and flattened. The dorsal spines
of the back are accentuated; the buttocks are flattened and broadened
transversely. The back of the neck is marked by deep transverse
folds, and the seventh spine does not stand out. The patient can walk
perfectly, though sometimes there is a pseudocoxalgia and lameness.
Attempts to straighten the body lead to visible forcible contractions
of various muscles, but the kyphosis remains persistent. There is a
sense of active resistance on the part of the patient, which can be
demonstrated by palpation. If an active attempt at straightening is
made, lumbar or sacral pain develops, followed by a very lively and
emotional state of anxiety on the part of the patient, with interrupted
and accelerated breathing, an expression of terror in the face, and a
rapid pulse. The patient then subsides into his earlier attitude, and
his anxiety disappears in a few seconds. It is much easier in many
subjects to reduce the camptocormia in the position of dorsal decubitus
than upright.


Burial after shell explosion; lumbar ecchymoses; regionary pains;
camptocormia, 5½ months. Cure by three months’ plaster cast about trunk.

=Case 244.= (ROUSSY and LHERMITTE, 1917.)

An infantryman was buried after shell explosion August 25, 1914, but
he sustained no wound or bone injury. There was, however, a large
ecchymosis of the lumbar region, and he had felt violent lumbar pains.
The trunk was carried flexed, symmetrically bent over and quite
incapable of being straightened completely. A plaster corset was
applied March 16 by Souques. Three months of this was followed by a
complete straightening, which lasted after the corset was removed. The
patient was discharged well.

As to these cases of camptocormia, some authors regard them as due to
anatomical changes in the vertebral column itself, or in the ligaments
and muscles, and accordingly regard the condition as a form of
spondylitis, syndesmitis, or psoitis. This view is held by Sicard, who
bases the idea upon the local pains and the results of cerebrospinal
fluid examination. According to Roussy and Lhermitte, hyperalbuminosis
of the fluid is extremely rare, and one case of their own _with_
hyperalbuminosis was nevertheless cured with great rapidity. Roussy and
Lhermitte even inquire whether the fluid albumin may not be due in some
way to an interference with venous and lymphatic circulation.

In some cases, this condition may be at first a response to pain,
a pseudospondylitis dolorosa, such as may be sometimes observed in
hospitals near the front. Later, however, the suffering in camptocormia
is due more to the abnormal position of the trunk, with strain upon
vertebral ligaments, than to the persistence of any original pain.
Moreover, these patients recover almost immediately from their pains
when the contraction is relieved.

In differential diagnosis, one has to consider, according to Roussy
and Lhermitte, Pott’s disease, traumatic spondylitis, as well
as Bechterew’s vertebral ankylosis, Pierre Marie’s rhizomelic
spondylosis, Kocher’s intervertebral disc contusions, and Schuster’s
myogenic ankylosis of the vertebral column; but in Pott’s disease, the
fixed pain points, rigidity of column, fluid examination, and signs
of myelitis, should suffice for the differential diagnosis. Traumatic
spondylitis follows the contusion after months and after a phase of
neuralgia. Ankyloses do not so much concern the trunk as the vertebral
column itself; disc contusion produces disorders in standing and gait
as well as pains and edema. Schuster’s disease shows paresis, hyper
reflexia, and amyotrophy not shown in camptocormia.


Shell explosion; partial burial; forcible flexion of spine. Paraplegia,
cured by suggestion. Then camptocormia, also cured.

=Case 245.= (JOLTRAIN, March, 1917.)

An infantryman in the Côte du Poivre was sitting on the ground in the
opening of a dugout eating soup, when a shell burst and the roof of the
sap fell in on him. The planks and the stonework fell heavily on the
dorsolumbar region. The patient was almost bent in two, head to knees,
legs buried, hardly able to breathe. He did not lose consciousness
and cried out, feeling for a moment very anxious and fearful that his
comrades had left. Only two hours later was it possible to dig him
out. He said he had been absolutely unable to make any movement, had
kept his body bent, and felt violent pains in the back. He was carried
back twelve hours later and reached the dressing station in eight
more hours, eventually reaching the neurological service two days and
a half after the accident. On entrance he was prostrated, complained
of lumbar pains and of inability to move, and was able to make only a
few contractions on the left side when asked to try. The right leg was
flaccid. The left knee-jerk was stronger than the right. Other reflexes
normal. Hyperesthesia to pin prick on the right side. Slight saddle
hypesthesia, reaching to the iliac crests above and perineum below with
preservation of touch sensation. Slight forward posture of vertebral
column. The patient complained of pain on pressure of the spinal
processes and the lumbar spine. There was slight ecchymosis about the
left iliac crest.

Lumbar puncture showed clear fluid without hypertension, in which were
a few lymphocytes. There was a large amount of albumin. The blood
pressure was normal. There had been a slight diarrhea following the
accident which disappeared on entrance to the hospital. The question
was raised whether the case was one of slight hematomyelia or was
pithiatic.

Suggestive therapy was tried, and liquid was injected into the muscles
of the lumbar region and the posterior surfaces of the thighs. In
a quarter of an hour the patient found himself able to raise the
foot above the bed. There remained an extensor paralysis of the
right leg. When the patient was made to raise the foot he began to
show the phenomenon of Souques, called camptocormia. He could walk,
nevertheless, and took a few steps sustaining the weight of his body
by placing his arms on his thighs. Though he complained of lumbar
pain, it was finally possible for him to pick up an object from the
ground and lean sidewise. He could not, however, stand up. Yet when the
patient was made to lie down, his back was spontaneously straightened.
Treatment of the camptocormia was also successful.


Astasia-abasia: Two cases from (a) thigh wound, and (b) shell-shock and
wound of thorax. Cures by faradism.

=Case 246.= (ROUSSY and LHERMITTE, 1917.)

An infantryman was wounded September 23, 1914, by a bullet in the
anterior and middle part of the left thigh. From the moment of the
trauma, he had not been able to walk, but gradually regained his
ability to stand, and then to walk. He was returned to the front
(January, 1915).

Slightly wounded again in the neck, January 6, 1915, he was evacuated
and operated on. After the operation he could neither walk nor stand.
His reflexes were normal; he could perform all movements when lying
down, although the movements were executed very slowly. As soon as he
could sit upright, he was taken with tremors and could not hold himself
in a vertical standing position, nor take a single step. If he was
given crutches, he dragged the two legs.

Under the influence of electric treatment--a mild faradic current--he
was cured at a sitting so that he could both stand and walk (March,
1916).


=Case 247.= (ROUSSY and LHERMITTE, 1917.)

Astasia-abasia after shell explosion occurred in an infantryman
observed by Roussy and Lhermitte at Villejuif, July 8, 1915.

The patient had been wounded September, 1914. The wound was a
superficial one in the thoracic wall, under the right nipple. He had
been cast into a very deep shell hole, but had been able to get back to
the aid station alone, taking very short steps only.

As soon as he reached the station, his gait became spastic, trembling
and hesitant. Given two canes, he could walk painfully, trembling.
At each step, he would balance his body back and forth. He gave the
impression of a man drawing some sort of vehicle, who had to make a
considerable effort at each step.

The faradic treatment cured this patient at one sitting.


War strain; fall into water-filled trench: Dysbasia, tremors, vasomotor
disorders. Cure by hypnosis. Case to demonstrate “traumatic” hysteria
WITHOUT somatic TRAUMA.

=Case 248.= (NONNE, December, 1915.)

An artilleryman (without hereditary or acquired neuropathic taint)
underwent much stress and strain in the war in Belgium, Lorraine and
Flanders. One night, on leaving his observation post, he fell into a
trench filled with water. He felt pricks in the groin and gradually
developed a pseudospastic tremor of the lower extremity, paraparesis
inferior, depression, irritability, pressure sensations in the head,
and sleeplessness. He passed through three hospitals before arriving at
Hamburg and received the diagnosis of concussion of the brain and cord.

Nonne found an emotional state of depression with hypochondriacal
fear, disturbance of sleep, deficient appetite, constipation and
pollakisuria. He walked upon two crutches, dragging his legs inertly
after him. There was marked cyanosis, lowered temperature and
hyperidrosis of the feet and lower legs; exaggeration of tendon and
skin reflexes and pseudoclonus; no Babinski or Oppenheim reaction.
There was anesthesia of the lower extremities and of trunk as high as
the ribs. Pulse 130. Visual fields normal. Sensory disorders absent.

After the first hypnotic treatment the patient was able to stand and
take a number of steps, and the tremor gradually diminished. After two
treatments standing became normal and walking was much improved, the
tremor ceased, cyanosis and hyperidrosis disappeared, and the movements
of the bowels and urination became normal. Thereafter the patient had
no attention paid to him deliberately and in a week’s time became well.

Here is a case in which, as Nonne states, the somatic trauma required
by Oppenheim as the basis of every traumatic neurosis did not occur.
Moreover, the sudden cures by hypnotism, or by any other method in
these cases, warrant us in supposing that there are no such fine
molecular changes as Oppenheim and von Sarbo assert. Such experience
as the cures in this group of cases confirms, according to Nonne,
the surprising result first achieved in this war (Bonhoeffer, Wagner
von Jauregg, Karplus, Wollenberg, Westphal) that the most severe
neuroses produced by somatic and psychic traumata can be cured in an
astoundingly rapid manner without residuals.

_Re_ the controversy over Oppenheim’s traumatic neurosis, Nonne holds
with the Charcot school that traumatic neurosis is clinically identical
with hysteria. Oppenheim admits the part played by psychogenesis,
but has always laid a greater emphasis upon the actual injury of
the neuronic apparatus in which he believes. He thinks that small
hemorrhages, inflammatory processes, and degenerative processes affect
the neurones unfavorably, and permit the psychogenic effects to occur
more readily. Of course the insurance-company attitude and the attitude
of railway corporations saw malingering in all cases, and to this day,
neurologists are inclined to see a great deal of “indemnity neurosis”
in these cases. Opposed to the corporation men and the neurologists
were the psychiatrists, who chiefly upheld an emotional theory of
genesis--whence we began to hear of the neuroses of fright and of
accident.

Oppenheim claims to have established with war cases the fact that
an entirely normal person without heredity and without antebellum
acquired soil, may develop a neurosis through war stress. Oppenheim
concedes that there may be purely psychic cases, but holds that there
are nevertheless, numerous purely physical cases and a great number
of cases of a compound nature, which are both physical and psychical
in their etiology. Oppenheim’s point is not that every single symptom
described _may_ not be upon occasion psychogenic, but that the data
of this war prove that neuronic injury, particularly injury of the
peripheral neurones, can also produce these effects. Nonne, Forster,
Lewandowsky, and others, opposed Oppenheim’s views vehemently. See
especially comments by Zeehandelaar.


Shell-shock; BURIAL HEAD DOWN: Brachial monoplegia, head-shaking,
speech disorder, corneal and conjunctival reflexes absent.
Determination of hysterical phenomena to parts buried.

=Case 249.= (ARINSTEIN, 1916.)

A Russian private was buried after a shell explosion, September 13,
1915, head down, so that only his legs stuck out of the débris.
Afterward his right hand refused to move, and there was edema of the
right wrist, with pain referred to the shoulder joint. The head shook
and made jerky movements during the day, but ceased them in sleep.
Speech was retarded; words were uttered clearly enough but in a
sing-song fashion; sometimes the man stammered. Hearing was diminished
in the right ear. Pupillary responses were lively, but the swallowing
reflexes were diminished, and the corneal and conjunctival reflexes
were absent. The tendon reflexes were lively on both sides. There were
no pathological reflexes.

At the end of October--six weeks later--the patient was sent home on
convalescence for three months, and improved rapidly after a short
time in family surroundings. He was examined again, two months after
discharge, and found normal in all respects. He returned to the ranks.

_Re_ Shell-shock in Russians, Arinstein concludes that concussion
hysteria may occur in a perfectly normal person, yet be innocent of
all organic signs indicating destruction of peripheral or central
neurones. Rifle or machine-gun fire had not in his experience brought
about concussion hysteria, which was invariably due to the bursting of
a large projectile. With reference to Schuster’s remark that a sleeping
man never acquires hysteria from the bursting of a shell near by,
Arinstein confirms Schuster, finding amongst 2000 cases no instance in
a soldier sleeping at the time the shell burst.

_Re_ effects of cannonading, Gerver reports Russian instances of a kind
of hysterical _clavus_, or sensation of a nail being driven into the
back of the head, in men who have been a number of days under stiff
shelling.


Multiple wounds and bullet wound of palm: ACROPARALYSIS. Cure, five
months.

=Case 250.= (ROUSSY AND LHERMITTE, 1917.)

A patient was observed at Villejuif, February 5, 1915. He had been
wounded, January 2, 1915, and showed scars of a bayonet wound on the
anterior surface of the right thigh, of a lance wound on the dorsal
surface of the right foot, and of a bullet wound in the palm of the
left hand.

There was left wrist drop with fingers extended. On the sensory side,
there was a glove anesthesia and analgesia up to the bend of the elbow.
The right leg showed a paresis and contracture, but there were no
sensory disorders in the legs. Reflexes were normal. The patient was
discharged cured, in May, 1915 (psychoelectric method).

This is an example of the so-called acroparalyses, paralyses limited
to the hand or foot, many of which have developed in this war, after
grazing wounds or more severe injury. More rarely they appear as if
spontaneously. Sometimes they are preceded by slight arthralgia or
vague pains.

The condition in the hand suggests a radial paralysis. The patient
is unable to flex his fingers, though he probably is able to make
some movements with his thumb. Sometimes, on request to move the
hand, a series of coarse oscillations follows, somewhat like a
tremor. These oscillations are, according to Roussy and Lhermitte,
apparently pathognomonic, and depend upon the contraction of the
muscles antagonistic to those whose movement has been requested. These
antagonistic muscles, themselves entirely incapable of voluntary
movement, are seen to be contracting effectively and jerkily to meet
the action of the agonists, also seen making jerky movements. If the
forearm is moved passively and rapidly, the hand flops about inert,
like the hand of a marionette, although not to the degree of hypotonia
in organic paralysis. The hand is often cold, moist, and cyanotic, and
even possibly analgesic and hypesthetic.


Bullet wound of arm: Apparent radial paralysis, not resolved by
self-preservative swimming movements. Paralysis actually hysterical.

=Case 251.= (CHARTIER, October, 1915.)

A professional acrobat, 22, Corporal in an African Chasseur regiment,
was rather instructively tattooed and had apparently performed some
of his service in disciplinary companies. In short, one might have
a legitimate suspicion of the objective value of any manifestations
he might present. However, one of his chiefs had written a favorable
letter concerning his services. He had had various crises of a
hysterical character since adolescence, and there was alcoholism in the
family.

He was wounded May 4, 1915, by a bullet which passed through the outer
and lower part of the right upper arm, and thereafter the forearm and
hand became completely inert, both for flexion and extension. There
was a considerable hyperesthesia. The wound healed quickly, without
complications.

August 5, about 10 o’clock at night, the man--then at his dépôt--tried
to commit suicide (motive not related with the war). He threw himself
into the Rhône from a height, where the water was deep and the current
rapid. His brother and a comrade, who knew that he was going to make
the attempt, saved him. Chartier himself happened to see the whole
scene, and noted that throughout the affair the forearm and hand of the
patient remained inert. It seemed as if there was a radial paralysis.
This was the more likely as the man had been wounded in the arm. First
care was given. The man had not known of Chartier’s presence. He had
been under water about two minutes.

From hospital he was evacuated three weeks later with a diagnosis of
radial paralysis, coming on service September 11. Examination showed
a slight paralysis of the extensors and flexors of hand and fingers,
and of the hand muscles. There was also a slight contracture of these
muscles, more marked in the flexors. There was pain upon reduction,
with some jerking of the muscles. Electrical reactions proved normal
in nerves and muscles. There was a segmentary anesthesia to pin prick,
reaching to the level of the elbow; deep hyperesthesia of the finger
joints. There was no trophic or vasomotor disorder.

In short, here was a case of functional paralysis with contracture of
the right hand, to be regarded as hysterical in the classical sense
of the term, both by reason of the anesthesia and absence of trophic
disorder, and on account of the hysterical history of the patient.
Functional reëducative treatment quickly improved the paralysis, so
that two weeks later the patient was able to extend fingers and hand.
His total recovery was hoped for, when, September 26, wishing to get
out of the hospital without leave, the patient jumped from a window and
broke his right leg. The functional paralysis of the hand persisted and
even grew more marked.

The interesting point in this case is that despite the powerful nature
of instinctive efforts with drowning persons, this patient, subject
to an hysterical arm paralysis, did _not_ make defensive movements
with the paralyzed arm; yet this paralysis was such as to be greatly
improved by psychotherapy.


Bullet wound in brachial plexus region: SUPINATOR LONGUS CONTRACTURE,
hysterical-looking. Callus of fractured rib probably at fault:
Treatment surgical.

=Case 252.= (LÉRI and ROGER, October, 1915.)

A man was wounded, December 21, 1914, by a bullet which entered about
the middle of the spinous process of the left scapula and was extracted
a few days later from the posterior border of the sternocleidomastoid
muscle, two finger-breadths from the left clavicle, that is, at about
Erb’s point. The left upper extremity was inert for ten days, but then
began to move again, although extension and flexion of the fingers did
not begin at once.

October, 1915, movements were normal, except those of extension of
the forearm, due to contracture of the supinator longus muscle, a
contracture that had developed about three weeks after the wound and
stood out along the external border of the forearm, almost suggesting
a musculotendinous retraction. There was a palpable, hard callus of a
fractured rib, presumably a cause of the permanent irritation of the
supinator longus, being precisely at the point where lesions usually
produce superior brachial plexus palsy.

Why should the supinator longus alone of the Duchenne-Erb group
be affected? Perhaps a single root was involved in the irritative
lesion. The biceps showed also a partial R. D. The deltoid was normal
electrically and in contraction.

The treatment planned for this case of isolated contracture of the
supinator longus was surgical operation of the irritative focus.
According to Léri and Roger, it is sometimes dangerous to use such
measures as massage and electric baths for a paralyzed limb, since the
massage or electricity excite not only the affected muscles, but also
the other sound muscles,--muscles that are already more powerful than
the paralyzed muscles and may go into antagonistic contracture. Even in
limited galvanization, it is desirable to work with weak currents, so
as not to diffuse the current into non-paralyzed muscles. In case of
radial or sciatic paralysis, apparatus permitting the extremities to
rest without over-action of the muscles antagonistic to the paralyzed
ones may well be applied.

We here deal with a case, therefore, which looked purely functional,
but in which careful examination and X-ray served to show an organic
focus of irritation.

_Re_ nerve concussion, Tubby offers the following definition: Nerve
concussion is damage to a nerve trunk without actual destruction of the
axis cylinders. The damage may consist of an effusion of blood between
the nerve fibres following compression of a nerve against the bone by
rapid passage of a foreign body near the nerve. Sometimes, however,
the lesion which causes damage to the nerve trunk without actual
destruction to the axis cylinders is nothing more than a temporary
anemia or hyperemia. In most instances, both motor and sensory function
are together interfered with, but in the case of large nerve trunks,
_e.g._, the popliteal, there may be a separate concussion of motor or
sensory bundles.


Contusion may effect a sort of STUPEFACTION OF MUSCLE and paralyze it
by a non-psychic process: The SYNERGY in contraction of biceps and
supinator longus is thus SPLIT. Biceps restored to synergy with the
supinator by massage and faradism.

=Case 253.= (TINEL, June, 1917.)

A man was wounded at about the middle of his biceps and three weeks
later was found to be able to flex the forearm only by means of the
supinator longus. The biceps remained absolutely flaccid and soft, so
that the diagnosis of a lesion of the musculocutaneous nerve (unlikely
as this seemed on account of the low site of the wound) was entertained.

However, the biceps and the musculocutaneous nerve proved electrically
normal. In short, this paralysis of biceps was functional in nature.
But, according to Tinel, there could be no voluntary suggestive or
hysterical element in such a paralysis, since flexion of the forearm
is normally produced by a synergic contraction of biceps and supinator
longus that cannot be separated voluntarily.

Treatment by massage and rhythmic faradization caused the biceps
function to return to normal, so that voluntary synergic contractions
of the biceps took place along with those of the supinator longus.

We here deal, according to Tinel, with a genuine functional paralysis,
nonhysterical--a paralysis due to a kind of stupor of the muscle. Such
paralyses due to muscular stupor ought to get well in a few days or
weeks. Should they persist, it is clear that a stuporous paralysis
might be transformed into a hysterical paralysis. In short, the direct
contusion of a muscle or group of muscles may be the point of departure
for various persistent paralyses.


Wound of arm: Blocking of impulses to certain hand movements. Recovery
with splint.

=Case 254.= (TUBBY, January, 1915.)

A private was wounded by a shell fragment, September 16, 1914, and
admitted to the London General Hospital, September 27. A high-velocity
shell fragment had passed through the soft parts of the left arm at a
spot exactly corresponding to the musculospiral groove. He could extend
the middle finger of the left hand, but the other fingers were held in
flexion. The last two phalanges of index finger could not be moved, it
was found, on account of severance of the extensor tendon some years
previously. Accordingly, the loss of function due to the shell injury
was that of thumb, ring, and little fingers. Supination could not be
executed completely to the extent of 15 degrees; there was no R. D.
upon electrical test, October 2. The sensation of affected fingers was
woolly. November 3, the little finger had recovered, but supination
could not be completely executed.

The treatment consisted in a bent malleable iron splint, with the wrist
and affected fingers hyperextended. November 20 all power had returned
with full supination, except for the two phalanges of index finger
previously injured.

Major Tubby thinks this a case of physiological blocking, as from a
small hemorrhage amongst the fibers or around the nerve.

_Re_ inhibition, Myers thinks it is the functional cause of the effects
of shell-shock. He thinks it is not a fixation of the _idea_ of the
paralysis of volition, but that it is a fixation of the _process of
inhibition_ itself that produces the effects we see in Shell-shock.
It is a block of ascending paths that produces the anaesthesia so
characteristic of Shell-shock. It is a blocking of sensory paths
that produces mutism or aphonia. But according to Myers, there is
also a block in certain cases of _descending paths_ that control and
coördinate various mechanisms. The result of a block in the descending
paths is shown in spastic, clonic, or ataxic phenomena of, _e.g._,
functional dysarthria. See also Case 253 (Tinel).


Eight months of war experience (often under heavy fire) without
reaction; then, shell-shock; unconsciousness: Right hemiparesis; pain
in the left side of head; heat sensations of right half of body;
diminution of hearing in left ear; a variety of asymmetrical bilateral
phenomena.

=Case 255.= (GERVER, 1915.)

A Russian private, 24, sustained shell-shock April 14, 1915. He was
observed, when the shell burst, to crouch down, and then to fall to
the ground, unconscious. The unconsciousness lasted about two days,
after which he was found to be oriented, though slow and stammering of
speech, hardly able to concentrate attention or sustain a conversation,
and giving the impression of a man stunned. There was difficulty in
the expression of thoughts, and a marked over-fatigueability. After
adding and subtracting accurately two-digit figures for a time, the man
quickly grew confused and said that trying to solve such a problem made
him dizzy.

His imagination was filled with gunshots, shell-bursts, and the
killing of comrades, and during any conversation the man frequently
shuddered. Concerning the shell-shock, he remembered only that a number
of shells had burst near him and that he came to in the hospital. He
kept looking to one side and to a distance, as if listening, sometimes
bending his head downwards. He would cry and sigh during conversation,
and then be quite unable to explain why. He said there were loud
noises in his ears, and that his head and the whole right side of his
body felt hot. Pain was felt in the left side of the head. The right
hand and the right foot were weak (on distraction, this hemiparesis
remained unaltered). Tremors affected all the extremities. He had a
sensation, possibly hallucinatory, of the creeping of insects on his
skin. The hearing of the left ear was objectively diminished. There
was palpitation of the heart and difficulty of breathing. Tendency to
Romberg. There was a general hypalgesia, more marked on the left side
of the body. Both conjunctival reflexes were diminished. Knee-jerks
and Achilles jerks were exaggerated. All the reflexes on the right
side were livelier than on the left. There was a moderate Babinski
reaction on the right side. Mechanical over-excitability of muscles.
Dermatographia. Both sides of the skull were sensitive on tapping, but
especially the left side. Mannkopf sign on pressure of the left side of
the cranium.

Hemorrhagic points without injury to the skin were noted on the skin
of the left hand and foot. Speech was stammering. There was a marked
digital tremor, sometimes spreading to the rest of the body during
examination. The muscles of the face, eyelids, and tongue showed sharp
fibrillary twitching. The pulse stood at 100 and frequently missed
beats. Battle hallucinations, visual and auditory, sometimes occurred,
the commands of superiors and the noise of guns, rifles, yelling, and
groans; the man would see trenches or redoubts, or a field full of
wounded soldiers or attacking columns of the enemy. He recognized the
hallucinations as such. His sleep was troubled by nightmares of the
same general description.

For eight months the man had been in action at the front, under heavy
gun and rifle fire. He was a courageous man, who had never felt fear,
regarding himself as used to battle and the bursting of shells. He had
not been wounded. The entire situation seems to have developed after
the single shell burst of April 14, 1915.


LOCALIZATION OF SHELL-SHOCK SYMPTOMS: Hemiparesis and hemianalgesia on
side of body exposed to explosion; contralateral irritative symptoms of
face and tongue.

=Case 256.= (OPPENHEIM, January, 1915.)

A soldier had a shell explode to his right, October 23, 1914. He
declared that the concussion launched him through the air. When he
recovered consciousness three hours later, he lay in a bog and was
unable to move either leg. Gradual improvement followed. The symptoms
were sensations of formication in the legs, pain in the back, blurred
sight, hardness of hearing, disturbance of speech, headache, vertigo,
weak memory. After a fortnight weakness in right arm.

He was admitted to hospital a week after the injury, unable to walk,
restless, given to palpitation and attacks of anxiety. On attempts to
walk, leg spasms and tachycardia.

Transferred to nerve hospital, December 2. Sleep poor, uneasy with
dreams. Tic on left side of face. On opening the mouth, left-sided
faciolingual spasm. Paresis of right arm. At first, right-sided
ankle-clonus and paresis of leg. Knee-jerks increased. Speech
hesitating. Right hemianalgesia. Concentric contraction of visual
fields. Tachycardia (120). In walking the right arm failed to swing
normally. Attacks of vertigo, with falling. Patient got up at night and
pushed against objects in his room.

There was only slight improvement while under observation. He became
psychically more frank and even talkative, and was moving more readily
when transferred.

_Re_ Oppenheim’s conception of the strongly peripheral element in
traumatic neurosis, he sums up by saying that a traumatism attacking
the organism at its periphery is in line to produce a neurosis without
any psychic mediation whatever. The rôle of the psychic process, in
Oppenheim’s view, is contributory to the fixation of neuroses. Even
when there is a free interval betwixt shell burst and neurosis, still
there are physical effects of trauma upon neurones.


Shell-shock; unconsciousness; after improvement in symptoms (4 months)
return to trenches; more symptoms after 5 days: Sensory disorders,
especially on left side (the side more exposed to explosion);
exaggerated reflexes on right side with slight clonus and with Babinski
sign. Improvement.

=Case 257.= (GERVER, 1915.)

A Russian Captain, 45 (heredity good; non-alcoholic, non-syphilitic;
always in good health) sustained shell-shock in a battle in
southeastern Prussia, August 13, 1914, and was unconscious for two
days. He was carried to one of the provisional field hospitals, and
then evacuated to Petrograd, where during a period of four months, he
was given electricity, suggestion, and baths. He was feeling so much
better in December, 1914, that he went back to the front and headed his
company in the trenches. He stood only five days of trench work, and
was sent for mental examination December 29, 1914.

The captain was of middle height, well developed but poorly nourished,
of a dejected and preoccupied appearance, looking to one side in
conversation, and finding difficulty in the expression of his thoughts.
He talked almost exclusively of his illness. He found difficulty in
adding or subtracting 2-digit figures. He seemed to have amentia,
frequently being mistaken as to the most important dates in his life.
He complained of general weakness and inability to work. Any endeavor
to concentrate caused vertigo, irritation, and pains in the head.
Day and night he was troubled about his health, his future, and his
family’s future. He was going to become an invalid and a burden. He
was tormented with the idea that people thought him a simulator. He
complained of lumbar pains. It seems that the explosion had affected
the left side of the body more than the right and he complained more
of pains upon that side. In the dark his gait was unsteady, and he
often had marked tremors of feet and hands. In excitement the tremor
would increase uncontrollably. The patient thought that his hearing
was diminished, especially upon the left side, and that his left ear
was weaker than the right. He slept poorly and had many nightmares;
his appetite was poor, and he was constipated. There was difficulty in
respiration; the pupils were slightly dilated and sluggish in their
responses. There was a marked tendency to Rombergism; dermatographia
marked; the skull and especially the lumbar spine was painful on
tapping; hyperesthesia of the lumbar skin; paresis of left hand and
left foot. The tendon reflexes were more marked on the right side than
on the left, and there was even a slight ankle and patellar clonus.
The Babinski sign was present on the right side. There were frequent
fibrillary contractions of the muscles of the trunk and back.

Objectively the hearing was somewhat decreased in the left ear, and the
vision of the left eye appeared to be somewhat impaired also. If the
eyes had been held closed for a time, there was difficulty in opening
them quickly. Aside from a somewhat elevated pulse and slight cardiac
arrhythmia, there was no disorder of the internal organs.

This patient remarkably improved but was not absolutely well at the
date of the report.

_Re_ organic signs in Shell-shock cases, Oppenheim warns practitioners
and experts against undervaluing war neuroses. He does not like to have
them set down in too offhand a way, as hysteria, wish-fulfilment, and
simulation. Hysteria is not likely, according to Oppenheim, in cases
with permanent cyanosis, disappearance of the radial pulse, trophic
disturbances, hyperidrosis, alopecia, fibrillary tremors, myokymia,
cramps, dilated and sluggish pupils, and weakening of tendon reflexes.
Hyperthyroidism also has been found by Oppenheim.


Shell-shock, explosion on left side: Sensory disorders especially on
left side; ecchymosis of right (uninjured) leg, possibly conditioned
upon shock of left hemisphere.

=Case 258.= (GERVER, 1915.)

An artillery officer had had a shell burst to the left side of his
horse, which veered to the right but did not fall. The officer’s left
hand immediately became so numb and weak that he could not hold his
reins with it; it shortly became more painful. The left foot showed a
tendency to the same anesthesia and paresis.

Curiously enough, a number of punctate hemorrhages appeared on the
right thigh and lower leg, upon the outer aspect. According to Gerver,
these hemorrhages into the skin of the _right_ leg may have something
to do with a disturbance of circulation related with effects wrought
upon the _left_ hemisphere. During the course of the disease, pains
occurred not only in the left arm and leg but also in the right leg.

_Re_ brain injuries produced by shell explosions without external
wound, Roussy and Boisseau have not found a single clinical instance
amongst 133 cases observed, which suggested cerebral softening, or
even hemorrhage into the brain substance, the cord substance, or the
meninges. These 133 cases were observed in army neurological centres
and contained instances of (_a_) mental disease (confusion, delirium,
amnesia), (_b_) nervous disease (astasia-abasia, tremors, paralyses,
contracture), and (_c_) an intermediary group (either mental confusion
with stupor, or hysterical deafmutism).


Shell-shock; unconsciousness: Hysterical deafness, speech-disorder,
gait. Recovery by reëducation. Brief relapse to deaf-mutism at noise of
drums. Improvement. Relapse to numerous and severe hysterical symptoms
at small guns fired on King’s birthday. Improvement. Speech wholly
regained in a quarrel. Recovery.

=Case 259.= (GAUPP, March, 1915.)

A musketeer, 22, had been blind for a time at 11 on account of some
spinal cord disease.

He was a soldier up to Christmas eve, 1914, when he was hurled backward
in a trench in the Argonne by an exploding hand grenade. He lay
unconscious for several hours, though without sign of physical injury.
Coming to his senses, he worked himself out of the trench and crawled
to another, but again fell unconscious. When he awoke he was in a
physician’s care in quarters, to which he had been taken by ambulance
men. Thence to the field hospital, and then to a private hospital at B.

Upon admission, January 17, he was hard of hearing on both sides, and
his speech was peculiar: choked off and retarded. His gait was heavy,
on a broad base. He was subject to headaches.

Exercises gradually improved the speech and the walking disorder was
quickly overcome. February 5 came a relapse through fright at the
rolling of drums near by. Speech was completely lost, deafness set in,
and the patient ran restlessly to and fro in tears. After a few hours
speech returned with still some minor difficulty.

From time to time came fainting spells and attacks of disorder of
consciousness, with loss of orientation and the idea of being in the
trench or under cover. He would ask whether it were raining through.
His mood herein was at times cheerful and excited. Speech further
improved from the middle of February, as well as did the other
symptoms.

On the King s birthday, February 25, occurred another relapse due to
his hearing small guns fired: Apathetic stupor, clonic spasm, aphonia,
abasia, severe deafness, poor sleep, refusal of food. The next day
he was still mute, but the spasms had ceased. He lay apathetically
in bed, taking a little liquid food. February 27 he was still mute,
though more active, not deaf, getting up alone, walking unsteadily on
a broad base, and playing cards at the table. March 2 the word _yes_
was again enunciated. March 3 he talked more freely and took a short
walk. March 4 speech of a sudden came completely back on the occasion
of getting excited in a quarrel among some other patients. The patient
thereafter began to talk a great deal, was bright and cheerful, but
still complained of a variety of nervous troubles. Speech was somewhat
difficult, but he was free from any definite aphasia or paraphasia.

_Re_ Shell-shock deafness, Jones Phillipson states that concussion
deafness is due to three contributory factors: (_a_) cerebral
concussion, (_b_) fatigue (violent oscillation of the perilymph,
continued noises, strain of organ of Corti), and (_c_) temporary or
permanent disorganization of the conductive apparatus.

_Re_ concussion deafness, J. S. and S. Fraser found in four cases
of actual explosion injury, a ruptured drumhead and hemorrhage into
the fundus of the internal meatus in three cases. They did not find
evidence of neuro-epithelial changes. Possibly the fundus hemorrhages,
besides giving rise to deafness, may start up the tinnitus and
giddiness that are sometimes found. In one case, there were changes in
the delicate nerve endings of the auditory ampullae.


Shell-shock: Deafness

=Case 260.= (MARRIAGE, February, 1917.)

A shell burst behind an English lieutenant in 1914 without causing
any wound but making him unconscious for an hour. During the hour
the Germans passed by and stripped him of all articles of value. He
came to and felt himself markedly deaf in both ears with an intense
headache. There was no hemorrhage, no discharge, no tinnitus, no
vertigo. Four days after the shell burst he could hear spoken words on
each side at two feet, but could not hear a watch that could usually
be heard from 3½ to 4 feet. With tuning fork C air and bone conduction
proved much subnormal, though air conduction was better than bone
conduction. With tuning fork C-5 air conduction was subnormal. Drums
healthy. Improvement followed; hearing became normal eighteen days
after explosion. The treatment was rest in bed with bromides early and
strychnine later.

Marriage states that the psychical deafness due to shell-shock is
usually bilateral and absolute. It is accompanied also, as a rule, by
other nervous signs and symptoms, such as aphonia, tubular vision,
paralyses, and anesthesias. Milligan and Westmacott state that the
deafness is due to a functional suspension of neuronic impulses. They
regard the brain as in a state of physical fatigue, and the mind as in
a state of strain. There is no organic lesion. The neuronic impulses
which are temporarily suspended are those which run from the higher
cortical cells to the periphery.


Mine-explosion: Unconsciousness: Deaf-mutism. Recovery of speech after
epistaxis and fever.

=Case 261.= (LIÉBAULT, October, 1916.)

A soldier, 24, teacher in civil life, was in a mine explosion November
27, 1914, at Vienne-le-Château. He was unconscious six weeks and
remembered nothing of what had passed. They had told him that he
had been blind for a month. After regaining consciousness he was a
deaf-mute and for seven months he did not speak. His mutism did not
bother him, as he thought he had always been mute. He had always been
able to write. He could not remember what had interfered with his
speech or tell whether he could think the words which he could not
utter.

May 22, 1915, there was considerable nasal hemorrhage, with fever. Upon
this day he began to speak, at first a few words, telegram style, and
with aphonia. A week later his voice returned. He was very irritable
during the period of mutism and had ideas of persecution and of suicide
and complained of becoming easily fatigued and exhausted.

His voice, however, became completely normal again and his respiration
better. On the spirometer he breathed four liters, but still got out of
breath easily. His diaphragmatic respiration was still imperfect. His
deafness remained at the time of report about as before, though he had
now been hearing for some time a slight resonance of his own voice and
could hear sounds emitted a few centimeters from his ear. At time of
report there was still general fatigue with insomnia.

_Re_ war deafness, Castex states that not merely shell bursts and
explosions are able to cause deafness, but the din of battle alone.
There are two big groups of war deafness: one due to drum rupture,
and the other due to labyrinthine shock. Labyrinthine shock--a much
more serious matter--is produced when a big shell bursts. In these
cases, the labyrinthine disorder is simply of the same general nature
as _commotio cerebri_. The labyrinthine shock cases often need to be
retired permanently from the front.


Shell-shock: Deaf-mutism.

=Case 262.= (MOTT, January, 1916.)

A deaf-mute, 24, not of a neurotic temperament or of a neuropathic
predisposition, was admitted to the Fourth London General Hospital
November 16, 1915.

He wrote, “I left England the 8th of March, and went to Gallipoli on
the 26th of May, and about the middle of August, one of our monitors
fired short. I felt something go in my head; then I went to the Canada
Hospital. They said it was concussion.” He had seen the monitors
firing. He came to in a dug-out about an hour afterward. He was quite
deaf and his head felt as if it would burst.

He could see and speak a little but lost his speech completely when
Barany’s tests were applied. The headache then passed away, leaving the
deaf-mutism. The ears, on examination, proved normal. The patient was
able to cough and whistle. He wrote his wife a letter, telling her how
he killed a Turkish woman sniper, but he did not remember that he had
written the letter. Although he said he did not dream, while asleep he
would assume the attitude of shooting with a rifle, as if pulling a
trigger, and then the attitude of using the bayonet: the right parry,
the left parry, and the thrust. Sometimes while asleep he would jump as
if a shell were coming, and he would catch his right elbow as if hit
there. He would then open his eyes wide and look under the bed. Then he
would wake up and begin to cry, but without sound. Just such habitual
attitudes occur in soldiers under anesthesia. In hypnotic sleep,
although he trembled at his trench experiences, he did not assume these
defensive attitudes.

Mott states in his Lettsomian lectures that hearing is often absolutely
lost, but that sometimes a man is absolutely deaf on one side alone,
either from the ruptured drum or from the violence with which wax has
been driven against the drum. Mott speaks of the frequency of auditory
hallucinations, and of hyperacusis--part of the patient’s general
hypersensitivity--which may increase the violence of the neurosis and
especially aggravate the headache.


Shell-shock: Deaf-mutism; convulsions and dream.

=Case 263.= (MYERS, September, 1916.)

A private, 28, was seen by Lt. Col. Myers at a base hospital. This
deaf-mute wrote, “I was standing and a shell bursted and that is all
I can remember.” This might have happened six days previously. The
patient wrote vaguely about a walk to “windy corner”; about being
billeted in a dug-out, a train journey, and another hospital. He was
deaf, deficient in sensibility throughout, especially in the left arm
and left side of the face, and had severe headache. Two days later he
started distinctly when hands were clapped while he was writing, but at
the next hand-clapping there was no response.

After Lt. Col. Myers wrote down, “Imitate me,” and made consonant
sounds, the patient succeeded imitating them. “You hear me a little
now,” Lt. Col. Myers wrote. “Is this the first time you have spoken?”
Patient replied, “I hope the Lord I can get my speech.” “But you did
speak just now. Read this word. Say it.” Whereupon he was got to say
his name and number.

The therapy was proceeding properly when suddenly he was seized with
convulsions, limb movements chiefly clonic, back arched, eyes starting,
later upturned. The patient pulled out a crucifix from a locker near
the bed and regarded it ecstatically (pulse 85, corneal reflexes
preserved). Three minutes later there was quieting down, and the
patient was induced to talk. He began to talk about his wife. He had
just been “seeing a farm and all the fighting.” A shell must have come
in there. He had “seen the Lord Who saved him.” Intense headache and
thirst followed. According to the patient the excitement was due to
recovery of speech.

He later said, “It was just like a dream when I came to. I was sweating
awful. I was seeing the Lord while I was in the farm by the Captain. I
dreamed that I had the cross in my hand to meet him coming. I saw the
trenches and the dug-outs and the wife.” In point of fact, the Captain
at the farm had had his arm blown off, and he had found him lying on
the straw unconscious. Under hypnosis it appeared that he had gone to
a dugout from the farm and that at the clearing station he had been
“raving, seeing things, shells, trenches, and things like that, sir.” A
slow recovery was made after evacuation to England. Seven months later
he returned to the front.

    This case appears to belong to the B group of mutism cases,
    according to the classification of Myers, namely, to the group
    in which the effects are psychical rather than physical.
    According to Myers, whether mutism occurs as an apparent result
    of physicochemical or of mental causes--that is, as an A or a
    B case--it is _actually_ always the result of mental--that is,
    psycho-physiological shock. Mutism in the A cases of physical
    nature, where the shock must have been grosser and more
    profound, generally proves more severe than in the B cases.
    As to the appearance of unconsciousness, apparently confirmed
    by the patients’ statements that they “lost consciousness,”
    it is a question whether these cases are not really cases
    of deep stupor. According to Myers, the mutism is in nearly
    every instance closely dependent on some form of stupor, being
    generally the relic of such stupor after it has passed off.
    Let the loss of consciousness be a profound stupor due to
    the lifting or burial of the patient, then from this stage
    there will be a transition to a state of ordinary stupor in
    which intelligence is active but the patient is unresponsive
    to stimuli. The patient is in a condition called by Myers
    _excommunication_, in which the inhibitory process may be
    regarded as protecting the individual against further shock. As
    the stupor now passes away, it is natural that the inhibition
    should appear lost in the case of hearing and speech, which are
    two main channels of intercourse with others.

    Dumbness is, by far, the commonest disorder of speech,
    occurring in about ten per cent of shock cases in the first
    thousand cases of shell-shock seen by Lt. Col. Myers.
    Stuttering and jerky speech have occurred in about three per
    cent. Loss of voice is rarer.

    As against the view of Babinski, that mutism, being curable by
    suggestion, must have been produced by suggestion, Lt. Col.
    Myers argues that the stupor preceding mutism is the antithesis
    of suggestibility and is, in fact, a condition of extreme
    _autofixity_.


Naval gun-fire effects on seaman: Aphonia. Two recurrences.

=Case 264.= (BLÄSSIG, June, 1915.)

A seaman from the _Derfflinger_ was brought into a naval hospital with
loss of voice, December 22, 1914, able to speak only in a whisper. As
a child he had had diphtheria, but recovered without complication. He
had always had a very well-controlled voice. Early in December he had
had a cold owing to sentry deck duty in bad weather. Two days after
the shelling of Scarboro,--December 16,--while in the munition chamber
of the big guns, he suddenly lost his voice. He had been greatly upset
during the firing of the guns. In two weeks he recovered speech.

February 12, 1915, he returned to the hospital with a complete aphonia.
This was immediately after the naval engagement in the North Sea.
Three days later he was treated with electricity directly applied to
the vocal cords. March 20 he was discharged with speech completely
recovered. As soon as he went on leave, however, his voice was lost for
the third time, and he was still aphonic at time of report.


Shell-shock MUTES observed, then DREAMED OF: MUTISM developed the
SECOND NIGHT after shell explosion.

=Case 265.= (MANN, June, 1915.)

A volunteer of 20 was made unconscious for a short time by a shell
explosion, but was still fully able to speak when brought to the field
hospital.

In the second night after the explosion, however, he dreamed that
he had lost his speech. In the ward, meantime, he had seen a number
of shell-shock mutes. Following this dream of aphasia, came several
weeks of mutism, which then cleared up. According to Mann, this is
experimental proof of the psychogenic origin of a mutism.


Mortar explosion: Hysterical deafness.

=Case 266.= (LATTES and GORIA, March, 1917.)

A young soldier, a peasant, fell down unconscious when a mortar
exploded killing several men. He regained consciousness a few hours
later but was deaf on both sides. He looked dazed and did not
spontaneously move, having to be called for meals. Communicating by
writing, he could tell all the details of the accident.

The laryngeal and corneal reflexes were absent and there was a
hyperesthesia and hypalgesia of the right side of the body. No
anatomical basis for the deafness could be determined.


Shell explosion: Onomatopoeic noises in ears.

=Case 267.= (BALLET, 1914.)

A Zouave was with his squad at Tracy-les-Val Church, October, 1914,
when the roof was burst in by a shell which wounded four men. The
Zouave felt a strange emotion with trembling, and whistling in his
ears. However, he helped his comrades into a neighboring car. From
that time forward, he was very emotional, and felt noises in his ear,
sometimes humming, sometimes whistling. At Compiègne Hospital a lumbar
puncture was made, perhaps with a therapeutic purpose, but this gave
no results. The noises were heard as a whistling _pseeee_ followed by
a _boom_,--an onomatopoeia recalling the whistling and bursting of
the bomb. There was, in short, no labyrinthine lesion, but merely an
obsessive mental phenomenon. There were no ear lesions objectively. The
man developed a stuttering some time after the humming and whistling in
the ear.


Injury of eyes by gravel from shell-burst: Photophobia, blepharospasm,
facial anesthesia, pains.

=Case 268.= (GINESTOUS, January, 1916.)

A soldier of the Ninth Engineers, 28, a Beaux-Arts student, was
wounded, December 19, 1915, by stones and gravel thrown in his eyes
by a shell-burst. The eyelids swelled and the eyes filled with tears.
He was treated at the relief station and then evacuated to Verdun.
The edema disappeared in five weeks, but it was impossible for him to
look at light. February 2 he was evacuated to Nice, where he received
the diagnosis of traumatic keratalgia, blepharospasm, and photophobia.
After eight days’ leave he went back to his corps; but the eye troubles
persisted and he was sent to the ophthalmological center at Angers, May
18, 1915.

Both his father, 67, and his mother, 58, were irritable and odd. Three
brothers and three sisters were also more or less neuropathic, and one
of the sisters had been in a hospital for the insane with a persecutory
mania. The patient had a daughter, fourteen months, well.

The man was a nervous, impressionable person, who wept at the slightest
emotion. With an effort of will he could open his eyes, but if one
tried to open them passively there was stout resistance. In the dark
the occlusion was not so complete. Both eyelids were wrinkled and
folded and made jerky, fibrillary movements. The conjunctiva and cornea
were normal (fluorescein test), but the palpebral conjunctiva was red
and injected. The patient said he had subcutaneous pains recurring at
irregular intervals above and below the left orbit, brought out or
exaggerated by pressure; but such pressure had no effect upon the lid
movements. Visual acuity was normal, but the use of ophthalmometer
was impossible, as was measurement of the visual field. There seemed
to be no disorder of chromatic sense. The reflexes could not be fully
examined; knee-jerks preserved. There was a zone of anesthesia to pin
prick, less marked to heat, on the whole left side of the face. W. R.
negative.


Shell-shock; burial; blow on occiput: Blindness.

=Case 269.= (GREENLEES, February, 1916.)

A man in the third Wiltshire regiment was buried in a shell explosion
and struck by a large mass of earth on the back of the head. When dug
out, he was found blind. It was thought at the time that the severe
blow at the back of the head had “concussed” the occipital cells for
sight.

Some months later the man was sent to Mr. Pearson’s home for blind
soldiers in London; but two months later was returned to Weymouth,
under Greenlees’ charge. He thought himself worse, since now he could
not see light at all. He had trained himself to take care of himself
and steered confidently aside from obstacles in walking about. He was
able even to learn the various colors by the sense of touch, according
to Greenlees; thus, blue was diagnosticated against red: according to
the patient, a piece of colored card always had a rougher feel if it
was blue than if it was red. In fact, his work consisted of making
colored net bags.

As to the possible interpretation of such a case, see Case No. 433 (man
who could see large letters sometimes).

_Re_ blindness, H. Campbell states that the number of cases of
hysterical blindness appears to be decreasing as the war continues. The
blindness he finds to be rarely an absolute one. As a rule, the vision
is merely blurred or there is a contraction of the visual fields. The
condition is much less frequent than that of deafmutism.

_Re_ hysterical blindness, Dieufaloy is cited by Crouzon as describing
a triad of conditions characteristic of hysterical blindness, namely,
(_a_) sudden onset, (_b_) preservation of pupillary reflexes, and (_c_)
normal fundus.


Shell-shock amblyopia (composite data).

=Case 270.= (PARSONS, May, 1915.)

Parsons describes a typical case of shell explosion amblyopia. After
more or less prolonged fatigue from marching and trench exposure,
the soldier is knocked down or blown into the air, and more or less
severely injured or wounded by concussion, fracture, bullets, or shell
splinters, losing consciousness, but perhaps not enough to prevent
automatic walking in a dazed state to the dressing station. Memory of
this phase is lost. The man is instantaneously stricken blind, possibly
also deaf; and possibly smell and taste are also lost. Blepharospasm is
intense; there is lacrimation; the lids are opened with such difficulty
that examination of the eyes is almost impossible (nor, according to
Parsons, have the pupils yet been examined at this stage).

In a week or two the blepharospasm diminishes, and the fundi, which
are found to be absolutely normal, can be examined. The eyes may be
found to be quite normal, the pupils reactive to light though perhaps
sluggishly and perhaps unequally. Sight is now somewhat restored, light
can be perceived, and large objects distinguished. The patient can
grope about and usually does not stumble against obstacles. The fields
of vision are markedly contracted, and more so than the avoidance of
obstacles in walking would suggest.

Vision is eventually recovered completely. The right eye (the shooting
eye) is often more deeply affected and recovers more slowly. Perhaps a
central scotoma may persist. Sometimes on manipulation of lenses the
full vision can be produced for the types. Parsons seeks to explain the
psychology of traumatic amblyopia in the light of deductions of Lloyd
Morgan, Mark Baldwin and McDougall.


Shell-shock amblyopia (excitement, blinding flashes, fear, disgust,
fatigue).

=Case 271.= (PEMBERTON, May, 1915.)

Pemberton calls attention to the following factors in a case of
amblyopia: First, excitement during a prolonged and somewhat critical
attack; second, overstimulation of eyes and ears due to brilliant
flashes, night firing from many batteries close together (the gunners
are always subject to temporary deafness from this firing); third,
natural fear from close bursting of shells; fourth, disgust at
decapitated and disemboweled soldiers; fifth, fatigue from twelve
hours’ work.

The artillery sergeant worked under heavy shell fire at Gun No. 1. A
direct hit killed three men serving No. 2 gun. The sergeant became
somewhat excited but worked his gun until the following dawn, when he
collapsed across one of the disemboweled corpses. He thus had been at
work for about twelve hours. The battery had fired 400 or 500 rounds.

A few hours later, the man was conscious but very feeble and much
shaken. There was amblyopia and contraction of the fields of vision to
rough tests, but no change in color vision. Taste sense was blunted,
and salt could hardly be told from powdered quinin tablets. Smell
also was practically absent, although he had never been able to smell
accurately. Hearing was not more affected than that of other men in the
battery, and there were no tympanic fractures. Both thighs, from about
the apex of Scarpa’s triangle to the knee, showed partial anesthesia,
such that a pin prick that should have been painful was felt only as
a tactile sensation, whereas lighter stimulation caused no sensation
whatever. The patient himself complained of numbness in these areas.
The gait was slow and spastic. The knee-jerks were brisk. Sent back to
the wagon lines for a week, the patient lost his sensory disturbance,
but the symptoms of mental distress increased. He walked weakly and
stiffly; he continually thought of the dead men at the next gun, one of
whom was a friend. He was finally sent to a hospital in England.


Shell-shock amblyopia.

=Case 272.= (MYERS, February, 1915.)

A private, 20, lay in the booking-hall of a station, October 28-29, not
securing much sleep; motored in a bus next day to another place at 7.30
p.m.; went into billets at 8 p.m.; mounted guard 10-11.30 p.m. and 1.45
to 3.45 a.m.; and went to the firing-line for the first time at 11 a.m.
October 31. The platoon advanced through two sets of trenches, which
were full, and had to retire. About 1.30 p.m. they were found by the
German artillery.

This man had been rather enjoying it and was in the best of spirits
until the shells began to burst. The platoon was retiring over open
ground. He was kneeling on both knees, trying to creep under wire
entanglements, when two or three shells burst near by. Three more
shells burst behind and one in front. The escape was described
by an eye-witness as a miracle. He managed to get back under the
entanglements and into the trench, and shortly, as the fire slackened,
rejoined his company.

His sight had become blurred immediately after the shell burst. Opening
his eyes hurt him, and the eyes burned when closed. The right eye
“caught it” more than the left. At the same time, he was seized with
shivering, and cold sweat broke out, especially about the loins. He
thought the shell behind caused the greater shock, like a punch on the
head without pain. The shell that burst in front had cut his haversack
away, bruised his side, and burned his little finger. This shell he
thought caused his blindness.

He was led to the dressing station by two comrades, opening his eyes
to see where he was going but finding everything blurred except
immediately after opening his eyes. There was no diplopia. Objects
seemed to dissolve. He was weeping and worrying about becoming blind.
The horse ambulance took him to a hospital and thence to another
hospital, and thence he went by motor ambulance at night to the
starting point, where he arrived five days after he had entered the
field. He could remember nothing about the ambulance trips. There
was a slight deafness which soon passed off. In hospital he shivered
almost incessantly in bed, and he kept thinking about his experience
and the shell bursting. The shivering ceased November 3. No micturition
from the afternoon of October 30 until the afternoon of November 2. No
movements of bowels from October 30 to November 5.

It seems that this soldier had been for two months in the Aisne
district, sleeping badly on account of lumbar pains and toothache.
There had been albuminuria, and the patient said he had failed to pass
a medical examination. The fields of vision were found to be distinctly
contracted. There was difficulty in taste and smell, which the patient
said he had lost since the shell-burst.

Hypnosis was tried but the patient “insisted on resisting.” The
suggestions were offered during the concentration period. November 13
taste and smell began to return and the fields of vision were less
contracted. He was transferred to England for further treatment, and by
November 27 had become much improved and not so “nervy.” February 1 he
had begun to attend hospital as an out-patient.


SHELL WINDAGE (NO EXPLOSION): Multiple affection of cranial nerves.

=Case 273.= (PACHANTONI, April, 1917.)

August 22, 1914, a French officer was leading his company to an attack
and carried on, though wounded in the side by a bullet. Suddenly he
felt as if he had received a terrible blow with a hammer on the left
cheek and eye and as if his arm had been torn off. He fell to his knees
without losing consciousness. _There had been no explosion_, and none
of his soldiers had been hit. He felt of his arm and carried his hand
to his head to make sure of the wounds. There were none, but he was
bleeding from the nose and the mouth. His left eye was closed and his
left cheek drawn “by an invisible hand.” His tongue had swollen until
it had to be pushed out of his mouth. He was breathing hard. He fell
upon his side without losing consciousness and he was carried by his
men to shelter in a trench. Placed on his back he felt that he could
not lift his head as “it had become too heavy.” His voice was lost.
He could neither cough nor spit. In order to get air he had to remove
bloody saliva from his mouth with his finger. The left side of the
head was swollen. On opening his eyes he could no longer see with the
left eye. His cheek was covered with ecchymoses but without wound. A
few hours later he was made prisoner by the Germans. For two months he
had an increase of temperature every evening and for three months he
lost his voice. Six months later there was still visual impairment.
He was anesthetic in the left cheek, unable to chew, paralyzed in the
left facialis region. There was alteration of taste, with atrophy of
the left side of the tongue deviating to the paralyzed side, and nasal
regurgitation. There was continual drooling and convulsive coughing. In
dorsal decubitus the head could be lifted with difficulty. There was
a kind of paresis of the esophagus, as he felt the bolus stop at the
level of the third ribs so that with each mouthful he had to swallow
a little water. Apparently he had a paralytic state of the following
nerves: optic, oculomotor, trigeminal, glossopharyngeal, pneumogastric,
spinal accessory and hypoglossal. There was evidence of a slight old
tuberculosis at apices. The man was slightly pale. There was an atrophy
of the optic nerve and some retinal swelling. No pupillary reactions
to light on the left side; but the accommodation reflex and sensory
reaction were preserved. Divergent strabismus of the left eye. The
taste on the left side and on the anterior part of the tongue was
slightly diminished. Diminution of galvanic and faradic excitability on
the left side of the face. No reaction of degeneration. Bitter, salt
and sweet tastes altered. Left-sided atrophy of the tongue. No reaction
of degeneration in the tongue and thyroid muscles although there was a
marked diminution in faradic excitability.

The author records this case of multiple lesions of cranial nerves
as due to shell windage. Thirty-one months after the onset of the
paralysis the cranial nerves, although manifestly regenerated, had
not regained conductivity. The officer was examined by Pachantoni at
Louèche-les-Bains in Switzerland.

_Re_ windage, see remarks under Case 201.


Wound of thigh: Claudication, vasomotor disorder, hypothermia, but
no exaggeration of tendon reflexes. Under CHLOROFORM, ELECTIVE
EXAGGERATION OF REFLEXES, _i.e._, in this case, hyperreflexia of
affected thigh, including patellar clonus, after other reflexes
(including conjunctival) had become extinct. The case described led to
the new formula of THE PHYSIOPATHIC SYNDROME (BABINSKI).

=Case 274.= (BABINSKI AND FROMENT, 1917.)

Babinski examined in August, 1915, at the Pitié, a soldier who had
been wounded in the upper and outer part of the thigh. He showed a
most marked claudication with outward rotation of the foot. There was
a muscular atrophy of the thigh but no appreciable disorder of the
electrical reactions. There was a slight limitation in the movements of
the hip, namely, the movements of flexion and internal rotation of the
thigh upon the pelvis; yet this limitation of movements did not seem to
be in proportion to the rest of the motor disorder. The X-ray showed
no joint lesion. The right knee-jerk was a bit stronger than the left,
though this was controversial. Achilles reflexes were normal and equal;
epileptoid trepidation of the foot, and clonus of the patella absent;
the limb showed marked and permanent vasomotor disorders and local
hypothermia; both phenomena were of a sharp and definite nature.

On the basis of the intensity of these vasomotor disorders, Babinski
felt that, in accordance with his general ideas, he was not dealing
with hysteria, and that he was in fact dealing with the so-called
physiopathic syndrome. Lacking for this syndrome was the exaggeration
of the tendon reflexes of the affected limb. Might it not be that the
improper attitude and muscular stiffness of the limb were based simply
on retractions of tendons? The patient was chloroformed. This procedure
was the more warrantable as a number of physicians had thought of the
patient as an exaggerator or even as a simulator. Under chloroform
there was in fact a slight tendon retraction; yet on the whole it
was clear that the attitude and stiffness of the limb were largely
dependent upon a contracture. When during narcosis all the other tendon
reflexes and skin reflexes had become extinct, there was still to be
observed on the affected side a hyperreflexia, and even a clonus of
the patella; and the clonus lasted an hour after recovery from the
anesthetic. This curious phenomenon of elective exaggeration of tendon
reflexes in narcosis, Babinski has observed to be not infrequent.
It is a valuable diagnostic sign for a sure proof of excess tendon
reflexes in cases where doubt prevails under ordinary circumstances.
Sometimes the contracture will yield, but only in the deepest sleep,
outlasting even the conjunctival reflex and the reactions to pricking
of the normal extremities. Moreover, the contracture would return from
20 to 25 minutes before any manifestation of consciousness. If an
endeavor was made to reduce the contracture under full anesthesia and
in complete unconsciousness, a spasmodic movement was provoked which
exaggerated the abnormal attitude of the limb. Sometimes even the leg
would be thrown into flexor contracture.

The case above described was the one which led Babinski to his new
formula of the PHYSIOPATHIC SYNDROME. This he describes in general
terms as follows:

These disorders consist in post-traumatic contractures, paralyses
or paretic states, but are not attended by any of the signs of the
so-called organic diseases, either of lesions of the central nervous
system, or of the peripheral nervous system, or of the great arterial
systems. In fact, these disorders somewhat resemble hysterical
manifestations. The underlying lesions appear to be sometimes
extremely small; in fact, so minimal as to be out of proportion with
the functional disorders that they produce. These disorders do not
correspond with any known anatomical regions, but they are singularly
tenacious, and, unlike truly hysterical (pithiatic) phenomena, they
are completely resistant to suggestion. Yet it is not merely in
resistance to suggestive therapy that these reflex disorders differ
from hysteria; for besides the contracture and the paralysis or
paresis found in the different segments of the extremity concerned,
the complete Babinski syndrome includes also muscular atrophy,
exaggeration of tendon reflexes, alterations of skin reflexes (even
amounting to areflexia), hypotonia, mechanical over-excitability of
the muscles with retardation of the muscular contraction; quantitative
changes in electrical excitability of muscles (excess or diminution
without R. D.), mechanical over-excitability, and occasionally
electrical over-excitability of the nerves, disturbances in objective
and subjective sensibilities (anesthesia and pains), heat regulation
disorders (especially hyperthermia), and disorder of the vasomotors
(cyanosis, skin redness, oscillometric lowering at the periphery of the
extremity in the presence of low temperature), secretory disorders, and
various trophic disorders of the bony system, the skin, and the nails.

Despite the permutations and combinations of these symptoms, according
to Babinski they amount to a new group of disorders and represent a
nosological species: a species of disease phenomena that lies midway
between the organic affections and hysterical disorders. Babinski
proposes the term _physiopathic_ for these phenomena, a term which
excludes the connotation of hysteria and all forms of psychopathia, on
the one hand, and seems, on the other, to express the fact of their
correspondence to a physical material perturbation in the nervous
system of a novel sort.


Bullet wound of ankle: Contracture effect of chloroform.

=Case 275.= (BABINSKI AND FROMENT, 1917.)

A man was wounded, September 1, 1914, by a bullet in the left ankle.
Contracture of the foot and of the four outer toes in extension
followed, with a flaccid paralysis of the great toe. The left knee-jerk
was a little stronger than the right; the left Achilles jerk also
appeared weaker but observation was difficult on account of contracture
of the foot.

Chloroformed, October 22, 1915: There was no sharply defined
asymmetry of the tendon reflexes. The left Achilles reflex appeared a
little weaker. In the phase of muscular resolution, the contracture
disappeared entirely, but it reappeared a little after the return of
the tendon reflexes. The reappearance of the _contracture preceded_ the
reappearance of _consciousness_ from twenty to twenty-five minutes.


Post-typhoidal reflex or physiopathic disorder of right leg. Elective
exaggeration under chloroform.

=Case 276.= (BABINSKI AND FROMENT, 1917.)

A typhoid patient, October 20, 1914, showed phlebitis and abscess of
the right buttock with contracture of pelvic trochanteric muscles. He
was sent to the Pitié on medicolegal grounds.

September 22 there was found a slight laxity of the patella tendon, as
well marked on the left side as on the right. The right side was more
cyanotic, due to the inactivity of the limb. There was no edema. Tendon
and skin reflexes were normal. The lack of power was diagnosticated as
purely functional, and the report was rendered that the soldier could
begin to walk as soon as he desired. The two knee-jerks were noted to
be stronger and polykinetic, and the right knee-jerk appeared a little
stronger.

The patient was chloroformed, October 25, 1915. Almost immediately,
the knee-jerks, Achilles jerks, plantar, and cremasteric reflexes
disappeared. During the first period of anesthesia, there was no
accentuation of the reflexes, but at the beginning of recovery the
anticipated reappearance of the _right_ knee-jerk was observed. This
knee-jerk was already sharply defined at a moment when the left
knee-jerk was still abolished. In a later phase of recovery, the
right knee-jerk was very markedly exaggerated and a patellar clonus
was demonstrable on the right side. Even percussion of the _left_
patellar tendon brought about a contraction of the _right_ adductors.
There was a true clonic and tonic spasm of these muscles. On the other
hand, percussion of the right patellar tendon was able to provoke no
contraction of either right or left adductors. Nor was there at any
time any ankle clonus.


Hysterical lameness (bullet wound of calf) cured, but the associated
“reflex” disorder (in the sense of Babinski and Froment) NOT cured.

=Case 277.= (VINCENT, April, 1916.)

A corporal was wounded by a bullet in the calf, September 8, 1914. At
the end of July, 1915, his lameness continued and he disliked to lean
on his left leg which bent under him. There was a slight atrophy of
the left calf. The lower leg could not be extended upon the thigh if
the foot was in dorsal flexion, and the dorsal flexion of the foot
was itself limited. There were no reflex, vasomotor or electrical
disorders. The man was given the usual treatment by Vincent and soon
learned to carry his body on either foot, and, being well disposed,
speedily abandoned his lameness, acquiring such skill in movements that
he became monitor over the other soldiers, watching over them in his
capacity as corporal.

For about a year he thus served as monitor, and when fully dressed
did not seem abnormal or look as if he were walking lame. However,
after walking, say 6 kilometers, rapidly, he dragged his leg; nor
was extension of the lower leg upon the thigh absolutely complete in
habitual walking, though he was able to extend perfectly if requested.
Dorsal flexion of the foot was also still somewhat limited, and the
measurements of the two lower extremities at both calf and thigh showed
a persistent slight atrophy on the left side. He was then sent into the
auxiliary service and did good work as draughtsman. In the winter the
left foot got cold rather easily.

This case is instanced by Vincent to support the contentions of
Babinski and Froment that the truly “physiopathic” or “reflex”
disorders do not completely clear up in the recovery from the
associated hysterical disorders. That limb, which is the seat of
physiopathic disorder, is not in a state of meiopragia.


Foot trauma: Pains and dysbasia, hysterical; slight atrophy of calf,
physiopathic. Differential disappearance of hysterical symptoms;
increase of physiopathic symptoms.

=Case 278.= (VINCENT, April, 1917.)

Clovis Vincent examined a man who had been wounded in the foot but
without injury to the bones. He was first examined in July, 1915, when
he complained of foot pains and was walking with crutches. The left
calf was smaller than the right (4 cm.). The tendon reflexes were
normal. There was no abnormality of electrical reaction. There was
no proportionality between the trouble with walking and the organic
status. A large part of the trouble appeared to be hysterical. In fact,
upon treatment, the man was soon able to abandon the crutches and to
walk, though lamely. He was put into the auxiliary military service.

However, the pains grew more marked and the lameness increased.
Incapable of working, the patient was sent to the neurological center
at Montpellier, whence he came to the neurological center at Tours
in September, 1916. He had never been confined to bed, and had never
ceased his daily walking, aided by a cane. The walking disorder was
very pronounced. The patient said he was still suffering much. The
difference between the two calves was now 8 cm. and the thigh was
atrophied, though the atrophy had been absent in July, 1915. There was
hyperexcitability of leg muscles. The right foot was colder than the
left. The hysterical phenomena, so pronounced in July, 1915, were now
absent, yet the reflex phenomena were sufficient to invalid the man.


Shell-shock paraplegia may AFTER TWENTY MONTHS develop vasomotor and
secretory disorders: The whole to vanish on treatment.

=Case 279.= (ROUSSY, April, 1917.)

A foot chasseur, 22, a farmer in civil life, sustained shell-shock _à
distance_, June 2, 1915. He had no wound, but lost consciousness. He
was evacuated for “contusion of back” to a hospital June 4 to 12; for
“contusion of back and _commotio cerebri_” to Portarlier, to July 21;
for “internal contusions and _commotio cerebri_” to Besançon, where he
was in three hospitals up to May 31, 1916, and the diagnosis “hysteria,
old _commotio cerebri_ and trepidant astasia-abasia” was rendered and
psychotherapy tried. The man was then evacuated to Saint Ferréol and
the diagnosis “hysterical paraplegia” rendered. He finally reached
Veil-Picard in February, 1917, still victim of paraplegia.

Up to this point there had been no signs suggestive of organic lesion
of the spinal cord or any hysteroörganic intimation whatever. But in
February, 1917, besides the motor disorder there was a hypothermia of
several degrees, with cyanosis and hyperidrosis of both feet, with a
marked diminution (and absence on one side) of the plantar cutaneous
reflexes. The man was also victim of “hysterical pregnancy.” The
cyanosis, hypothermia and hyperidrosis lasted six weeks.

March 23 the man was given treatment and for the first time in 21
months was able to stand and walk. The foot now turned from blue to
red, and instead of cold became warm, even hot. In about a week the
hyperthermia diminished, and, with the other troubles, disappeared.
There remained only a slight swelling of the foot and ankle joints, due
to the painful exercises given the patient.

It would seem, then, that a hysterical paraplegia of long duration may
finally associate itself with marked vasomotor and secretory disorders
and that these may be altered with extreme rapidity on the very day in
which the hysterical phenomena are removed, and quite disappear in a
fortnight.


Tetanus clinically cured: Phenomena in part reproduced UNDER CHLOROFORM
ANESTHESIA five weeks afterward.

=Case 280.= (MONIER-VINARD, July, 1917.)

An infantryman, wounded at Notre Dame de Lorette, May 9, 1915, by a
shell fragment in the right popliteal space, was given a preventive
injection of 5 c.c. of antitetanic serum, evacuated to a hospital, May
12, and developed signs of tetanus August 1, with trismus and pains and
spasms in the right leg.

The disease progressed with dysphagia, stiffness and paroxysmal
hypertonia of the legs, especially of the right leg, fixed orthotonus
of the trunk, neck hyperextended, arms stiff but able to move.
Antitetanic serum was given daily. At the end of eight days there was a
marked improvement and the whole course ran to approximate recovery in
25 days from the onset of tetanic symptoms, at which time the man was
able to get up and walk on a crutch. The external popliteal nerve had
been sectioned, and the foot was in a marked equinovarus.

Chloroform was administered for the purpose of straightening the foot,
September 2, that is, about five weeks after the apparent end of the
tetanus. The first stage of the anesthesia lasted about two minutes,
but at this point the trunk and leg muscles passed into a state of
diffuse contracture. In fact, a _tetanic syndrome_ took place _in
the midst of the anesthesia_. At a time when the corneal reflex was
completely abolished, it was still impossible, with the exertion of
the greatest strength, to flex the segments of the lower extremities.
Moreover, the trunk was stiffly extended and the jaws were in trismus.
Tonic and clonic contractions were produced by the efforts made to
straighten the foot, and these contractions passed from the right
side to the left. The chloroform was now increased and a transient
resolution of the muscles was obtained, lasting hardly more than a half
minute. As all efforts to reduce the pedal deformity failed, anesthesia
was stopped. The contractures and paroxysms lasted a few minutes. The
knee-jerks were extremely exaggerated and there was a bilateral ankle
clonus. After a brief phase of excitement, the patient emerged from
anesthesia, began to talk with his comrades, and ate his usual meal
without inconvenience. The chloroform anesthesia had lasted twenty
minutes, and 60 grams had been administered.

It was now determined to section the tendo Achilles and the tibialis
posticus. September 8 the man was chloroformed again and the same
phenomena were exactly reproduced. Sixty grams of chloroform was again
administered. The tendon resections permitted placing the foot in the
proper attitude. Next day the patient was examined neurologically.
The skin reflexes were found normal. The Achilles and knee-jerks
were somewhat exaggerated, but equal on the two sides. There was
no ankle clonus. Sensations proved normal. There was a mechanical
hyperexcitability of the muscles of the anterior aspect of the thighs
and of the calf.

In another case chloroformed 17 months after recovery from tetanus
no such phenomena appeared. It would seem that the impregnation with
tetanic virus or toxin must last in the nervous system a good deal
longer than the apparent disease clinically lasts, but that this
belated and concealed intoxication eventually passes.

The phenomena are perhaps _analogous to_ those of _Babinski and
Froment’s_ so-called post-traumatic physiopathic or _reflex phenomena_.
It was following the special work of Babinski and Froment upon the use
of chloroform anesthesia in detecting physiopathic conditions that
Monier-Vinard made his observations in cases of tetanus.


Shell-shock from falling of shell at a distance: Hysterical hemiplegia,
terminating in brachial monoplegia. Case to show that the reflex or
physiopathic disorders of Babinski and Froment may occur without
mechanical injury in the region involved.

=Case 281.= (FERRAND, June, 1917.)

A soldier of the class of 1917 who never went to the front, while
in training at Belfort, felt violent emotion on the occasion of
the falling of a big shell in the town of Belfort. The explosion
was a good distance from him. He lost consciousness a few moments,
February 23, 1917, and almost at once found himself unable to move
his left side. He was hemiplegic three months, but his leg shortly
regained power. December 23 he entered a neurological center with his
arm flaccid and a paralysis affecting the shoulder also. There was
an almost complete anesthesia of the arm terminating in segmentary
fashion about the shoulder, and the whole of the left side was slightly
hypesthetic, although there was no disorder of motion except in the
arm. The tendon reflexes of the left arm were exaggerated, and there
was even contracture upon percussion of the muscles themselves.
Percussion of the thenar and hypothenar eminences produced movements
of the hand. There were several vasomotor disorders. Percussion
led to large vasomotor plaques, and rubbing of the skin produced a
reddening which passed away slowly. The hand was red and cold. Slight
electrical hyperexcitability of flexors with feeble galvanic current;
excitation of the extensors not associated with any contractions of the
antagonist muscles. Threshold lower for flexors on the affected side
in the forearm. Half centimeter atrophy of the biceps. The forearm and
hand were possibly slightly increased in volume from a blue edema of
the dorsal surfaces. The man was very timid, complained little, and
accepted all treatment, which, however, was not very effective. This is
presented by Ferrand as a case with physiopathic disorder in the sense
of Babinski and Froment, though it does not present any sign of organic
lesion whatever.


Shell fire: Delayed shell-shock symptoms, sub-lethal, appearing in
England.

=Case 282.= (MCWALTER, April, 1916.)

A soldier was picked up insensible in the public street and brought
to hospital by ambulance, unconscious, breathing stertorously, pupils
dilated, lips parched, unresponsive to stimuli, but without signs of
injury or alcoholism.

The pulse grew slower, the respirations more sighing, the heart-beat
more diffused and labored; but towards evening, about eight hours
after admission, he began to move the eyelids and lips, and muttered a
response to the request for his name. After ten more hours, respiration
grew better, and Croton oil led to a movement of the bowels. Natural
sleep intervened, and 18 hours after the onset of unconsciousness, the
man woke up, and in the course of a few days became fairly well though
still dazed and confused.

This soldier had never received any definite injury in his war service,
but McWalter attributes his break-down to the effects of the constant
shocks from the bursting of shells, and the scattering of shrapnel.

McWalter generalizes that a soldier, in the course of some civil
occupation _after_ the war, might develop symptoms, even fatal
symptoms, and still the death in the case would be a direct consequence
of the war.


Shell-shock symptoms, some initial, with recovery--others late and
gradual, with deterioration.

=Case 283.= (SMYLY, April, 1917.)

A soldier became blind, deaf and dumb, as well as paralyzed, as a
result of shell explosion. When he arrived at the hospital, he was
able to see but had visual hallucinations. In a few days he recovered
his hearing. There was a fine tremor of the hands, controllable by
suggestion. There was an almost complete amnesia, but the patient
remained able to read and write.

The pain persisted several months. The patient was physically well
and seemed perfectly intelligent despite his aphasia and amnesia.
One night, he sprang out of bed, shouting, “The guns are coming over
us!” and from that time forward was able to speak. Amnesia, however,
supervened for the months in the Dublin Hospital, and the patient
believed that he was still in France. He also became unable to read or
write, and was unable to recognize any letters except those he had been
taught to speak during his period of dumbness. Still later he got a
flaccid paralysis of the legs. From seeming perfectly intelligent, he
began to seem markedly deteriorated. Hypnosis with waking suggestions
had no power upon him. After a time, intelligence reappeared, but there
had not been any recovery of locomotion at the time of report.


Wounds, gas, burial: Collapse on home leave.

=Case 284.= (E. SMITH, June, 1916.)

A non-commissioned officer went through the first eleven months of the
war in France and Flanders and was subjected to every kind of strain
therein. He was wounded twice, gassed twice, and buried under a house,
in each instance being treated in the field ambulance and returning to
the trenches. Some time thereafter he was granted five days’ leave.

On reaching home, while waiting for a train, the officer suddenly
collapsed and became unconscious. For months thereafter, he was the
subject of a severe neurasthenia; “the whole of his trouble seemed
to be due to the dread, lest on his return to the front, the added
responsibilities which would fall upon his shoulders might be too
much for him.” He thought his intelligence had been numbed by his
experience. He thought his memory was unreliable, and that he could
understand neither complex orders nor even the newspapers.

As to the reason for his maintenance of composure at the front, this
may be laid to the excitement, the officer’s sense of responsibility,
and the example he felt he should set his men. This kind of case
“demands a great deal of patient and sympathetic attention before the
real cause is elicited, and then months of daily reëducation to build
up anew the man’s confidence in himself.”


Bullet wound of neck: Late sympathetic nerve effect.

=Case 285.= (TUBBY, January, 1915.)

A Belgian was wounded, October 21, 1914, at Dixmude. The bullet
wound was just below the right mastoid process. He was admitted to
the London General Hospital, October 29. He said that the bullet had
passed into the tonsil, lodging there, but that on the third day, while
vomiting, he brought up the tonsil with the bullet in it. There was in
fact a large ragged wound at the site of the right tonsil. He could
swallow fluids only, but articulated clearly. There was a question
of injury to the following nerves: facial, glossopharyngeal, vagus,
hypoglossal, spinal accessory, and sympathetic. None of these nerves,
however, appeared actually to have been injured. The difficulty in
swallowing was due probably to the faucial wound, and it is hard to
see how the pharynx could have been involved on account of the perfect
articulation. November 3 the right sympathetic nerve was slightly
affected; the right pupil was smaller than the left although it reacted
to light. November 12 the patient left the hospital and nothing
further is known of his history. Thus there was a late effect upon the
sympathetic nerve thirteen days after the wound.

_Re_ peripheral nerve disorders, see remarks under Case 252 (Tubby).


Fall from horse under shell fire: Crural monoplegia, hysterical.
Reminiscence? Autosuggestion?

=Case 286.= (FORSYTH, December, 1915.)

A patient of Forsyth had been exercising a high-spirited horse.
Artillery fire close by made the horse leap sidewise, and the rider
fell, his back striking the ground. He seemed to be curiously shaken
out of proportion to the gravity of the fall. In a day or so, he lost
the use of one leg.

He recalled a rather similar incident: He had taken a hand in a local
uprising in a distant quarter of the world. While he was escaping up
a mountain track, a rifle-shot from the enemy brought down his horse,
which rolled over and threw him violently against a boulder, where the
small of the back met the force of the impact. He felt intense pain and
lost consciousness. Upon recovery he found he was paralyzed. At the
end of several days, in a hiding-place in the rocks, he found himself
still unable to move his legs. The friend who had carried him to the
hiding-place refused to leave him. He thought of suicide, but then
discovered that he could move: at first, the big toes, then the ankles,
then the knees, and finally the hips. He was finally able to get into
the saddle.

Moreover, years before, he had heard that a man who broke his back was
paralyzed in the legs.

_Re_ autosuggestion, Babinski remarks that suggestion may work
in hystero-organic cases not precisely as in hysterical cases.
Autosuggestion may here replace or accompany the ordinary
heterosuggestion. Some temporary disturbance--a slight pain, a
trivial injury, or a mere bruise--may start up a complex process of
autosuggestion in which it may be difficult to unravel the part played
by the patient’s own reflexes, his previous experience and beliefs (in
this case, the reminiscences of a similar accident), the solicitude of
his friends, and the medical examination itself. Babinski believes that
hysterical paraplegia or monoplegia never appears automatically under
the influence of emotion; never appears after the manner of sweating,
diarrhea, or blushing.


Shell explosion; struck in cave-in: Symptoms in right leg (antebellum
experience).

=Case 287.= (MYERS, March, 1916.)

A private, 26 years old, had 11 months’ service and one month’s service
in France. He arrived at a base hospital the day after his shock.
Concussion had caused the dug-out in which he was standing to collapse.
A beam struck him on the left side of the face, and pinned him to the
ground on his right side. A piece of iron fell on the left side of
his back, and his right leg was pinned by a cross beam on the back of
his thigh. He was dazed by the shock; was released and was able to
walk, but complained of a pain in the right groin and a giving-way
of the right knee. The medical officer arrived about an hour later.
A numbness, or state of no feeling, in the right thigh appeared, and
increased to the point of total analgesia to the level of the upper
margin of the patella save for a narrow strip in the mid-line on the
posterior aspect of the leg. The only area of complete anesthesia and
algesia was on the outside of the lower half of the leg.

According to the patient, it seems that about three years before, he
had been buried four feet deep in a brick yard, beneath a heap of
clay. He had felt it most in the right leg, but the thigh had been
merely stiff and sore, and not numb. The patient admitted that the
present accident immediately reminded him of his previous experience.
There were no tremors or sensory disorders in the face, arms, chest,
back, or abdomen. There was diminished sensibility to cotton wool of
the left buttock (across which a plank had fallen), and there was a
degree of hypalgesia of the buttock. The right thigh showed a degree
of thermanalgesia and slight loss of vibratory sense. The corneal
and conjunctival reflexes were diminished, and the knee-jerk was
unobtainable on the right side. Three days later, there was a marked
improvement with almost complete return to normal, whereupon the
patient was sent to a convalescent camp.


Emotional subject, ALWAYS WEAK IN LEGS; shell explosion; wound of back:
PARAPARESIS.

=Case 288.= (DEJERINE, February, 1915.)

A Lieutenant, 25, was wounded at Arras about 10 a.m. October 20, 1914,
just as he was leaning on another officer’s shoulder looking at a card
in a chateau room. A shell burst in the court yard. A fragment came in
the window, struck him in the back and pushed him forward, whereupon
he felt pain in the back and a severe dyspnea, due to the gas from the
shell. He lost consciousness several times and the dyspnea lasted for
about two hours. When he was picked up he could not walk.

He was carried on a stretcher to the ambulance at Avin-le-Compte.
During the fortnight there, he was also several times dyspneic.
Strength left his legs and he could only get about on crutches. There
was now a suppurating wound in the interscapular region where he had
been struck by the shell fragment. Evacuated to Paris, he was operated
upon on account of a tremendous abscess in the back, and the shell
fragment and some bits of cloth were removed. The wound healed; but
vague pains in the left thorax remained, especially when the man walked.

On examination, July 28, 1915, he would in the standing position hold
his legs together with the feet resting on their external borders,
especially on the left side. The toes were in plantar flexion, and
the soles were arched upward more on the left side than on the right.
In walking, the legs were always held in extension, the feet twisting
outward. If an attempt was made to walk quickly, the man walked more
and more upon the external borders of his feet, in such wise that the
plantar surface and the heel turned up and became visible from above.
He would get tired after five minutes’ walking even if he spread his
legs out for a broader base of action. He could lift his legs only
about 10 cm. from the bed, but could flex and slowly extend his lower
leg on the thigh. He could not adduct or abduct the feet. Movements
of extension and flexion of leg on thigh were jerky and abruptly
terminated, as also movements of thigh on hip. The patient could not
sit, and when leaning forward he could not straighten up against
resistance. The reflexes were normal. There was no sensory disorder.
The electric reactions were normal. Pupils normal. There was slight
hypertension of the spinal fluid and a slight excess of albumin. There
were no lymphocytes.

In accordance with Dejerine’s idea that these neuropaths always have
antecedents looking in the same direction, it was found that he had
always been an emotional person, easily affected, sympathetic with
other people’s troubles, given to weeping. As Lieutenant, he had not
had the courage to harangue his soldiers. He had often during his life
felt his legs weaken during times of emotion and had sometimes been
unable to walk, though nothing of the sort had happened during the
campaign. He was sure he could get well, and wanted two months’ leave
in order to get back to the front. There were no hereditary features
in the case. A physician had told him that he had had meningitis. This
possibly followed whooping cough. He had had orchitis after mumps at
16. He had not had children, nor had there been miscarriages since
marriage at 21.


Wound near heart; delayed medical care; fear of having been shot
through heart: Paraparesis (antebellum always “hit in the legs.”)

=Case 289.= (DEJERINE, February, 1915.)

An infantryman, 20, was sent as a Colonel’s bicyclist about 1 p.m.
September 30, 1914, with a message to one of the battalions. He was
exposed on the way to shell and rifle fire, and was wounded by a bullet
which entered 8 cm. below and internal to the left mammillary line and
came out in the region of the left hypochondrium. He crawled to some
village houses 20 or 25 meters away. Another cyclist came to transfer
the order, but could not help him. A friend came to his aid but was
struck by a bullet 10 meters off and remained on the ground for an
hour while the young cyclist lay behind a tree on the roadside. At 3
o’clock it was possible to take him to a house around which shells were
raining. Shortly afterward the house caught fire. The man was evacuated
6 kilometers to an ambulance in the night, and that night six of his
wounded comrades died in the same room. The man had lost much blood
and began to think that his heart had been hit. He choked, had violent
palpitations, and intense thirst. By automobile next day he was taken
to the railway station at Maison and was there for a day practically
without food.

That evening, 36 hours after the wound, he was evacuated to Juivisez
and stayed there one night in the temporary hospital. The hemorrhage
had now practically ceased. When he arrived next morning at Vincennes
he could hardly move, was unable to walk, had violent palpitation,
precordial pain, and two nervous seizures, with outcries and weeping.
Several days later he could not walk at all or raise himself in bed. He
was operated on May 29; he afterward felt the same leg weakness and was
still unable to walk. Early in December, when observed by Dejerine, he
was able to stand on crutches with legs flexed, toes on the ground, and
heels up. In walking he would scrape the ground with the dorsum of the
foot. The wound was now healed. Suppuration had been intense and the
scars were extensive. Lying down, the man could move, though slowly,
his lower extremities in every way, nor was there any diminution in the
strength of his flexors and extensors. The patient in making movements
against resistance would let go quickly and jerkily. The plantar
reflexes were flexor but weak. There was no other reflex disorder, no
evidence of sensory disorder, nor any sign of neuritis or arthritis.
Lumbar puncture gave a normal fluid without tension.

There were no hereditary features in the case. The man had been in
childhood nervous and irascible, rolling on the ground, crying and
weeping when crossed. He had had three attacks of appendicitis--one at
15 years and two at 19 years. After each attack he had felt weakness in
the legs. He remembered, too, that after his nervous crises on being
crossed, he had always felt this same weakness.

According to Dejerine, these paraplegic neuropaths, like functional
gastropaths, cardiopaths, and victims of urinary disorder, have had
earlier spells of the same kind, though milder than the attack which
brings them to medical notice.


Wounds: Tic on attempts to walk; tremors. Recovery except for frontalis
tic (ANTEBELLUM HABIT emphasized).

=Case 290.= (WESTPHAL AND HÜBNER, April, 1915.)

A substitute officer (mother nervous; always slightly excitable, easily
fatiguable; had had a habit of wrinkling his forehead) sustained wounds
September 8, 1914, in the foot and thigh. The wounds healed well, but
in the hospital he slept badly and had battle dreams. When he essayed
to walk, he had contractions of face muscles. There was a lively tic
involving both face and neck muscles, with the head pulled to one side
and backward. This grimacing was but slightly influencible by the will.
There was a marked tremor of the arms. Gait was _trippelnd_. There were
tremors of the whole body. There was also a slight hemi-hyperesthesia.
The tendon reflexes were very lively; vasomotor disorders (feelings of
cold and perspiration).

Seven months later the phenomena had all disappeared except for slight
tic-like frontalis contractions.

_Re_ heredity and soil, Mairet investigated 22 cases of Shell-shock,
and found a hereditary taint in eight, and an acquired predisposition
in nine. He found hereditary taint definitely absent in seven, and
acquired soil definitely absent in six; whereas the rest of the cases
were doubtful. He found both the taint and the soil in five cases; two
cases with hereditary taint alone; no case acquired, non-hereditary.

In eight cases with head trauma, Mairet found three with hereditary
taint, four without such; against one with an acquired predisposition,
four without such, others doubtful.

_Re_ cases of somatic trauma (not affecting the head), among five
examined, there were none with hereditary taint, three definitely
without taint, and five definitely without predisposition. According
to Babinski, neither hereditary taint nor prepared _terrain_ needs be
found in hysterics.

A predisposition is not thought important by Oppenheim, especially as
so many normal persons are predisposed.


War strain (fatigue, emotion): Hysterical hemiplegia. Precisely similar
hemiplegia ANTEBELLUM.

=Case 291.= (ROUSSY AND LHERMITTE, 1917.)

A sergeant in a regiment of cuirassiers was observed at Villejuif,
January 25, 1915. He had lost power on the left side as a result of
fatigue and emotion, November, 1914. He had a complete paralysis of
the left arm and a paresis of the left leg. There was an anesthesia
of hysterical type in the left arm, and also of the left leg as far
as the middle of the thigh. He dragged his leg in walking (_démarche
en draguant_: the toe is dragged along the ground, the trunk is bent
forward, and at every step plunges somewhat toward the paralyzed side.
The patient is able to walk, however, by means of a cane or crutches.
This walk is characteristic of hysterical hemiplegia. According to
Roussy and Lhermitte, the number of cases of hysterical hemiplegia
(better, hemiparesis) is not large). The plantar reflexes on both sides
were those of flexion. Upon treatment (not specified), at the end of
six months he went back to service in the cavalry.

The point of note in this case is that this patient had had a precisely
similar phenomenon on the same side, which lasted a month, at the age
of sixteen years and a half. It is noteworthy that in this case there
was no traumatism and only the factors of fatigue and emotion to serve
as an occasion for the hemiplegia. In fact, hysterical hemiplegia is
said very rarely to follow physical trauma to an extremity. There are,
however, some cases in which hemiparesis follows a slight head wound,
particularly if over the region controlling the paralyzed limbs.

During the six-months’ course of successful treatment, no atrophy of
limbs appeared, and there was never any inequality of the reflexes.


A good soldier (son of a tabetic sometimes hemiplegic), at 17 victim of
hysterical hemiplegia, has AT 24 A RECURRENCE after two months’ field
service. “Functional excommunication” of left arm and leg.

=Case 292.= (DUPRÉS AND RIST, November, 1914.)

A cuirassier, 24, one month in the field, began to feel in September,
1914, crawling sensations in left arm and leg; then fingers, later hand
and forearm, and finally upper arm began to work awkwardly and feel
heavy, and there was a little of the same sort of thing in the leg.
Hand and forearm were by the middle of October completely paralyzed,
whereas the arm and shoulder were only paretic. Anesthesia at this
time reached the elbow. The man had to be evacuated, after two months’
active and skilful field service, in one instance (September 19)
carrying out a clever and useful interception of hostile telephone
messages.

It seems that at the age of 17 also the man had had a left-sided
hemiplegia, with sensory and motor symptoms, lasting two months, cured
by electricity applied with a small electrode in his village. The
war situation was therefore actually a recurrence of the transient
hysterical paraplegia.

Moreover, the patient’s father, 52, an old tabetic, had also several
times shown a hemiplegia (however on the right side), a phenomenon
which had strongly affected his son.

It was curious that the slight residuals of movement which the
cuirassier could perform could be made only while he was looking at the
parts he was requested to move, and were impossible with eyes closed.
The anesthesia was a total one when observed in November, 1914, coming
to a sharp and circular termination at the shoulder and garter-wise
above the knee--tuning fork insensibility in the same areas. The left
patellar reflex was diminished when the eyes of the patient were
leveled at the knee; but a surprise test brought the knee-jerk out
normally. The hand and fingers were a little darker in color, and the
whole left arm a little colder than the right. There was also a slight
amblyopia on the left side.

This hysterical paraplegia proved rather resistant to psychotherapy.
The patient seems to have systematically eliminated from consciousness
and from action the entire function of the left arm and a good deal of
the left leg. Duprés and Rist speak of this as a kind of functional
excommunication of the parts.

_Re_ relapses, Wiltshire remarks that the frequency of relapses and the
ways in which they are produced favor the conception that the original
cause of Shell-shock must be psychic. Sir George Savage remarks that
cases of Shell-shock should not return to the service under a period of
six months on account of the frequency of relapse. Others have recently
argued that such cases should not be sent back to the front at all.
Harris notes that relapse may follow so apparently slight a factor as a
vivid dream. Remarks concerning the true nature of relapses are made by
Russell. Russell, for example, disapproves anesthetics in curing such
a hysterical phenomenon as deafmutism. This sort of treatment does not
get at the real cause of the condition, so that the man is very liable
to relapse with the same symptoms. Ballet and de Fursac note the many
cases of relapse after treatment and after discharge. Sometimes the
relapses were due to some unfortunate happening, but in other instances
no external cause could be made out. Fear of having to return to the
front is a factor in certain cases, so that the true answer to the
relapse question may not come until after the war.

Roussy and Boisseau insist upon the value of rapid cures
(psychotherapy, electricity, cold shower, etc.), in diminishing the
number of relapses. They maintain that these rapid cures abolish any
chance for the man to brood over symptoms and thus to exaggerate and
fixate them. These workers send their hospital return back to the
regiments with a statement relative to diagnosis and the request that
he be immediately returned to hospital if neurotic symptoms appear.


War strain; burial: Deafmutism. ANTEBELLUM speech difficulty.

=Case 293.= (MACCURDY, July, 1917.)

A private 20 (always rather tenderhearted, disliking to see animals
killed; rather self-conscious; a bit seclusive; “rather more virtuous
than his companions”; shy with girls; sore throat a year or more before
the war, with inability to sing or talk; always a lisper) enlisted
in May, 1916, spent five advantageous months in training and became
increasingly sociable. However, on going to the front October, 1916,
he was frightened by the first shell fire and horrorstricken by the
sight of wounds and death. He grew accustomed to the horrors and five
months later was sent to Armentières, where he had to fight for three
days without sleep. He grew very tired and began to hope that he would
receive wounds that might incapacitate him at least temporarily for
service.

He was suddenly buried by a shell, did not lose consciousness, but on
being dug out was found to be deaf and dumb. On the way to the field
dressing station he had a fear of shells. The deafmutism persisted
unchanged for a month and then was completely and permanently cured in
less than five minutes. He was made to face a mirror and observe the
start he gave when hands were clapped behind him. He was assured that
this start was an evidence of hearing; that his hearing was not lost,
nor was his speech. He had no relapses during two months.

According to MacCurdy, this case is a typical one of war neurosis of
the type of a simple conversion hysteria. The man never suffered from
anxiety or nightmares.

_Re_ burial cases, Grasset suggests that some of the patients probably
think that they have actually died; both sensation and motion have been
lost, and it is naturally these that permit a man to believe that he is
still alive. The classical case is recalled, of the almost absolutely
anesthetic boy who, with eyes closed, at once fell asleep. Foucault’s
patient also said he actually thought he was dead after an explosion.


War strain: Shell-shock and psychotic symptoms, with determination to
parts injured ANTEBELLUM.

=Case 294.= (ZANGER, July, 1915.)

Several years before the war, a cavalry officer had a severe concussion
of the brain after a fall from his horse, but got no manifest symptoms
therefrom except a mild transient deafness. There must have been a
vestibular nerve injury, however, since there was a marked bilateral
subexcitability of this apparatus later determined.

In September, 1914, as the result of strains and privation in the
field, he got vertigo and lachrymose spells, with some obsessions as
though he would have to shoot himself in the foot or spring out at the
enemy from the trench.

In hospital at Jena, insomnia, anxiety, excessive perspiration and
salivation, feelings of the death of various parts of the body,
especially the forearms and hands, associated with hypesthesia of the
parts, were determined. He had a feeling of vertigo on walking and
was very sensitive to noise. He now developed a very intense and very
variable degree of deafness on both sides, diagnosticated as nervous
deafness. The caloric test demonstrated vestibular subexcitability
above mentioned. We may suppose that in this already injured organism
fresh disorder had set in on a psychogenic basis in the same region
that had been injured years before.


Mine explosion; emotion at death of comrades: Unconsciousness eight
days with hallucinatory delirium; later, dizziness. History of previous
trauma to head with unconsciousness and dizziness.

=Case 295.= (LATTES AND GORIA, March, 1917.)

Sent at end of May to the front, an Italian soldier (Class 1895,
laundryman) was placed in an advanced post where he at once sustained
great hardships.

Father drunkard, mother healthy, sister nervous. Two brothers healthy,
one brother died of tuberculosis. Patient had scrofula, scarlet fever,
and bronchitis (tendency to rave intensely when in fever). At four,
sustained a trauma on the head (skull depression), dizziness, loss of
consciousness.

June 7, a mine exploded in his vicinity, smashing several of his
comrades. He did not himself fall to the ground, but was overwhelmed by
a violent feeling of anguish. After a while, he lost consciousness. He
woke up at Bologna, June 15, as after a long sleep. During the interval
he had been in a state of intense hallucinatory delirium day and night.
Then his mind began gradually to clear, first with amnesia of the shock
which had caused the trauma. Then he recalled this fact too. Dizziness,
however, grew in intensity so that he fell to ground many times during
the day. There were intermittent tremors in the limbs.

Under observation, August 7, a sturdy, robust man. Somewhat dull in
demeanor. Senses intact. Cranial nerves negative. Tendon and skin
reflexes lively, especially on the right. Memory intact, except for
above-mentioned oniric delirium with restlessness and shouting at
night, especially while falling asleep and waking up. Frequent intense
dizziness.

The condition remained unchanged for a week. Patient transferred to
another department, for acute catarrhal bronchitis with fever.


Sniper stricken blind in shooting eye.

=Case 296.= (EDER, March, 1916.)

An Australian, 19, was admitted to hospital for loss of sight in the
right eye. There had been a _right ptosis_ from childhood. January 7
nothing could be perceived but light.

According to the patient, he was sniping through a loop-hole, November
15, when a bullet knocked a piece from the stock of his rifle. He
continued at his post. There were five more shots, when another bullet
struck the sand around the loop-hole. His right eye began to water.
He shut the loop-hole and retired for an hour. His eye improved, he
returned, opened the loop-hole, braced the rifle, and found he could
not see the sights. He went to the physician. Vision grew rapidly
worse, and in a few hours perception of light failed. He had been
stricken blind in the shooting eye (the seat of a congenital deformity).


Anticipation of warfare: Hysterical blindness.

=Case 297.= (FORSYTH, December, 1915.)

Anticipation of warfare may provoke a neurosis as in a case of
Forsyth’s. The man went blind training in England.

It seems that four months before, while mounting sentry at night,
marauding gypsies had felled him by a blow on the head from behind. He
had returned to duty after a day or two and was now expecting to be
moved to France. He said that while sitting with a friend, he began
to feel giddy, turned a somersault, and fell unconscious; and that on
coming to, his mind was clear but everything was dark. For ten days he
had been blind, although once he could see his parents, who visited him
in hospital, almost clearly. His appearance under examination strongly
recalled that of a blind man. He was induced to read some large print,
then smaller print, and finally very small print. He then lapsed into
blindness.

He remembered that before enlisting, he had trained in a smithy, and
heard that blacksmiths often went blind at the forge.


Bareback riding: Spasmodic neurosis (similar ANTEBELLUM episode).

=Case 298.= (SCHUSTER, December, 1914.)

A soldier, 32, had to do a long stretch of riding bareback. As a
result, he later suffered from tonic muscular spasms whenever he had
to exert himself seriously, especially whenever he had to move his
legs and when sudden movements or sudden strong contacts were made.
The attack appeared to be reflexly dependent on the pain. The case is
regarded as one of the Wernicke _Crampusneurosen_, a disease somewhat
related with hysteria.

A condition somewhat like the one developed in the war had occurred in
this man at the age of seventeen after a drenching, but the attack was
at that time much milder. He had, however, frequently had cramps in his
legs.


ANTEBELLUM spasm of hands, functional.

=Case 299.= (HEWAT, March, 1917.)

A boy, 19, had been passed as fit for laboring work at home. He had
been a farm boy from 14. Once at 17 he had developed whilst working
amongst turnips in wet weather, pain in the hands, which got worse and
was followed by pains in legs, arm, and neck, that kept him in bed a
week, and from work ten days. Even on returning to work, his hands were
swollen, though he was able to drive a horse. The fingers had been
somewhat firmly flexed on the palms ever since this illness at 17.

He was sent to Netley after three weeks of army work, as having a
spasm of both hands. He was found to be mentally below par, nervous,
apprehensive, stuttering in speech and not readily responsive, with
defective vasomotor control, though of good average bodily development
except for asymmetry of chest.

Both hands were found firmly closed; tips of fingers applied to palms;
thumbs freely movable; forearms well developed, especially the flexors.
Counterforce was exerted upon passive extension of fingers. There was
no sensory or reflex disorder, and while the patient was asleep, it was
found that the first and second fingers of both hands could be fully
extended. Yet there was a definite contracture of the palmar fascia
which prevented full extension of the third and fourth fingers. He was
awakened by this test and the fingers became firmly flexed at once.

The man was treated by milk isolation behind screens, without
permission to read, smoke, or talk. Twice a day he was encouraged to
move the fingers and made to perform finger exercises. He became able
to extend the fingers over half their normal excursion in three days,
and was then able to abduct and adduct the fingers. He was allowed up
in two weeks’ time, with full diet and screens removed. The contracture
of the palmar fascia was still in evidence, but the power of movement
in the hands and fingers was so satisfactory that he could be sent back
to duty in three weeks. The interpretation of Fergus Hewat is that the
painful condition of the hands which set in in the illness at the age
of 17, had caused an obsession which had developed into a functional
spasm of the hands.


Quarrel: Hysterical HEMICHOREA, DOUBLY REMINISCENT, of a former
hysterical chorea, itself related with an organic chorea of the
patient’s mother.

=Case 300.= (DUPUOY, October, 1915.)

A nineteen year old soldier, for some months a bit distressed and
irritable, had a dispute with an old man whose jug he unluckily
happened to smash. The old man said something was going to happen to
him for that. That day, in point of fact, he fell and sustained an
injury with water on the right knee. He was upbraided by the captain
and evacuated to the ambulance. The fellow thought the old man with the
broken jug had interfered, dreamed of the old man’s threats, and felt
his hand on his shoulder.

Next day hemichorea developed on the right side, a partial and rhythmic
chorea with jerky, regular contractions, fifty to sixty per minute,
affecting synchronously the muscles of the leg, arm, face and tongue.

Dupuoy speaks of the reason for the hysterical “choice” of this
disease, since his mother had had a probably organic hemichorea, also
on the right side, with which she died at thirty years in a stroke. The
boy was at that time thirteen years old and had had a rhythmic chorea
six weeks, limited to the extensors of the hand on the forearm, treated
in hospital.

This new hemichorea was quickly and completely cured by psychotherapy.


Hallucinations and delusions in a soldier, of antebellum origin.
Treatment by explanation of causes.

=Case 301.= (ROWS, March, 1916.)

A private, 31,--a case of Capt. W. Brown,--was admitted to hospital
suffering from hallucinations of hearing and delusions of supervision
by his family and friends; he heard his relatives telling him what to
do and what not to do. He thought they belonged to a secret police
entrusted with the task of supervising his actions and seeing that
he did not again transgress as he had done. An inquiry into his past
revealed the following facts:

He had been a bank clerk before the war and once because of a nervous
breakdown as a result of drinking and smoking had been given a three
months’ vacation. On this occasion he went with a prostitute--his first
and only offence in sex matters. He later thought the behavior of his
family indicated that they knew of his misdeed. He heard the voices of
members of his family, became rapidly worse and more depressed, and
attempted suicide.

He went to a private asylum. Later, he emigrated to Canada, but he was
still pursued by the voices and he returned to England. He enlisted at
the outbreak of the war and went to France. He was soon invalided and
sent to Maghull.

The cause of his condition, according to Rows, was his affair with the
prostitute and his previous drinking. This was explained to him as the
basis of his strong feeling of self-reproach. The hallucinations and
idea of suicide had developed therefrom. Recovery “to a large extent.”


A poor risk (hereditary and acquired); emotionality: Tremors and
convulsive crises with lowering of pulse.

=Case 302.= (ROGUES DE FURSAC, July, 1915.)

A man, 36 (boat painter to 30 and thereafter a wine seller; paternal
grandmother insane, father alcoholic and suicide; gonorrhea, 20; two
attacks of lead colic, 25 to 30; purulent pleurisy, 31; phlegmon of
mouth, 34; also a chronic alcoholic), at the time of examination showed
arteriosclerosis and slightly hypertrophic liver; unequal pupils,
slightly contracted and sluggish to light. He complained of frequent
headaches, possibly due to a combination of plumbism and alcoholism.
He was not in any respect demented, and had an excellent memory. He
had always been emotional, being unable to go to a funeral without
many tears, or remain in a house where there was a corpse without
threatening to faint. He was always overcome if he saw a fight going
on; and even in his wine shop he would escape when there was a fight
and get a neighbor to bring the police.

He was mobilized on the fifth day, sent first to a territorial regiment
and then, in October, put into the reserve of an active regiment
and sent to the front. He reached the first line trenches in the
night, greatly affected by ruins he saw on the road. He slept poorly
and had nightmares. At daybreak he woke up to see a pile of corpses
near by, and felt an indescribable terror on account of the corpses
and the noise of bullets, machine guns, and shells. By superhuman
efforts--according to the man--he mastered his emotions and took his
turn at the observation post. Another sleepless night. Next day he got
such tremors that his sergeant sent him to the hospital where he was
at first thought to be suffering from a fever. But his temperature was
found normal, and he was sent back to the trenches.

He passed another night without sleep, and next day he could not hold
his gun for trembling. The Captain sent him back to be a kitchen man in
the rear, and here he remained six weeks--restless, trembling, eating
very little. He would have anxious spells. In the morning, as he was
carrying coffee to the men in his company, on seeing a pile of corpses,
he dropped his pot and ran back to the kitchen declaring that _whoever
wanted to carry coffee might_, but he would not go back. He spilled a
pot of soup on his left foot. The Captain had him evacuated, saying:
“Go! when you come back, I hope the war will be over!”

He was sent back to a hospital near Paris, where he was all right
for a few days, happy as a prince. The burn got well, and as the
time approached when he would probably have to go back to the
front, the terror returned. He had visions of corpses, and imagined
bullets whistling, machine guns popping, and shells bursting. He
wept, lost appetite, hid in corners, made three suicidal attempts
by poisoning,--though the sincerity of these attempts was doubtful
(zinc oxide ointment; rose laurel leaves; verdigris). Sent back to a
dépôt before getting leave, he had crises of tremor with anxiety, and
was then sent to Val-de-Grâce on the mental service, and finally to
Ville-Évrard. He unhesitatingly confessed his terror, becoming more
and more anxious and tremulous, and almost _losing his pulse_ while
describing his experiences. He said he would commit suicide rather
than return to the front. He stayed at the Hospital, working in the
garden rather calmly, but when it was a question of leaving, even on
convalescence, his terror and anxiety returned. Every time he was
examined there was an emotional explosion, with expressions of anguish,
generalized tremors and crises of clonic convulsions with respiratory
disturbance even of threatening suffocation, depression of pulse. It is
this latter which is the most important element in the proof that such
a case is not a case of simulation.

_Re_ war cases, Bennati remarks upon the great number that do not fall
into known categories. There is, he thinks, an anaphylactic group
in which the trauma acts as the secondary toxic agent; and there is
another group in which exhaustion works after the manner suggested by
Edinger: that is, by a physiological overwork of certain structures.


Martial misfit, dwelling on horrors of war at home; exposure; shell
fire: Mental exhaustion with depression, emotionality, tachycardia.

=Case 303.= (BENNATI, October, 1916.)

An Italian corporal, in civil life a writer (mother very nervous;
patient himself rickety, unmarried; relatives well off), was in front
line trenches for some fifty days. He was repeatedly excused from
service on account of fatigue, distress, poor appetite, insomnia,
depression and even confusion (aimless shots fired off in the night).
It turned out that he had been in just this state of mind when he left
home and family and that the very thought of war had seemed dreadful to
him. He did not at all enjoy leaves at night, as he stumbled and fell
about in the darkness and had shells burst near by. He lived immersed
in mud. He reacted unfavorably to antityphoid injection.

The very day he went on winter furlough he greatly improved, but then
suddenly relapsed into depression, emotionality, inattentiveness,
sluggishness of mind, and exhaustion. The tendon reflexes were lively,
the abdominal reflexes sluggish. There was tachycardia (120), the
Mannkopf-Thomayer tests were positive at 76 and 80, oculocardiac
reflexes 84 and vagotonic. Stellwag and v. Graefe symptoms.


Hereditary instability.

=Case 304.= (WOLFSOHN, 1918.)

An English soldier, 23, had been ten months on active service in
France, when he was buried by a shell December 19, 1915. He became
unconscious and later suffered from nervousness and stuttering,
depression, insomnia, frightful dreams, and tremor. Improvement was
such, under treatment, that he was again returned to the front. A shell
burst near him once more and again he grew dazed, trembled, had lapses
of memory and fell into a state of general nervousness. He improved
again in hospital.

On returning to the front in a few days he saw a bomb burst some
distance away. He began to stammer and to wander about aimlessly.
Insomnia, tremor of legs, arms and head, fatiguability, feeling of
lassitude, occipital and vertical headache, fear of aircraft and
crowds, frightful dreams, absences and aimless wanderings appeared.
There was one attack of deafmutism. Whenever the patient saw aircraft
he ran. He was easily startled by noises.

He was the son of an excitable, alcoholic father and of a nervous and
bad tempered mother. A sister had had nervous prostration. The man
himself had always been more or less moody and a nail-biter. According
to Wolfsohn, 74 per cent of the war neuroses have a family history
of neurotic or psychotic stigmata, including insanity, epilepsy,
alcoholism and nervousness; 72 per cent show previous neuropathy.

According to Wolfsohn, wounded soldiers do not show war neuroses
except in rare instances. In the wounded soldiers studied by him no
neuropathic or psychopathic stigmata occurred in the family history and
previous neuropathic tendencies in the patients themselves were found
in about 10%.

A soldier that is excessively fatigued or has been under undue mental
anxiety, expecting to be blown to pieces, may go into psychoneurosis
more easily than one without such emotional strain.


Genealogical tree of a shoemaker.

=Case 305.= (WOLFSOHN, 1918.)

An English private, shoemaker, 37, was partially buried in a shell
explosion and came to, stupid, shaky, weak and fearful of the dark.
Twice, in a dazed state, he attempted to murder companions and was
afterwards amnestic. He had always been of a violent temper and his
outbursts had been followed by petit mal. He had also always been
afraid of the dark. One of his children had fits; three were hysterical
and had temper fits. The man’s father was in an insane hospital. Sundry
other facts are shown in the genealogical tree presented herewith.

    M violent temper                                  Pedigree
    | prison record
    |                                          Note the stigmata all on
    +-m insane                                       paternal side.
    | +-f prostitute
    | +-f imbecile                            (The chart reads from left
    | +-f imbecile                                    to right.)
    +-f ment. def.
    |
    +--------------M violent outbursts
    | f            | (died as result of one)
    | +-m imbecile |
    +-m temper     +--f-+-+-m
    |              |    f m
    F              | insane
                   |
                   +-m crook
                   | +-m crook
                   | f                 insane criminal
                   +-----------------M violent temper
                   | f               | sexual maniac
                   | +-m St Vitus    |
                   | |   dance       +-m fits
    M              | +-f             |   mental degen.
    |              | +-f             +-m emotional
    +-f            +-m crook, rebel  |   enuresis
    |              |   prison record +-m violent
    +--------------F                 |   outbursts
    |                                +-m violent
    +-m                              |   outbursts      PATIENT
    |                                +----------------M petit-mal
    +-m sexual maniac                |                | violent temper
    |                                +-f nervous      |
    F                                +-f nervous      +-m fits of
                                     +-f nervous      |   temper
                                     +-f violent      |
                                     |   outbursts    +-f hysterical
                               M     |   restraint    |
                               |     |                |
                               +-----F nervous        +-f hysterical
                               |       breakdown      |
                               F       follows        |   nervous
                                       husb^{s}       +-m clever musician
                                       outbursts      |   & in studies
                                                M     |
                                                |     |
                                                +-----F
                                                |
                                                F


Fall from horse in battle; fear of being crushed: Hysterical crises.
Case offered as showing TRAUMATIC HYSTERIA in a young physician WITHOUT
HEREDITARY OR ACQUIRED PSYCHOPATHIC TENDENCY.

=Case 306.= (DONATH, 1915.)

A physician of twenty went into the war as a volunteer Hussar. During
an attack, he fell from his horse without losing consciousness, though
he was at the time much afraid of being crushed. The attack ceased and
he returned to the lines on horseback.

Immediately there developed an emotional crisis, and thereafter he
broke into weeping on the slightest occasion. He was afraid he was
going to lose his reason; that some spiritual power was going to
suppress his ego and madden him. He wept as he was going under narcosis
to be operated upon for an intercurrent appendicitis. He became so
sensitive to noise that he wanted to choke the offender. One day he bit
himself on the arm in his excitement. Sensory tests could not be executed
on account of his fear of the brush. Reflexes were normal.

It took four hypnotic seances to get him in proper rapport with his
physician for psychotherapy.

This case is cited by Donath as one in which traumatic hysteria has been
proven to exist in a man without any sign of neuropathic or psychopathic
taint, either in his previous history or in his relatives.


A perfect soldier type. Mine explosion; burial; superficial wounds: War
neurosis.

=Case 307.= (MACCURDY, July, 1917.)

A lieutenant, 29, had been a regular soldier for eight years before
the war and was made a non-commissioned officer almost at once after
enlisting. He went out as a sergeant with the original expeditionary
force and got through the retreat from Mons and the first battle of
Ypres intact. He enjoyed the fighting hugely and even got indifferent
to the burial work. The death of chums saddened him, but he carried on
and soon forgot about the incidents. He might be regarded as a perfect
soldier.

In August, 1915, there was a slight touch of rheumatism. Two or three
months later the Germans exploded a mine immediately in front of the
trench where he was. He went pale for the first time in his life, but
kept his men “standing to.” Thereafter he began to think for the first
time about danger. Mining was hereabouts the chief form of attack, and
he frequently heard Germans digging beneath a dug-out. He slept well in
billets, but was too restless for sleep on active duty.

He got more and more on edge during the next weeks. Six weeks after
the mine explosion he was buried in a dug-out. Though he did not
lose consciousness, he was dazed and had to lie down for two hours.
Nervousness, chronic headache and insomnia, even in billets, followed.
His imagination played upon the blowing out of dug-outs and the bowling
over of men by shells. He had become company sergeant-major and the
responsibility made him grow worse and worse. At times he tended to
jump when the shells came, but was outwardly perfectly calm. He began
to take morphia, though with little result. He had suicidal thoughts.

After two months of these symptoms he was sent to England. He began
to sleep fairly well and three months later applied for light duty;
was greatly bored by the company accountant work given him; got a
commission and was sent back to the front nine months later, January,
1917. He got on with the active fighting very well, sleeping four or
five hours a night. In April he was sent to Arras. He had had a dream
that he was going to be bowled over, buried and wounded in the neck.
Sleep got poorer. In April he led his men in an advance and actually
was bowled over, buried and hit in the neck as well as in the knee and
the hand, though all the wounds were superficial. He was carried back,
dazed, to hospital, where he grew fairly comfortable in ten days and
even undertook a journey down to the base.

He arrived in collapse, remained in camp at the base three weeks,
getting steadily worse. Something, he could not tell what, was going to
happen and kill him. He could not concentrate, even to read. He thought
of suicide. He slept practically not at all, waking from a doze with a
start, feeling that something had hit him. He had dreams of being taken
prisoner and on waking would in fancy start a fight to escape from
imagined imprisonment back to the British lines. After two weeks in
various hospitals he spent ten days in a hospital for nervous cases and
grew better. Riding on trains he was terrorized in every tunnel lest he
should be crushed.

According to MacCurdy, an anxiety neurosis would have developed had
not his superiors sent the lieutenant back to hospital after the final
burial in April. As this perfect soldier said: “_There is no man on
earth who can stick this thing forever_.”


Shell-shock; thrown against a wall: Tremors--TREMOPHOBIA.

=Case 308.= (MEIGE, February, 1916.)

Meige has studied shell-shock tremors, especially those occurring
without external wound.

A corporal was with his squad on the Nouvron Plateau, January 13, 1915,
when he was thrown against the wall by a bursting shell, which killed
or wounded several comrades but did not wound the corporal. Whether
he lost consciousness is unknown, but he lay on the ground for some
time, until he could be moved through a communication trench. After
the explosion he began to tremble, and was still trembling on his trip
back. Constantly trembling, he lived on at the front for a fortnight,
but without eating; and, although he had been a good rifleman, he had
lost all his former skill with a gun.

There was a delay of a month before evacuation, but the trembling did
not cease, and he was passed through various units, to the neurological
center at Villers-Cotterets, where he remained for two months,--April
13 to June 15, 1915,--with a diagnosis of hysterical chorea. He was
examined by Guillain, who found, besides the generalized tremors,
lively knee-jerks and Achilles jerks, an excessive emotionality,
particularly marked when the guns were going or bombs bursting. Lumbar
puncture yielded a perfectly normal fluid.

June 19 the corporal went to the Salpêtrière under P. Marie. July 14 he
was evacuated to the civil hospital of Arcueil, where he remained till
September 24, when he was sent home to convalesce, from October 26 to
December 15.

He returned to the Salpêtrière December 15, 1915. Throughout these
various movements from hospital to hospital, his status was unchanged.
At the time of report about a year after shell-shock, he was still
constantly and uniformly trembling. All four limbs were affected,
perhaps the right arm and the left leg more markedly. There was no
tremor during sleep, but there was a tremor when the patient lay awake
in dorsal decubitus just as when he was sitting or standing. The tremor
was worse in the evening than in the morning, and the patient could
get to sleep only very late. There was slight tremor of the head; the
eyelids and the tongue showed a few tremors, which were not synchronous
with those of the limbs. Nystagmus was absent. To diminish the effect
of the trembling, the patient held his forearms flexed and kept his
elbows close to his body. If the trembling of the legs got intense, the
patient would rise and walk a few steps. Any movement, such as carrying
a spoon or a glass to the mouth, led to an exaggeration of the tremors;
and there was at this time a suggestion of the intention tremor of
multiple sclerosis. The tremor was increased when the eyes were closed.
Any sudden noise or sharp command, or recalling to mind of trench
service, would bring about extraordinary motor crises, in which there
was an intense and generalized tremor, so the patient would lose his
balance. Any attempt at eliciting reflexes would produce generalized
violent tremor. Sensations were normal; tendency to hyperidrosis; pulse
in repose, 60, rising to 120 if one struck the table sharply.

Meige remarks that a number of examples of tremors suggestive of
Parkinson’s disease were observed in the War of 1870. Might the
explosion have caused properly situated lesions in the encephalon of
such a nature as to produce a Parkinsonian tremor? The tremors were
stationary, and if due to some lesion, the lesion remains now exactly
what it was at the beginning. There was no digital tremor such as is
characteristic of Parkinson’s disease. Moreover, the intention tremor
of such a patient, rather than Parkinson’s disease, suggests multiple
sclerosis, of which latter disease, however, there is no other sign.
Nor does there seem any evidence that these tremors were of cerebellar,
paretic, goitrous, or of any definite toxic origin. On the whole, Meige
regards it as a neuropathic manifestation resembling what is found in
traumatic neurosis. He believes that there is not sufficient evidence
that it is the consequence of any structural change in the nervous
system.

Meige remarks that the analysis of any case of tremor must take the
mental state into account. This patient, perfectly conscious of his
tremors and their critical exacerbations, was much chagrined thereby.
He suffered mentally from his impotence, especially when bystanders
would intentionally bring about his paroxysms. He looked like one
shuddering from fear, and it is actually probable that he was afraid
of his own tremors and shuddering. He was, besides subject to tremor,
also a victim of tremophobia,--a kind of phobia described some years
since by Meige, somewhat resembling ereutophobia, or fear of blushing,
described by Pitres and Régis.


Four hours in a freezing bog: Hysterical glossolabial hemispasm twelve
hours after rescue. No sensory disorder of face or tongue; sensory
disorder of arm, but no motor disorder.

=Case 309.= (BINSWANGER, July, 1915.)

A man, 27, in good health, called on the second day of the
mobilization, got into the line two weeks from mobilization, first in
the West, and then, from mid-September, in the East. He was in the
artillery and stood shell fire in a big battle very well.

However, December 27, 1914, while engaged in transport service, on
the way back with his horse, he fell into a bog and gradually sank to
his neck. Attempts to get the man and his horse out failed. All that
saved him from drowning was the freezing of the bog surface. After
four hours he was freed by his comrades, apparently frozen stiff, but
with consciousness completely preserved. On the next day, at about
five o’clock,--twelve hours after his release from the frozen bog,--he
had a seizure. It began with headache on the left side and loss of
consciousness that lasted 24 hours. The right leg was paralyzed and
very painful. He passed through various hospitals and finally arrived
at the Jena Nerve Hospital, January 25, 1915.

He was a tall, powerful man, with a slow regular pulse, accelerated
heart sounds, lively dermatographia, increased muscular excitability,
general increase of knee and Achilles reflexes (left greater than
right), slight patellar and ankle clonus present on the left side,
Babinski reaction absent, plantar reflex more lively on the left than
on the right, but abdominal reflex more lively right than left. Head
painful to percussion in the left temporal region. Touch and pain sense
segmentally absent in both right extremities. Arm movements free;
tremors absent. Active movements almost impossible in the right leg;
on passive movement marked pain. Slight muscular tension about knee-,
hip-, and ankle-joints. The patient got about with a cane, trailing
the left leg. Romberg sign.

The right angle of the mouth was withdrawn slightly upward and outward,
and lagged a little in active movements. The protruded tongue deviated
completely into the right angle of the mouth and there remained, but
without tremor. The uvula deviated to the right, and the right palate
was held higher than the left. Lively palatal reflex. Speech intact.
The patient’s chief complaint was attacks of coughing, which increased
his headache to the point of intolerability. A harmless drug caused
the coughing and headache to disappear. The patient was a quiet,
willing man, who industriously went through his exercises, and on the
Kaiser’s birthday was already walking in the marketplace. His tongue
contractions gradually improved. His body-weight increased.

In the course of two months the glossolabial and palatal contractions
had largely disappeared. The walking movements of the right leg had
improved, although there was still a distinct paresis, and a stiffness
in the right knee and ankle joints. Climbing stairs was impossible
on account of difficulty at the hip. March 30, 1915, the sensory
improvement was marked. There was a feeling as though the last three
fingers of the hand were asleep; walking was improved; he could walk
one or two hours a day. The walk was still slightly spastic-paretic,
May 28, when he was discharged.

It is remarkable that the hysterical attack had such a long incubation
period in this case: twelve hours after his removal from the marsh.
There were doubtless physical factors of refrigeration, on the one
hand, and on the other, psychic factors of fear of sinking alive in
the marsh, at the bottom of the phenomenon. The most marked feature,
of course, was the glossolabial hemispasm. In the presence of this
hemispasm, it is remarkable that there should have been no anesthesia
or analgesia of the face, cheek, or tongue; and moreover the paresis of
the right mouth and tongue was far less marked than the contracture.
It is also striking that the right upper extremity, although it had
sensory disorder, failed to show motor disorder.


Slight bruise by horse: Apparently invincible complaints of pain. Cure
by single-handed capture of many Russians.

=Case 310.= (LOEWY, April, 1915.)

An infantryman was standing below an embankment when a horse fell upon
him, bruising him slightly on the left hip. This infantryman later
continually complained of pains in the opposite hip though there had
never been a contusion there, nor anything felt there. These complaints
could not be influenced by exhortation, by diversion, or by drugs. If
they were purposely ignored, the patient reacted complainingly and in a
way to suggest delusions of persecution.

Nevertheless, this querulous man soon proved an effective soldier in
a storming attack in which the whole battalion distinguished itself,
putting himself forward particularly. In fact, by himself he captured a
whole group of Russians!

Thereupon all the pains in the hip ceased, nor did they recur so long
as he was under observation. Morose and complaining before, he now
became cheerful.


Kick in abdomen by horse: General spasticity; tremors; eye symptoms
(_e.g._ monocular diplopia); convulsions. Improvement.

=Case 311.= (OPPENHEIM, July, 1915.)

A cuirassier was kicked by a horse on left side of abdomen, November
24, and lost consciousness. A month later, in hospital, hardness and
tenderness to pressure of abdominal wall, _spastic muscles_ everywhere,
pseudospastic tremor of legs, and complaints of double vision were
noted. He also had attacks of convulsions, in which he became
unconscious, twitchings appeared, but the tongue was not bitten. Urine
was often involuntarily passed in these attacks, but he was not always
continent outside attacks, as, for instance, in coughing.

On admission to nerve hospital: Right-sided monocular diplopia;
mild ptosis; ocular movements free. Rapid tremor on shaking hands.
Stood with straddling legs affected by vibrating tremor. Knee-jerks
considerably increased. In the dorsal position movements of the left
leg were accompanied by marked tremor. He even could not go to sleep
easily on account of twitching of the left leg.

His comrades observed that he had convulsions at night, and often
spoke in his sleep. Inoculation against typhoid fever was made early
in December. Later, permanent rise of temperature to 37.8. Several
attacks, lasting about ten minutes, came under observation of the
physician.

In January, progressive improvement in the motor sphere and also
psychically. The urinary disturbance likewise disappeared, but the
spasms persisted.


Windage from a shell; fear; fall, unconscious: Homonymous hemianopsia
(organic? functional?) with blinking and vasomotor excitability.

=Case 312.= (STEINER, October, 1915.)

A volunteer, 19 (never ill; no nervous disease in the family) after a
period of training went into the field October 3, 1914. November 5 a
shell struck near his trench, but failed to explode. Up to that time
everything had been quiet. The soldier had been looking out of the
loop-hole, surveying the landscape. He felt a great fear, felt a blow
in the neck, and fell down unconscious. How long he was unconscious is
unknown. Sometime later he walked back with his comrades.

About an hour later, this volunteer--who was a very intelligent young
man, possessing some knowledge of biology, including the nature of
visual fields--noticed a black spot in the field of vision, which
came and went, but after a few hours remained continually without
disappearing. Otherwise there was no complaint except a feeling of
dizziness when stooping.

Upon examination there could be found no disorder of the internal
organs. Neurologically there was blinking, vasomotor excitability,
slight reddening of the face, and dermatographia. An expert in
ophthalmology confirmed the existence of a homonymous defect in the
fields of vision. This defect could not be influenced by suggestion or
by any other treatment, nor did any other change whatever occur in the
condition.

Steiner inquires whether this hemianopsia is to be taken as organic
or functional. The air-pressure of the shell hissing past might have
produced a concussion, or the falling unconscious might have produced
a _commotio cerebri_ or a slight hemorrhage. The tic-like blinking and
vasomotor excitability, however, suggest functionality.


Shell-shock PSORIASIS. Post-traumatic eczema.

=Case 313.= (GAUCHER AND KLEIN, May, 1916.)

A soldier, 28, came to the Saint-Louis skin clinic, May 15, 1916, for
leg lesions three months old. These lesions were cicatricial, squamous,
irregular-contoured, and had developed following a wound. The lesions
were eczematous.

On the trunk, arms and elbow were lesions of psoriasis. These lesions
had appeared after shell-shock. The man had been bowled over June
16, 1915, by a _marmite_. The psoriatic lesions appeared shortly
afterwards. The patient had never seen anything of the sort before.

In this case the trauma provoked eczema; the emotion, psoriasis.
Gaucher and Klein say that they have been struck by the recrudescence
of psoriasis since the outbreak of the war, and remark, also, that
there has been a relative increase of new cases since July, 1914.

There are cases of psoriasis following nervous shock, emotion and
trauma. Sometimes the psoriatic lesion develops upon the scar of a
wound. In the above case, as in the case of a woman of 25, a refugee
from the Arras bombardment, the psoriasis began _de novo_ and slowly
developed immediately after the catastrophe of the Jena. Five, possibly
six, out of eight cases totaled, appear, unlike the case sketched
above, to have developed in cases either tuberculous or of tuberculous
stock.

_Re_ psoriasis, Vignolo-Nutati remarks that this is a relatively
frequent skin disease amongst Italian soldiers. He states that many
of these cases are due to nervous shock. Some are related to wounds
appearing near the scars. In all cases an emotional disturbance is the
chief cause. Vignolo-Nutati had 86 cases of psoriasis in six months, 52
of the men coming from the front. Eighteen of the men said that they
had not previously suffered from the disease.


A sergeant gets the CROIX DE GUERRE and SHELL-SHOCK together: Transient
deafness; later pseudohallucinatory electric bell ringing, reminiscent
of civilian work; stereotyped movements, reminiscent of war experience.

=Case 314.= (LAIGNEL-LAVASTINE AND COURBON, May, 1916.)

A sergeant, 24, had worked about Parisian hotels from the age of
thirteen and a half. He won the _croix de guerre_ and was evacuated for
his wounds April 24, 1915.

It seems that he carried the remains of his company, which had been
decimated the night before by a mine explosion, on to the enemy trench,
getting there first and facing three Germans, whom he beat down. At
this time, gas shells began to rain about. Making a number of violent
expiratory movements to get rid of the gas, he found himself unable to
progress on account of the fall of the shells, and sat motionless with
his hands before his face. He was cast to the earth by an explosion,
which at the same time blew off a revolver which the wounded lieutenant
had passed to him. He sat up, and, observing that the soldiers had
gotten the trench, went back to the lines, where he told his story.

He then found that he was deaf, and wounded in the left leg. The wounds
rapidly healed, but sundry other symptoms developed. He had a peculiar
sensation back of the forehead. He could not think, read or write and
was very weary. He got better in a few months, but disorders kept
returning.

His deafness had left him in about a fortnight, but when his hearing
came back spontaneously, there were peculiar sensations. He constantly
heard an electric bell, intense and continuous, like that of a French
cinema advertising its films. The sounds seemed to begin in the ear
and to run out as a sort of whistling. This sensation was preceded by
buzzing and associated with noises like those of a musical triangle
or a steam whistle. The noise kept up during waking hours, but was
often forgotten while he was at work. In sleep he heard nothing, except
sometimes battle noises. August 20, 1915, he was given the diagnosis:
labyrinthine shock--hearing returned.

About ten weeks after evacuation, when the headaches and thought
blocking began to disappear, a generalized tremor, especially of
the head, set in, which the patient called St. Vitus’ dance. Then a
peculiar gait began, which lasted several weeks and then transiently
reappeared. Every few steps his legs would bend, and he could only walk
forward in the attitude of a man who is concealing his height. After
resting a few minutes he began to walk regularly again and the cycle
began over again. He had to walk with two canes. If he felt some sudden
emotion, or sometimes without any obvious reason, he would stop short
and look straight ahead, with body bent, and arms before his face. This
would last but a moment, whereupon he would walk again normally.

When this anomalous walking disappeared, curious face movements and
gestures began. If a strange person arrived, the forehead and eyebrows
would contract, the eyelids would stand wide, which gave him an
expression of surprise lasting a few seconds. At the same time the
mouth would open and remain so for some moments. A forced expiration
would be executed, suggesting a fish out of water. He would then
imperatively strike the table with his fist, or the ground with his
foot.

Laignel-Lavastine and Courbon explain the anomalous movements as
stereotypies due to secondary automatism. They are not convulsive, are
not preceded by emotion or followed by a sense of relief, and are not
tics. They are gestures and postures without present significance,
but adapted to certain former circumstances. The electric bell effect
is a sort of pseudohallucination, differing from true hallucinations
in little except the absence of the externalizing feature. The
stereotypical movements are reproductions of things done in the battle,
and the pseudohallucinations relate to the former hotel work of the
soldier.


Cinema worker, two days after being waked up by a shell, develops a
nystagmiform tremor of eyes and tachycardia. Graves’ disease? Tic
(“occupational virtuosity”)?

=Case 315.= (TINEL, April, 1915.)

A soldier was waked up with a start Sept. 22, 1914, by a shell burst.
The man was not wounded or shocked, and merely felt a good deal moved.
The next day but one he felt a little movement of his eyes, which was
at first intermittent but in three or four days became continuous and
troublesome. These movements were those of nystagmus, almost transverse
and very rapid, and suggestive rather of a vibratory trembling than
of a true nystagmus of the eye or of labyrinthine disease. When the
patient fixed an object, the nystagmus would stop for a few seconds and
then immediately reappear. There had never been any vertigo, nausea,
vomiting, deafness, ocular disorder, or disorder of equilibration.
During the tests for nystagmus, the morbid nystagmus would stop and
be replaced by the normal nystagmus which was obviously slower and
more regular. The condition had persisted from September, 1914, to the
meeting of the Neurological Society, April 15, 1915. The patient said
he had become very emotional and got palpitations on the slightest
occasion, such as a fast walk, going upstairs, or hearing a loud noise.
There was also a slight vibratory trembling of the fingers and a
permanent tachycardia (120-140 beats). Tinel regards the case as one of
neurosis, due to a neuromuscular hyperexcitability comparable in some
ways with that found in Graves’ disease.

Meige, in discussion, called attention to the fact that not every
nystagmus is of organic origin and that there is a rare form of tic
of nystagmiform nature. The victim in this case was an employee in a
moving picture house, and very possibly his occupation had permitted
him to utilize what Meige speaks of as a “occupational virtuosity” of
the eye muscles.


Synesthesialgia: FOOT pain on rubbing dry HANDS, following bullet wound
of leg.

=Case 316.= (LORTAT-JACOB AND SÉZARY, November, 1915.)

A foot chasseur was wounded, September 15, 1914, low in the right
thigh, a bullet entering outside the biceps tendon and emerging on the
inner aspect of the leg, 4 cm. below the knee joint. He at once began
to feel pains in the right foot, which grew swollen and red. The leg
began to flex upon the thigh and, after straightening under anesthesia,
was placed in plaster. An arteriovenous aneurysm developed in the
popliteal space; operation, October 22nd, followed November 1, by
ligature. The pains in the foot grew better after this operation; but
as soon as the wound was cicatrized they came back again as before.

For seven months the foot pains remained sharp and continuous, such
that the man could not leave his bed. If a bright light struck his
eyes, the pains grew much more marked, especially in the morning on
awakening. The patient found that when his _hands_ were _dry_ he could
not use them because of the violent _pains_ which rubbing them would
cause in the _right foot_. Accordingly he kept putting his hands to his
mouth to moisten them. Finally he kept a wet rag by him which he could
pass from one hand to the other.

The pain was what made walking difficult. Foot movements were only a
bit less ample on the affected side than on the normal side. There was
a general muscular atrophy of the lower extremity (30.5: 34 about calf,
and 40: 49 about thigh). Right knee-jerk more lively than left. Right
Achilles jerk absent. Negligible disorders of electrical excitability
in the territory of the right sciatic nerve. The skin of the foot was
a little thin and pale; the temperature was low; and the nails had
transverse striations. The pains grew gradually a little less marked,
but if the room temperature was increased or lowered or if the foot
became cold, the pains became extreme. Pressure on the popliteal space
produced pain on the external border of the foot; likewise pressure
on the calf. Lasègue’s sign could not be tested for on account of the
contracture of the flexors of leg on thigh. Due to the direct action of
the bullet, there was an objective hyperesthesia of the dorsum and sole
of the foot. The toes were anesthetic. A cold foot bath increased the
pains, and a warm foot bath diminished them (contrary to experience in
analgesias).

This was a case of synesthesialgia in the right foot, brought about by
rubbing dry hands, exactly as if there were a direct contact with the
foot. Milder painful reactions were brought about by bright lights and
loud noises; but on the whole, these other effects were insignificant.
It must be remembered that the man was wounded and plainly had also
organic nervous disorder. He sometimes complained of radiations of
the pain up to the left hypochondrium, and sometimes he showed the
classical sensation of “esophageal globus” (lump in the throat). In
short, there was in him a special excitability of the nervous system
which may partly explain the synesthesialgia.


Shell-shock; burial: Clonic spasms; later, stupor with amnesia.

=Case 317.= (GAUPP, March, 1915.)

A reservist, 28 (laborer in civil life, of a nervous family; even
before mobilization had attacks of weakness at his work or in the
company of others) January 3 or 4, 1915, fainted in the trench while
shells were striking around him. On January 5 he was brought to
hospital in deep stupor. He went to the reserve hospital at N. by
hospital train, January 8, and arrived at the Tübingen clinic January
18.

A slip of paper stated that after burial in the trench he had been
brought from the field unconscious. Clonic spasms of the upper part
of the body are said to have occurred. At the reserve hospital in N.,
January 10, he was still unconscious, at times twitching his face and
the upper part of his body, and once at night excited and delirious.

At first in the clinic he was apathetic, speaking not a word, looking
vacantly into the air as if lost in a dream. He went to the section
passively, and lay passively in bed.

In the examining room, he stood speechless with unemotional face,
sometimes looking up to the ceiling, slowly scratching his head,
failing to answer questions, although fixing his eyes upon the
physician. He could not be communicated with in writing, playing
uncomprehendingly with the pencil or scratching his head with it. He
would start with fright at a sudden noise or an unexpected touch.
Sometimes he would heave a deep sigh, grasp his head in his hands, or
lay hold of his hair with a hopeless expression of face and shake his
head to and fro.

Next day, January 19, he made a few slow, low answers. He was found
to be entirely disoriented and with associations impeded, although he
could get out his name and residence with difficulty. Some of his color
identifications were correct, such as red and green; some impossible,
as yellow, brown, violet. A comrade who was called in and could speak
the Cologne dialect, was talked with at first with difficulty, later
more easily. Although the patient was visibly freer, he remained
without apparent emotion, retaining a rigid and dreamlike expression of
face. It was hard to find words, although objects were named correctly,
and there was no paraphasia or agnosia. Vision and hearing were normal;
walking, manual movements, eating were all undisturbed though slow. The
patient had to be led to the toilet. It seemed as if all intellectual
life was at rest, and that in the absence of impulses from without,
there would have been complete apathy. It was made out that the patient
thought he was still in the trenches.

Next day, the stupor had decreased and the patient spoke, getting his
bearings for a time. There was a complete amnesia as to the cause and
duration of his condition. During the next period, up to the beginning
of February, 1915, consciousness cleared and the apathy was replaced
with anxiety, weariness, and a dull headache.

During February, the patient gradually returned to his senses, and
remained in a state of general nervous exhaustion. Amnesia was complete
for at least two weeks of his life and recollections were fragmentary
for the first three days of his stay in the clinic. He worked willingly
in the garden with the other patients. On February 26, the patient was
cured and went back to the reserve battalion in a much strengthened
condition.


Battles (including liquid fire); eventually shell-shock: Hallucinatory
delirium, mutism, asthenia--after a few days puerilism (history of
convulsive crisis in adolescence) with regression of personality to
late childhood.

=Case 318.= (CHARON AND HALBERSTADT, November, 1916.)

Puerilism (Dupré) appeared in a soldier, 21 (uncle and cousin insane;
patient had difficulty in studies at fourteen and nervous spells for
two years, with loss of consciousness, fall and convulsions probably
at rare intervals; a student at eighteen) after he had taken part in
a number of battles with the Chasseurs Alpins. He was exposed once
to liquid fire July 21, 1916. He entered the military psychiatric
center at Amiens. Mental troubles had followed the bursting of a
shell near him. He said a few words, such as, “Alsace; fire; blood;
snow; it hurts.” These phrases, spoken in a low tone, with an anxious
appearance, eyes fixed, suggested hallucination. He seemed to be
listening. Aside from the isolated words above mentioned he showed
complete mutism. There was physical weakness, difficulty in walking
without support, exaggeration of patellar reflexes, pains in the head
and limbs. After several days, he said, “Milk; bread.” After this the
anxiety and the slow and difficult walking disappeared, whereupon the
puerilism appeared.

Now the soldier began to run instead of walking. He galloped and
gamboled like a child imitating a horse, or he would sit on a board
seeming to paddle. He would skip along the halls. The puerilistic
phases were rather brief and for the most part he lay in bed. There was
still a certain asthenia. He made little paper boats in bed, keeping
them in a small metal box along with bits of bread, looking glass and
the like. If a gesture was made to take them away, he would protest and
press the box to his breast, looking childish and anxious, and if the
box were taken he would weep hot tears. Sometimes he would stick out
his tongue at the attendants. His mother came to see him and afterwards
he would say, “Mamma told me to be good, to eat well, to get well and
to go home.” He would use childish grammar,--“Me eat much.” Asked why
he had hollowed out a small hole in the wall of the room, he answered,
“I did it for fun, but I will not do it any more. Mother doesn’t want
me to.” The patient was unwilling to answer a question correctly; would
sometimes answer incorrectly at first and correctly afterward.

It appears that the man had adopted the language, occupations and
attitude of a child, showing a regression of personality ten to twelve
years backwards. There was a neurotic basis in the convulsive crises
of adolescence. On the basis of this predisposition following shock
there appeared an attack of confusion, upon which, several days later,
supervened ecmnesic phenomena of hysterical nature assuming all the
features of puerilism.


Bomb-dropping from airplane; unconsciousness: Battle dreams. Leaves of
absence failed to relieve. Episodes of dizziness and fugue.

=Case 319.= (LATTES AND GORIA, March, 1917.)

M. Alessandro, Class ’79, baker (father a drunkard; brother an idiot,
in asylum), had typhus in youth, and as a boy had periods of intense
“pavor nocturnus,” but no convulsions. He enjoyed good health in the
army before the following event:

On July 13, 1915, a bomb, dropped by an airplane, fell near an Italian
soldier, killing many comrades, and throwing the man to the ground
unconscious. He awoke several hours later at a hospital in a stunned
condition. During the night, under the influence of terrifying dreams,
he would leave his bed to look for enemies who, it seemed to him, were
throwing stones and firing. He managed to grasp a rifle and fire at the
images he saw. He was given a 60 days’ leave of absence during which
he did not improve; and then again 90 days’ furlough, which he spent
at his home, where terrifying dreams, tremor of limbs and asthenia
continued.

He came under observation February 10, after his second leave.
Nutrition fair. Insomnia. Constant terrifying dreams. Coated tongue.
Tremor of hands, head, body, ceasing during voluntary movements.
Episodically he had spells of dizziness followed by absent-mindedness,
whereupon he wandered aimlessly about, of a sudden becoming aware of
being in a place, but not knowing how he came there.

Special senses intact. Several points of cutaneous hyperesthesia,
particularly mammary and pseudo-ovarian on the left, pressure whereon
provoked a lively emotional reaction with acceleration of pulse,
redness, lacrimation. Knee reflexes lively, cutaneous reflexes normal,
except the plantar which were very lively. Restless, hyperemotional, he
wept for insignificant reasons and wanted to leave hospital for fear of
dying there. He was discharged unimproved after a fortnight.


Nostalgic temperament; depression on entering service; rheumatism. A
box falls from an airplane near by: Fear and tears; later depression,
nostalgia, dreams, hyperthyroidism.

=Case 320.= (BENNATI, October, 1916.)

An Italian private in the infantry was recalled to military service. He
was a small farmer, and being disposed to homesickness, grew depressed
from the day he left for service. His sleep was disturbed, he was
greatly affected by the wet and damp of the trenches, and was in a
state of continual fear. Finally, pains, hypersensitiveness, and fever
developed.

As an enemy airplane passed over one day, a box fell at the man’s
feet and threw him into a profound fear with tears. He was conducted
to a tent to rest; his regiment was shortly sent to the rear, and he
remained on active service for a few days despite the fever and pains.
Finally the swelling of his leg compelled him to take to bed. (Fatigue
in antebellum life had always shown itself in aches of the legs.) He
had now been in active service about a month and his homesickness
overcame him. He was in a state of deep physical and mental depression.
It was not his own troubles so much as those of his family which
preoccupied him. His knees hurt him so that he had to weep; or if
Sardinia was mentioned, he cried, and said, “Oh, how I love Sardinia!”
He grew fatigued very easily. He had many dreams about Sardinia, his
father, and the war, especially dreaming about being wounded in the
legs (question of being stimulated by the joint aches). The reflexes
were normal, though slight tremors set up in the legs after testing.
The thyroid gland was somewhat swollen, and it appears that the patient
had noticed this five days before entering hospital. The patient was
rather vagotonic; pulse-rate stood at 56; oculocardiac-reflex, 56-84;
Mannkopf negative; Thomayer and Erben marked (56-88 and 88-60); von
Graefe marked; Stellwag present.


A shell pitches without bursting: Unconsciousness; stupor; MAMA MIA!;
oniric delirium; amnesia. Recovery in five weeks.

=Case 321.= (LATTES AND GORIA, March, 1917.)

An Italian soldier of the Class of ’95, a mechanic (mother cardiac; as
a boy, pains in joints and heart; since boyhood, no illness), had a
big Austrian shell pitch near him, July 23, 1915. The shell failed to
explode and injured no one. The patient, however, fell to the ground,
unconscious, and remained in the camp hospital for two days, quite
immobile. This event followed an advance by his company under very
fatiguing circumstances without sleep for a period of four days.

July 26, the patient was observed in profound stupor, non-reactive,
constantly and monotonously repeating the phrase, _Mama mia!_, with
fixed gaze and smiling as if at visions. He swallowed food. The pupils
reacted poorly to light, and the cornea and nasal mucosa seemed
anesthetic. The tendon and skin reflexes were lively. The muscles were
hypotonic; bradycardia, 56; no control over feces or urine.

July 27-28, restlessness at night, gasping movements, and poses of
terror.

July 29, he called for his mother, who had been dead for several years.
He was still stuporous and insensible.

From August 1 to 10, he improved slowly and became able to carry bread
to his mouth after it had been put in his hands. He still did not speak
and made signs when he wished to urinate or defecate. Pulse 50-60.

August 12, the patient began to react to intense light and to pain
stimuli, as well as to pressure. He ate voraciously.

August 15, visual stimuli were responded to, the pulse had risen to 80,
the skin reflexes were no less lively. There began to be terrifying
dreams at night, with motor reactions.

August 17, the patient looked about more alertly, promptly seeing bread
when placed in the center of the field of vision and saying words to
the man who might try to remove the bread. He did not yet react to
acoustic stimuli, nor was there any other change up to August 21.

August 22 a notable improvement set in. The hearing was now slightly
diminished, questions were answered after a brief refractory period.
After a few questions, however, a state of exhaustion would ensue,
which would disappear only after a short rest. There was amnesia for
the entire period following the day of his departure for the front,
May, 1915. At this time, instead of eating voraciously, he showed
anorexia. The skin and tendon reflexes, instead of being lively, were
now dull. There still were battle dreams of enemies trying to kill him.

August 25, there was an area of hypesthesia on the inner aspect of the
right thigh, but otherwise no disorder of sensation. The pulse stood at
80 and there were no other neurological phenomena.

August 31, the patch of hypesthesia of the thigh and the retrograde
amnesia disappeared. There was still a slight diminution of hearing.
The accident of the non-exploding bomb could now be recalled, but there
was a memory gap for all facts up to the latter part of August.

September 2, dreamless sleep; no signs of abnormality except a slight
diminution of hearing. Discharged, well.


Jostled carrying explosives; no explosion; unconsciousness: Deafmutism
and foggy vision. Gradual recovery from these symptoms. Then, on rising
from bed, camptocormia.

=Case 322.= (LATTES AND GORIA, March, 1917.)

An Italian of the Class of 1891 (convulsions and pains in the spine,
with rigidity, as a child; typhoid fever at 18; brother sickly,
neuropathic; mother subject to periodic convulsions; father alcoholic
and nervous), on the night of November 26, 1915, was carrying a number
of tubes of explosives. A comrade stumbled and fell over the soldier,
who fell to the ground unconscious. None of the glycerine tubes
exploded, and none of the soldiers round about were hurt.

The man regained consciousness at the camp hospital, but remained
deafmute and also impaired as to vision. It was as if a screen of fog
lay between him and objects seen.

During fifteen days of observation at the camp hospital, he had
terrible war nightmares. The mutism, the visual disorder, and the
deafness then gradually disappeared without special treatment.

However, when the patient rose from bed, it was found that his lumbar
vertebral column was stiff. He walked bent forward and was unable
to bend or straighten the back. There was a hyperesthesia along the
vertebrae, especially on pressure. X-ray examination showed no bone
lesion. The larynx and cornea were sensitive, and the plantar reflexes
were absent. The abdominal reflexes were present. The pupils reacted
to light and accommodation. There were two areas of analgesia in the
nipple regions. The expression of the patient’s face was relaxed and
drooping.


A heavy cannon slides and grazes a man: Unconsciousness; stupor;
amnesia (anterograde amnesia persistent). Complete recovery in less
than seven weeks.

=Case 323.= (LATTES AND GORIA, March, 1917.)

An Italian soldier of the Class of 1895, a peasant (family healthy;
non-alcoholic; good scholar) was, July 19, 1915, helping drag a heavy
cannon up hill. The big gun slid, hit several men, and grazed the
patient, making a slight abrasion on his leg. He immediately lost
consciousness, and arrived at the camp hospital in a stupor, which
lasted so long that catheterization was necessary.

A week later he was observed in hospital, immobile and non-reactive,
with a swollen abdomen and fecal impaction. The pupils were widely
dilated and reacted poorly to light. The corneal reflexes were absent,
and the nasal mucosa was anesthetic. Pulse 50. The patient failed
to eat. Next day there was no change in his condition. He was quiet
throughout the night.

On the morning of July 29, a number of answers were obtained to
questions put in a loud voice, though he was unaware of much more than
his name, being ignorant of the name of his country, his age, his
division, where he had come from, what had happened to him, or where he
was. He had now begun to eat spontaneously.

During the following days, up to August 4, the amnesia gradually
dissolved for the facts before the trauma. He remembered having been
greatly frightened at the time of the accident but could not remember
the accident itself, and the gap for subsequent events was still
complete. The pharyngeal reflex was still poor. August 5, he began
to remember the details concerning the accident. About the middle of
August there was no longer any diminution of hearing and ideation
became more free and rapid.

September 4, he was discharged, well.


Shell explosions SEEN: Emotion; insomnia. Artillery HEARD twelve days
later: “finished off.”

=Case 324.= (WILTSHIRE, June, 1916.)

A lance-corporal, 36, had had a nervous debility four or five years
before the war, caused by an overstudy of music. He had not stopped
work at that time, but suffered from depression, anorexia, and
insomnia, lasting for some weeks.

The lance-corporal got on well at the front for 11 weeks, until finally
eight shells pitched near him. Although he was unhurt, he began to
suffer from anorexia, insomnia, and depression. While in billets 12
days later, some English artillery became heavily engaged, whereupon
“The noise promptly finished me off.” The insomnia, depression, and
anorexia became more marked, and the patient could not sleep unless
heavily drugged.


Shell-shock: Emotion. More shells: Insomnia; war dreams. Head tremor
and tic, two weeks after initial shock.

=Case 325.= (WILTSHIRE, June, 1916.)

The psychic trauma is, according to Wiltshire, more important than
physical trauma in the following case of a sergeant of infantry, 28,
a man without neuropathic taint. This man had been nine months at the
front and through Mons, but had been quite well until three weeks
before coming to hospital.

“Twenty-three days ago, I was issuing rations when they got the range
of us--and killed the other chaps. I got blown away and knocked over.
I saw everything--fellows in pieces. Then a second shell came. I got
lifted and knocked about ten yards.” Then he began to shake but carried
on.

Two days later, “Shells dropped on the dug-out and killed the other
chaps. I have not slept properly since this. If I go to sleep, I wake
up seeing people killed, shells dropping, and all kinds of horrid
dreams about war.” One or two of the men killed had been pals.

A fortnight after the first incident, while in a base hospital,
head-shaking began. The patient would jump at the least sound. There
were spasmodic tic movements with the extension of the head, protrusion
of lower jaw, and contraction of occipitofrontalis muscle. Sometimes
the left shoulder girdle was affected in the same way. There was a
slight fine tremor of hands and eyelids and difficulty in keeping the
eyes fixed on an object.


Hyperthyroidism, hemiplegia, irritative symptoms after exhaustion (by
heat?).

=Case 326.= (OPPENHEIM, February, 1915.)

A man (not previously nervous, no faulty heredity, heatstroke August
21) suddenly fell down in a great heat, after a fatiguing march,
and remained unconscious for several hours, waking with vertigo,
headache, paralysis of left side, vomiting, and twitching of the
face. On September 23, admitted to reserve hospital. Knee phenomenon
increased. Urinary retention; catheter used. Speech disturbance,
facial twitching. Vomiting had stopped September 10. Catheterization
could be avoided through warm sitz-baths. October 30, on sitting up,
occipital pain and vertigo. November 15, urinary symptoms improved.
Also improvement otherwise. December 1, gait vacillating and uncertain.
Headache. Admission to nerve hospital, December 3. Here complained of
twitchings in the frontals and corrugators. Wide palpebral gaps. Rare,
or absent, movements of lids. The extended hands showed active, rapid
tremor. Tendon phenomena increased in the arms and especially in the
legs. Abdominal reflexes increased. Active tremor in the legs. Gluteal
tremor. Very pronounced Graves’ symptoms. Syndactylism very pronounced
in the feet, between second and third toes. Later on, improvement under
half-baths, etc. Worse after ten days’ leave of absence, especially
marked increase of tremor (rest tremor), augmented on movement.

_Re_ heat stroke, Wollenberg has called attention to the effect of the
heat of the summer months upon German soldiers. Cases of heat stroke
have not been rare in the German army. About half the cases have
convulsions or epileptoid seizures, as well as tremors and nystagmus.
About a quarter of the cases have shown confusion and delusions, with
anxiety and mania. A degree of mental impairment has followed a number
of these heat strokes, together with sundry signs of organic disorder,
such as reflex changes, pupillary changes, and difficulty in speech.


Forced marches; skirmishes; rheumatism: Generalized TREMORS. On the
road to recovery in six months.

=Case 327.= (BINSWANGER, July, 1915.)

A German letter carrier, 27, entered the war at the outset, made forced
marches in great heat, was in a number of skirmishes and in the capture
of Namur, and fell ill early in September, with swollen and painful
right foot and rheumatic pains in knees and shoulders. He was put on
garrison duty; but the rheumatic pains in the joints increased toward
the end of September, and he was treated in hospital for rheumatism.

He became able to walk only in the second half of December, marked
tremors affecting the whole body. His bodily condition had been good.
He slept well, and while at rest in bed he felt entirely well; but upon
every attempt to get up and put his feet down, these violent trembling
motions would always reappear. Treatment by hydro- and electrotherapy
remained entirely unsuccessful. February 8 he was transferred to a
nerve hospital.

He had been in the postal service from 1903. He was of normal bodily
and mental development and had had no previous illnesses. His military
service had been executed from 1909 to 1911. He had always been a
passionate smoker but had not abused alcohol. His mother is said to
have been for some time paralyzed, following a fright.

Physically, the patient was a slender but strongly-built and fairly
well-nourished soldier. The first sound at the apex of the heart was
rough and impure, and the heart was somewhat enlarged to the left.
The pulse was irregular, 106. The arteries were somewhat stiff.
Neurologically, there was a marked dermatographia of comparatively long
duration. The periosteal reflexes were increased; the deep reflexes
could not be properly examined. The whole leg trembled and heaved
unsuccessfully on attempts to raise it voluntarily. After even a
slight stroke on the patellar tendon, the trembling became excessive
and irregular, and the leg passed into a heaving spasm which would
outlast the percussion for some time. The patellar clonus could be
obtained with the knee extended. The shaking movements were somewhat
more marked on the right than on the left side. Similar phenomena
occurred when the Achilles reflexes were being examined. The triceps
reflexes on both sides were increased but there was no tremor or spasm
of the arms. The plantar reflexes were very lively, and following these
reflexes appeared tremors of the legs. When the spinous processes
of the vertebral column were percussed, a general shaking spasm
appeared. Tactile sense was everywhere normal, but the pain sense
was increased. Upon slight pin-pricks in the skin of the legs, there
would occur a marked shaking spasm of the leg, passing directly to the
other leg. These phenomena were more marked on the right side than
on the left. When sitting upon a chair with back supported, a slight
tremor would appear when the hands were raised and stretched out, more
markedly on the right side than on the left. Movements of the arms
were normal. However, the hand-grasps were: right, 105; left, 80. In
dorsal decubitus the movements of the leg were performed comparatively
well at first, but after a few repetitions, the shaking spasm would
occur on both sides, and the movements would become very awkward. The
heel-to-knee test would then fail. If the patient were put on his feet,
he would immediately fall into spasms, first in the right leg, then in
the left. The trunk would now be involved, and soon the arms, whereupon
the whole body, with the exception of the head, would be seen trembling
and shaking, and the patient would fall forward, trying to get support
by leaning against a wall, seizing a chair, or sinking down slowly.
The spasms disappeared at once in dorsal decubitus and in sitting with
supported back. Outward irritation by the acoustic, optic or tactile
avenues would bring out spasms in the legs, always more markedly on the
right side than on the left. Psychic irritations would cause spasms.
The muscles of the limbs were held in great tension, the flexors and
extensors being alternately affected. When the patient was moving
along a wall with a difficult, swaying gait, his efforts reminded the
examiner of the attempts of a heavily intoxicated man to walk. Upon
attempts to create passive movements of the lower limbs, severe shaking
and trembling movements set in, followed by a general spastic tension
of the leg musculature such that it could not be further flexed or
extended.

The patient was put in the psychiatric section, as too seriously ill
for the nerve hospital. He improved after a few days, being then able
to walk without much support although still with some shaking and
tremor. If his attention was diverted, passive movement of the leg
could be carried out without developing spasm. He was treated in a
room by himself with removal of all outward irritation. His legs were
treated for an hour, three times daily, by means of moist packs. On
account of complaints of insomnia he was given small doses of hypnotics.

The main thing here, according to Binswanger, is the psychotherapy. The
patient was told almost daily in the course of conversation, first,
that the illness was being cured; secondly, that upon recovery he would
be employed in the future only on the postal service. He was told that
he would have to avoid marked physical exertion, of course, but that he
still would be fit for office work and could serve the fatherland in
this way. Still he could not be transferred back to the hospital, he
was told, unless he became entirely well, so that he could move with
perfect freedom.

February 23 the patient was performing daily exercises in walking and
standing; the spasm became very slight on standing, and often would
entirely cease, but it remained still plainly present in the legs; the
trunk and arms were free. External irritations were now less prone to
excite spasm. Sleep became quiet and dreamless. He was transferred to
the nerve hospital, able to move about freely in house and garden and
only tremulous after long walks and considerable bodily and mental
fatigue. He was given a week’s furlough home. He wished very much to
get into the postal service; at the time of the report he had not
attained this goal. He had renewed attacks of trembling upon exertion,
and was transferred at the end of June to a convalescent home.


Shell-shock; emotion: Hyperkinesis, fear, dreams.

=Case 328.= (MOTT, January, 1916.)

A private, 21, was with 30 men carrying sandbags in the daylight, under
shell fire. He was thrown into a deep hole by an explosion, climbed
out, and saw all his mates dead.

He was admitted to the Fourth London General Hospital, June 20, 1915,
having been at Boulogne for a fortnight. He was lying in bed on his
back, making continuous jerky lateral movements of head, and movements
of arms, especially of the left arm. He was groaning slightly, now and
then raising his eyelids with a staring expression of bewilderment
and terror. He was able to mutter answers to questions. He would
occasionally raise his right hand to his forehead. If he was observed,
these movements became exaggerated. They ceased in sleep. He muttered
even when unobserved. He continually said, “You won’t let me back.”
Asked as to dreams, he replied, “Guns.” Voluntary movements were made,
which prevented obtaining reflexes. When his pupils were to be examined
by a man in uniform, he showed a marked facies of terror; his pupils
were dilated; the eyes opened wide, the brows were furrowed, and there
was an anxious scowl. The flash of an electric light produced the same
effect.

June 24 the patient was much better. He said the explosion which had
killed his friends after he had been only a few weeks at the front,
was the first serious event in his service. He kept seeing it again,
with bright lights and bursting shells. Sometimes he would hear the men
shouting. In dreams he both saw and heard shells and men. There was
pain in the back and right side of the head.

June 26 he was improved but still had pain in the back of the head,
especially when trying to remember, and a slight tremor of the hands.
He had been given hot baths at Boulogne on account of being very cold
and shivering. He had always felt sick at the sight of blood. He was
boarded for Home Service six months after admission.


Shell fire and barbed-wire work: Tremors, anesthesias, temperature and
pain hallucinations.

=Case 329.= (MYERS, March, 1916.)

A corporal, 39, had been working under shell fire at barbed-wire
entanglements. The man was big and robust, but much depressed,
complaining of noises in the head, pricking pains, unsteady legs,
fatigue, irritability, loss of confidence. He showed tremors of arms
and legs on movement, and stood unsteadily with eyes closed. He said:
“My legs have been very unsteady, especially when some one is looking
at me. They must have thought me drunk at times.”

The head and tongue were tremulous, the knee-jerks exaggerated, the
soles insensitive to touch and pain; but sensibility to deep pressure
was retained. There was a gradual return of right answers on further
trials, aided by comparison with effects of stimuli applied to the
dorsum of the foot. Though he gave correct replies on heat and cold
tests over the arms, he gave wrong answers over the dorsum of the feet,
less often over legs, sometimes over thighs.

Later during examination, the feet became tremulous. He felt a “silly
childish fear,” and his hands began to feel cold and clammy; whereupon
he began to reply _hot_ or _cold_ when the tubes were not applied
at all (temperature hallucinations). There were apparently pain
hallucinations in the soles and errors in response to the compasses.

_Re_ the temperature hallucinations noted by Myers, these are to be
distinguished from true vasomotor disorders. Babinski believes that he
has definitely established that, though hysteria may cause a slight
thermo-asymmetry, yet never a definite vasomotor or thermic disorder.

_Re_ hysterical pains, the most frequent are probably those of
hysterical pseudo sciatica, in which true signs of sciatica are absent,
namely, (1) loss of Achilles jerk, (2) scoliosis, (3) Lasègue’s sign
(pain on thigh flexion with leg extension), (4) Neri’s sign (with trunk
bent forward, affected knee flexed), and (5) Bonnet’s sign (pain on
thigh adduction).


Shell-shock: Emotional crises; twice recurrent mutism; amnesia. A
comrade in the same explosion gets off with transient phenomena.

=Case 330.= (MAIRET, PIÉRON AND BOUZANSKY, June, 1915.)

December 15, sitting back of a wall were three minor officers and
an _homme de liaison_, when a 105 shell punctured the wall and
burst, killing one and wounding another severely. One of these, _a
sous-lieutenant_, lost consciousness for a quarter of an hour and had
some severe headaches for a few days, but nothing more. The other, the
_homme de liaison_, was found standing, bewildered, looking at the
dead. When his name was called, he jumped and started off, weeping and
crying out.

When caught, he was still somewhat clear, recognized his superior
officer, answered yes and no, but kept asking, “Where is the other?”
Next day he kept weeping and said not a word.

He was evacuated through a series of hospitals and was sent to
convalesce with his sister at Montpellier, having now got back his
speech. He had a seizure of fear in the street and was picked up by
the police and was carried to a general hospital January 21. Here he
could not speak, could hardly write, being unable to find his words.
He walked slowly, bent over, eyes abnormally wide open, with a look
of terror. The lighting of a match made him start off weeping. The
symptom picture included tinnitus, vertigo, deafness, some reduction
of the visual field (especially on the left side), hypesthesia and
hypalgesia on the left side, hyperalgesia on the right, painful points
(epigastric, inguinal, supra and infra mammary left), reflex, muscular
and tendon, hyperexcitability on right side, jactitation, impairment
of recollective memory, complete memory gap for the accident and
everything thereafter, retentive memory reduced, imagination impaired,
nightmares (awaking with a start).

A few days later he was able to pronounce his name with difficulty
and to say yes and no. February 4 there was an appendicular crisis,
whereupon mutism became absolute again and lasted into May, despite
suggestive therapy.

May 10, improvement in memory for things before the accident grew
better, nightmares had become less frequent, the jactitation had
continued.

There was no neuropathic predisposition in this case except infantile
convulsions in two sisters, followed by nervous crises in one.

_Re_ appendicular crisis, which was the occasion of a relapse in
mutism, see remarks under relapses under Case 292.

_Re_ mutism, Babinski counts mutism, hysteria major, and rhythmic
chorea as so characteristically hysterical that no nervous disturbance
of an organic nature can resemble them. The description of hysterical
mutism is due to Charcot. According to Babinski, mutism is just as
curable as hysterical deafness, and perhaps more curable. Yet mutism
persists unchanged for many months unless it is treated properly
by some form of suggestion. “It may be almost said that a subject
suffering from speech defect, who nevertheless succeeds in making
other people understand by all sorts of varied and expressive gestures
the circumstances of his condition, is a hysterical mute and not an
aphasic.” According to Babinski, no true case of hysterical aphasia has
been published since the beginning of the war; all the cases have been
cases of mutism.


Shell explosion; fainting: Hysterical crises of emotion; fright at a
frog in the garden. Hereditary and acquired neuropathic taint.

=Case 331.= (CLAUDE, DIDE AND LEJONNE, April, 1916.)

A lieutenant, 28 (mother nervous; father had nervous spells at fifteen;
patient himself nervous as a child), was under a great moral strain at
the outbreak of war, and was utterly exhausted in a hard battle that
lasted more than twenty-four hours.

A shell burst near him September 25 at the Somme, whereupon he
fainted. He was evacuated to Amiens for three weeks; kept his bed;
somnambulistic; subject to nervous crises.

He passed to the hospital of Ferté-Bernard for a month, the crises
becoming more frequent. He was sent to a convalescent dépôt for three
days, thence for three months to La Plisse; got better; lived at home,
but went to a show where they played the _Marseillaise_, was profoundly
moved thereby, and had more crises; accordingly went back under medical
care and finally to his dépôt, where, upon seeing his old comrades, he
had more crises, and was finally evacuated to the neurological center
of the Eighth Region.

He there seemed mistrustful when asked to tell his story. There was
a noise of cannon, whereupon he got up, ran in all directions in the
garden, bumping into trees in the greatest terror, yelling, “There they
are!”; gesticulating, soliloquizing: “Bomb! Shell! Bayonet!” His pulse
was rapid. After he was calmed down, he began to talk again in a very
clear, distinct, somewhat tremulous voice. A metallic sound made him
shudder and cry out, “The drums!” and another scene of rushing about
followed.

In the consulting office he wept. Battle dreams and nightmares,
soliloquies and terror, seminal losses, occurred during the next few
days.

August 4, while alone in the garden, he heard a noise, went toward it
and spied a frog, whereupon he had another crisis of fear and emotion.
He got another lieutenant, and both returned, sticks in hand. Pointing
to a hole in the earth, Lieutenant A. said, “Trenches! There they
are!” “What? Who?” said Lieutenant B. “The Boches!” said Lieutenant A.
Whereupon Lieutenant B also saw them and cried out bravely, “Go away!”
However, the second lieutenant immediately saw that he had been the
subject of suggestive hallucination.

Fifteen days of calm followed, during which the lieutenant became more
sociable and grew better having no more crises.

Four other cases of “hysteroemotive nature” are reported by Claude, all
of them showing a special constitutional basis before the war. In the
differential diagnosis, alcoholism, cyclothymia, obsessive psychosis
and occasionally systematized delusional psychosis may be considered.
There were occasional stereotypical features in the cases, but of a
very fugitive nature. Dementia praecox is hardly to be considered.

_Re_ “hysteroemotive” cases, Babinski holds that the claim of emotion
as a single factor capable of causing hysteria by itself, is a false
claim. To be sure, the patients themselves may give accounts which lead
to the idea of an emotional hysteria. Dide, one of the authors of the
above case, states that functional disorders occur only in subjects
whose emotional tone has been relaxed. The heaviest bombardments are
not in line to produce these disorders when the morale of the troops
is good. The bloodiest affairs may leave no single case of nervous
disorder when the morale is good. Dide found in a whole year’s work
but a single functional case,--an oniric delirium, following a trench
mortar explosion. Roselle and Oberthür also state on the basis of
intensive experience, that large projectiles do not cause any intensive
emotional reactions. Clunet’s observations upon the shipwrecked _La
Provence II_, quoted by Babinski, run in the same direction. It will
be noted that the five cases called “hysteroemotive” showed a special
constitutional basis antebellum.


War strain; slight wound; burials; shell-shock: Neurosis with anxiety;
war dreams; apparent recovery. Relapse with depression.

=Case 332.= (MACCURDY, July, 1917.)

A man, 27 (normal mischievous boy, successful in work, unmarried, shy
with women), enlisted October, 1914; adapted himself well to training;
at first enjoyed his work, though later bored with routine; and in
February, 1915, went to the firing line in France. The first shell-fire
experience made him break into a cold sweat with fear and slowed him
down for a time. However, he enjoyed the active operations until, after
eight months in the trenches, he was invalided home with nephritis.
After four months’ convalescence he was recommended for a commission,
obtained after two months’ training. After two further months in the
regimental dépôt, he went back to France as lieutenant in June, 1916,
plunging into four months of heavy fighting on the Somme, in which he
was wounded slightly once and was one day buried three times by earth
from shell explosion. The last time he was buried he was unconscious
for ten minutes and was relieved for three days. He got frequently
knocked out for short periods by shell concussion.

At the end of October, 1916, he was sent to the Ypres section, where
he worked with a pioneer battalion that buried many dead. After a
month of this pioneer work he became mildly depressed; fatigue set in,
and now for the first time he began to jump nervously when the shells
came over. To counteract this nervousness he began to drink and in a
fortnight developed insomnia. The Somme front scenes kept constantly
in mind as he tried to sleep. He felt as if he had to go up to the
trenches next day and that he did not want to go. There were hypnagogic
hallucinations of trenches and shells, recognized as imaginary and
productive of no fear. Week by week he became more nervous, became
unable to locate shell falls, and felt as if they were all coming at
him. Early in 1917 he had taken heavily to drink and grew greatly
fatigued in the struggle to prevent betraying his fear to his men. The
horror at bloodshed, to which he had long since become accustomed,
reappeared. He actually wished that he might be killed.

He carried on until March, when one day on a raid seven men were killed
around him and he was immediately thereafter buried. He reported sick
and was found to be somewhat febrile. He carried on for two more days;
had to report sick again; was sent to hospital and for two or three
weeks had bad headaches back of the eyes and a sleep interrupted by
sudden wakings with a start. Nightmares now began for the first time.
They dealt with the Somme front, merciless shelling coming nearer and
nearer. Finally, he would wake with a shriek when a shell landed on
top of him. In the day time any noise would be interpreted as a shell.
Hypnagogic hallucinations of Germans entering the room appeared. After
a little over a week in French hospitals he was transferred to London;
grew better; was sent to a hospital in the country where outdoor
exercise and recreation helped him.

Two weeks later the death of one of his best friends depressed him
a good deal. He failed in an attempt to sing at a concert, and then
grew much worse, with the old dreams every night and hypochondriacal
complaints of sweats and loss of weight. He was convinced that he was
physically and nervously a permanent wreck.

According to MacCurdy, this case is a typical case of war neurosis of
the anxiety type, except that a relapse with depression is somewhat
atypical.

_Re_ anxiety, Lépine counts trauma as one of the most important
factors. The reduction of morale in physically injured cases may at
times require their rapid withdrawal to a safety zone. The delirium of
the physically injured sometimes takes on a melancholic tinge. Fatigue,
loss of sleep, and cold are other factors of a physical nature. Among
the moral factors, Lépine thinks responsibility (for certain _âmes
scrupuleuses_) is hardly less important than the factor of felt danger.
The contacts of highly cultivated men with the rougher soldier element,
may also count, as well as the separation from home and friends, and
the factor of despair concerning the ending of the war.

_Re_ sexual influences, the factor of sexual continence, though it
may have some importance in producing morbid anxiety, seems to have
less importance under war conditions, when self-preservation is more
in the eye than the sexual life. On the whole, the pre-existent
emotional constitution (Dupré) is of greater importance. A previous
wound may cause a man to acquire such a constitution. Amongst physical
states, hypotensives are candidates for depression; tuberculosis is
particularly important.

_Re_ MacCurdy’s case, the factor of alcoholism was mentioned. The
importance of alcoholism, Lépine has particularly stressed. He
particularly emphasizes the number of men who have taken to drink to
get over their emotions and to forget. Visual hallucinations, angry
excitability, sudden persecutory ideas, nocturnal occurrence of the
symptoms, flushing of the face, suggest alcoholism. Some of the cases
of encephalitis which are supposed to be due to some unknown bacterium,
may really be alcoholic in origin. A third of Lépine’s cases were
alcoholic; perhaps two-thirds really alcoholic if one took into account
the factor of sensitization.


Bombardment from airplanes: Fear; suicidal thoughts; oniric delirium
(“moving picture in the head.”)

=Case 333.= (HOVEN, May, 1917.)

A soldier (born at seven months, somewhat feebleminded, given to
depression, early victim of convulsions, talking only at five years,
with a history of once leaving his father’s house with suicidal ideas
after being scolded, already invalided in peace times) on enlistment
remained with the regiment but a few days and was then sent to a
workers’ company of blacksmiths.

Toward the end of February, 1916, his cantonment was bombarded by an
airplane escadrille. The patient was much frightened, ran away and hid
in a ditch, felt sick, stopped eating, wanted to kill himself and had
to be evacuated to Calais and then to Chateaugiron.

He was there found to be well oriented, but depressed and bewildered.
There was an emotional tachycardia. At night he would fall into a
delirium like the oniric delirium of Régis, always dreaming of the same
bombardment scene, saying it was like a _moving picture in his head_.
The delirium affected him so that he actually tried to make away with
himself.

The dream delirium did not last long but recurred several times on very
slight emotional occasions. It was possible to excite his hallucinatory
dreams experimentally by showing him battle pictures.

Some cases of such delirium develop, according to Hoven, after moving
picture shows of battle scenes.

_Re_ oniric delirium, Chavigny states that mental confusion and oniric
delirium are the two forms of mental disorder that come most frequently
after explosions. He believes that at least 95 per cent of these cases
are rapidly curable; and, in fact, found amongst 60 cases observed in
his army service that only two were so severe as to require being sent
to the interior: all the others were cured in six days at the outside.
These cases, according to Chavigny, ought to be treated in special
wards at the front (bed, quiet, purgation, baths). Chavigny prearranges
slight emotional shock for these cases by talking with them about their
families. Their apparent apathy vanishes in a trice.

Régis, who has named the state “oniric delirium,” states that the
condition never lasts more than a fortnight, is caused by emotional
shock, and occurs in all cases with mental disorder following battle;
but similar hallucinatory conditions have begun to appear also amongst
alcoholics, in garrison or at home. There is emotional constitution in
most of these cases. There is not so much evidence of heredity. Out
of 50 of Régis’ cases, 22 had been wounded, and 28 not. Régis states
that the psychoses are rather more apt to affect men in the reserve,
and are severest in officers. These cases should not be committed to
institutions, but ought to be treated in special military psychiatric
wards containing separate rooms. Very fine-spun diagnosis may be
necessary now and again on account of the occurrence of infectious
deliria and phenomena of the banal psychoses that may closely resemble
oniric deliria.


Shell-shock; emotion (best friend mangled): Stupor with amnesia.

=Case 334.= (GAUPP, March, 1915.)

A soldier, 23 (in civil life a turner, of Polish descent, and of a
somewhat nervous and easily excitable disposition), early in August
went from Strassburg into the Vosges and Lorraine. August 26 a number
of shells exploded near him. The troop was excited and took refuge in
a cellar. His best friend was torn to pieces by a shell. When the body
was removed, the man felt sick and lost consciousness. He arrived at
the clinic in Tübingen in a stuporous condition, by hospital train,
August 31, 1914. He walked weakly to his bed, supported by two men, and
lay in the bed, apathetic and reacting to questions only with a stare.
Things put in his mouth were swallowed. He remained motionless.

Next evening he answered a low _Yes_ to a nurse’s question about
eating. A little afterwards, he said he supposed he was a prisoner in
the enemy’s country. A while later he got properly oriented but still
did not know how he had come. September 2, however, he was much clearer
and said he had awakened out of a long dream. There was a complete
amnesia, however, from the moment when he went to help remove the torn
body of his friend up to September 1. Memories became clearer for the
period before the shell explosion. The patient became very lively,
talking vividly of war experiences, imitating the hiss of shells with
an expression of intense anxiety, getting accustomed to the battle
scenes, saying that he was now seeing everything again as if real. He
remained anxious for some days, complaining of weight on his chest and
of feelings of inner restlessness and tension.

Amnesia for the period August 26 to September 1 remained; all that he
could say was that he had been thrown sidewise for some distance by the
air pressure of the shell.

From September 6 onwards, he grew calmer but he was still very labile,
given to lively imaginings and emotion. By mid September he could be
discharged for garrison duty.


Emotional shock; shooting a comrade: Horror, sweat, stammer, recurrent
nightmare. Improvement on “tracing back.” Brief recrudescence on death
of child.

=Case 335.= (ROWS, April, 1916.)

A man after a charge was placed on outpost duty. It was dark, and he
was in a state of considerable tension. He heard a noise which he
thought came from somewhere in front of him. Suddenly the space around
him was illuminated by a flare of light, and he saw a man crawling
over the bank. Without challenging, he fired and killed the man.
Next morning, he found to his horror that he had killed a wounded
Englishman, who had advanced beyond his comrades and was crawling back.

A physical expression of horror, together with an intense sweating and
a very marked stammer, persisted for months. At the same time, he was
tormented with a fearful nightmare, and in his sleep he was heard to
say, “It was an accidental shot, sir; yes, Major, it was not my fault.”
In the day time, also, his attention was concentrated on the memory of
the incident, so that “I cannot forget it no matter how I skylark.”
Carrying his story back to this trying time led to his recounting
his terrible secret, and a marked improvement followed. The physical
signs of the intense emotion gradually disappeared. The vividness of
the dreams diminished, and his attention was less concentrated on
the one subject. It is interesting to note that the production of a
marked emotional state by the death of one of his children led to a
recrudescence of his former symptoms: an expression of “horror and the
stammer.” But they disappeared again in a short time.


Emotional shock: Phobias.

=Case 336.= (BENNATI, October, 1916.)

An Italian corporal in the infantry, a robust man of a well-to-do
family, took a good deal of pleasure in the war life. One day a
comrade was injured by a missile of some sort, and died almost
immediately. This comrade, after being hurt, had thrown himself
against the corporal, who was asleep at the time. He woke up sharply
and immediately felt sick. His status was one of great terror,
lacrimation, lack of spontaneity, and insomnia. He would wake up from
sleep and start from a terrible dream. He had a number of phobias and
was especially interested in other persons who had the same sort of
mental state as himself. He was in a state noted by Bennati as one
of “emotional anaphylaxis” to various events around him. There was a
horizontal nystagmus, the Mannkopf sign was positive (87-72), Thomayer
90-114, Erben 114-90. There was a slight tendency to dizziness when the
Erben movements were made.


Shell-shock; fright: loss of consciousness next day: Generalized
tremors; “somebody above with a mallet.”

=Case 337.= (WILTSHIRE, June, 1916.)

A sapper of 19, with a nervous mother, had had an attack two years
before his war neurosis, of a somewhat similar nature. This former
attack had been caused by overwork; there had been no accident or
fright, but the man had been unable to work for five months.

At the front, he had been well up to ten days before observation. In
a dugout a shell had pitched on top of the bank, followed by another
shell bursting in front. There was a slight falling in of the dugout
but no special damage.

The patient carried on that night but reported sick next morning,
feeling queer and shaking slightly above the waist. He remembered
getting half-way down the road to see the M. O., but nothing more until
he came to in the dressing station (perhaps 2½ hours later). After two
days in hospital, he was transferred to a convalescent camp, and then
admitted to another hospital. He complained of twitching and slight
frontal headache; funny feelings at night prevented his going to sleep.
Thus: “A man was over my head with a mallet, going to hit me.” There
was a dream of “somebody above me all the time.” Both arms, head,
and tongue were in a state of constant tremor, and there were jerky
movements of the legs. There was some spasm of the right leg. Both legs
went into violent tremor on examination, and during examination there
was free perspiration.

_Re_ tremors, all sorts of tremors of unknown nature are apt to get
the designation _hysterical_. Meige believes that the Shell-shock
tremors, which are apt to be very persistent, are very possibly due to
changes in the nervous system. Ballet has noted how the tremors, as
in the above case, are often associated with expressions of fear. Now
and then there is an obsessive disorder dubbed tremophobia by Meige,
which produces a vicious circle. Tremors lead to obsessions, and the
obsessions in turn exaggerate the tremors. These Shell-shock tremors
are apparently not related to (though they may need differential
diagnosis from) such conditions as paralysis agitans, multiple
sclerosis, hyperthyroidism, cerebellar disease, neurosyphilis, and
alcoholic or other intoxication.

Roussy and Lhermitte distinguish the tremors into (_a_) atypical ones;
that is, disorderly, irregular movements seemingly determined by the
subject’s caprice; and (_b_) typical tremors, such as those found in
the well-known nervous diseases and presumably imitated in hysteria
from these well-known diseases. Generalized atypical tremors are, as a
rule, combined with a variety of other Shell-shock symptoms, and often
exhibit a sort of mimicry of fear.


Shell-shock; burial-work: Amnesia. Shell whistling conditions idea of
something nasty.

=Case 338.= (WILTSHIRE, June, 1916.)

A private, 19, in the R. A. M. C., was sent in with a field ambulance
note as follows:

    “Private ---- was close to a shell which burst among a company
    standing in the road, killing 20 and wounding 20 others. He
    worked well in assisting the wounded, and then proceeded to
    clear up the fragments of the killed. Whilst doing this, he
    suddenly lost his mental balance and has been in his present
    state nearly 24 hours. He has been given bromides.”

    An M. O. attached to the same ambulance wrote: “This man is
    suffering from mental shock caused by having to clear away
    the remains of a number of men killed by a shell. He does not
    recognize his friends, and at frequent intervals has periods
    of terror, exclaiming, ‘Cover it up.’ He is sleepless (without
    drugs); he takes food badly. He is possibly suicidal or may
    become so.”

According to the patient himself, he had been quite well for four
months at the front. He was on the La Bassée Road with the troops after
a day or two of heavy work under shell fire. “And I remember the flash
of some shot and a shell burst I think, and I can’t remember anything
more. I awoke in the morning, in the train” (48 hours later). “I can
only remember men calling out.” He complained of a feeling in the
head, as if expecting something. “Something seems to be coming,--as
if something was going to happen,--something nasty, whenever I hear
anything like the whistling of a shell coming towards me.” This patient
was without tremor and was physically normal. So far as the patient’s
own story went, the case might well be regarded as one due to physical
concussion, but the notes of the medical officers give evidence of a
psychic element.


Depression with suicidal thoughts after witnessing death of comrade.

=Case 339.= (STEINER, October, 1915.)

A farmer, 52, volunteered and was put in charge of a drinking-water
still. He had never been ill nor was there any nervous or mental
disease in his family. From the end of August he was frequently under
shell fire, but the only effect thereof was a somewhat poorer sleep
than normal.

December 14, 1914, a young comrade, a volunteer, wanted to clean his
dirty kettle at the drinking-water still. The farmer later described
this volunteer as a young fellow “like milk and blood” (as we might
say, “like peaches and cream”) and as the handsomest young man he had
ever seen in the war. The rules forbade such use of the still, and
young “milk-and-blood” was told to go down to the brook, and then come
back and get the distilled water. The young man complied, but while at
the brook he was shot and killed in full sight of the farmer.

The farmer grew much excited and trembled all over. Thereafter he could
not eat or sleep; he reproached himself, although he knew he had acted
quite correctly; wished he had been in the place of this comrade;
and had suicidal thoughts. He was deeply depressed, wept easily,
and showed manual tremor. Steiner terms the farmer’s account of the
person of the deceased “reactive idealization.” After a week there was
considerable improvement. B. was sent back to work, which he felt would
be beneficial. He was put in less dangerous surroundings, and this also
had a good effect.


Marching and battles: Neurasthenia?

=Case 340.= (BONHOEFFER, January, 1915.)

A subaltern had been treated before the war for nervousness, dizziness,
and “mattigkeit” (convulsions in infancy), but proved himself a good
soldier, having gotten his rank after the first period of practice.

He was in three battles in Belgium, but on the march one day suddenly
had a spell of weakness and is said to have had convulsions. There was,
however, no biting of the tongue, and no enuresis. After a week in the
field hospital, he was sent back to Berlin where he had some somatic
feelings of anxiety without subjective disturbance or any disorders of
consciousness except a certain amount of inhibition; he was sleepless
and hypersensitive, cried easily, and was apprehensive on being
touched; he winked violently on examination of his eyes, and while
being tested for reflexes made violent contractions of a semi-voluntary
nature.

After four days in bed, which was a prescription hard to carry out
at first on account of the anxiety sensations, these sensations
disappeared, and at the same time the fears. Weight began to increase;
memories returned, except that even upon recovery he could not remember
that he had ever had any true subjective feelings of fear. He was
discharged 19 days later, desirous of going back into the field.

The peculiar absence of subjective feelings of fear in this case is
something like what Awtokratow reported from the Russo-Japanese War,
terming them neurasthenic psychoses.

_Re_ neurasthenia, Babinski believes that, by means of his logical
dismembering of the old hysteria concept, he has shown that the
exhaustion phenomena at the bottom of neurasthenia are precisely these
that cannot be cured by suggestion. There are numerous cases in which
hysteria and neurasthenia are combined. From these combined cases,
suggestion causes the hysterical or pithiatic symptoms to be removed.


English schoolmaster’s account of his war dreams.

=Case 341.= (MOTT, February, 1918.)

A sergeant, who had been a schoolmaster, was asked to write down his
dreams by Captain W. Brown, who had sometimes charge of Mott’s cases at
the Maudsley Hospital. The first dream was as follows:

    “I appeared to be resting on the roadside when a woman
    (unknown) called me to see her husband’s (a comrade) body which
    was about to be buried. I went to a field in which was a pit,
    and near the edge four or five dead bodies. In a hand-cart
    nearby was a _legless body_, the head of which was hidden from
    sight by a slab of stone. [He had seen a _legless body_, which
    was covered with a mackintosh sheet, which he removed.] On
    moving the stone I found the body alive, and the head spoke to
    me, imploring me to see that it was not buried. Burial party
    arrived, and I was myself about to be buried with legless body
    when I awoke.”

The second dream was as follows:

    “After spending an evening with a brother (dead 11 years
    ago) I was making my way home when a violent storm compelled
    me to take shelter in a kind of culvert, which later turned
    into a quarry, situated between two houses. Men were doing
    blasting operations in the quarry, and whilst watching them I
    saw great upheavals of rock, and eventually the building all
    around collapsed (explosion of a mine). Amongst the débris
    were several mutilated bodies, the most prominent of which was
    _legless_. I tried to proceed to the body, but found that I was
    myself pinned down by masonry which had fallen on top of me.
    As I struggled to get free the whole scene appeared to change
    to a huge fire, everything being enveloped in flames, and
    through the flames I could still see the _legless body_ which
    now bore the _head of my wife_, who was calling for me. I was
    struggling to get free when my _mother_ seemed to be coming to
    my assistance, and I awoke to find the nurses and orderlies
    standing over me.”

It appears that the patient had been shouting in his sleep, beginning
in a low voice and gradually becoming louder until at last he was
shrieking. The _legless body_ occurred in all his dreams; the sight of
this had evidently produced a profound emotional shock. He had worried
a great deal about his wife, who was much younger than himself, so that
we have this incongruous association of the _legless body_ and the
_head_ of his wife calling him; finally, what more natural than the
_mother_ to come to his help. The emotional complex is not incongruous
in this dream, for fear is linked up with the tender emotion.

_Re_ war dreams, see remarks under Case 333 concerning oniric delirium.
Roussy and Lhermitte say that emotion and concussion are the causal
factors; but in a case like 341 we have persistent war dreams of the
same general nature. Such a case as Mott’s would not be regarded as one
of oniric delirium, for the patient is not living throughout the day in
a dream, but merely has certain set dreams. The true oniric delirium
cases may lead to fugues of medicolegal importance. Mott’s conception
is that the terrifying experiences that come to light in the dreams are
repressed by the conscious activity of the mind in the waking state.
For this process, the phrase _psychic trauma_ might be used. Rows
speaks of a prolongation of mental disorder through memories which get
revived in dreams. The memories of past and recent events pile up on
one another. Elliot Smith remarks on the number of cases in which the
dreams show a coalescence and blending of episodes alien to the war.
_Re_ such combinations, see Case 342 of Rows, below.


Trench experience: War dreams, shifting to sex dreams. Recovery on
giving the patient an insight into the nature of his dreams.

=Case 342.= (ROWS, April, 1916.)

A patient broke out of a hospital after being refused permission
to leave the grounds. He grew much depressed and said he had been
disgraced and would commit suicide rather than bring disgrace on his
family. Investigation into this emotional outburst showed that his
father had deserted the family, that he had gotten into prison, and
“tainted me.” The patient was worried also about an idea of loss of
sex power, gathered from a book by a quack doctor, read years ago.
It appeared also that this doctor had advertised a special bread and
special medicine which would preserve the nervous system, and that for
years the patient had fed himself and his family with the bread and
medicine. When the true state of affairs was shown to the patient, his
restlessness at night disappeared. The mental condition of this man in
fact became practically normal, and the marked tic of facial muscles
and the general tremulousness of the man disappeared.

It is of note that this man’s dreams began with a terrible incident in
the trenches and then shifted to sex acts. He woke to find the clothes
disturbed.

This is an example of hallucinations dispelled by tracing them to their
source, and giving the patient a clear insight into their nature.

According to Ballet and de Fursac, after the acute phase of stupor
and excitement with hallucinations and delirium passes, the patient
remains a depressed and psychasthenic subject. In this psychasthenia
we find inhibitory phenomena, hyperemotionalism, and over-imagination.
Amongst the inhibitory phenomena are many of the hysterical effects.
The hyperemotionalism yields anxiety, worry, tremors, respiratory
and vasomotor disorder, dizziness, convulsions. The third main
disorder of the psychasthenic state into which the patient relapses
is over-imagination, whereunder we find bad dreams (bombardments,
drum-beating, corpses, attacks), somnambulistic hallucinatory episodes.
It is these hyperemotional and hyperfantastic features that distinguish
the Shell-shock syndrome from ordinary psychasthenic states.

_Re_ the sex element in this case, see remarks under preceding case
(341) and also Lépine on the sex factor (Case 332). Rows believes that
those cases which do not recover after a short period of rest and quiet
in hospital are cases in which there is some emotional state based upon
the constant intrusion of the memory of some past event. The physical
expression of the emotion of fear or terror may persist for a long time
quite unchanged and be proved to be due to this old factor.


Emotional shock: Recurrent dreams of war and peace incidents. Recovery
followed tracing the dreams to their origin.

=Case 343.= (ROWS, April, 1916.)

A soldier and a comrade were carrying a pail of water to the trenches.
It was very cold and they set down the pail in order to warm their
hands. The comrade placed his hand against the man’s cheek and said,
“That hand is cold.” At that moment he was shot dead.

This incident was involved not only in dreams at night, but in the
daytime too, if he were quiet and closed his eyes, he could feel the
cold hand against his face.

He was troubled at the same time by another dream, in which he ran
down a narrow lane at the bottom of which there was a well. He dipped
his hands into the water, but on withdrawing them, he was horrified
to find they were covered with blood. This dream was connected with a
love affair, in which a good friend interfered and angered him so much
that he attacked him when next they met. He left him on the ground so
injured that it was necessary to take him to a hospital. The patient
became anxious as to what the result might be and left the district. He
traveled, but never heard whether his victim had died.

When these two dreams were traced back to their origin they
disappeared: the patient made a rapid recovery and was able afterwards
to bear a severe trial satisfactorily.

See remarks under Case 342.


War dreams, including hunger and thirst.

=Case 344.= (MOTT, February, 1918.)

(_Recorded Dream of a Second Lieutenant._)

“During the five days spent in the village of Roeux I was continually
under our own shell fire and also continually liable to be discovered
by the enemy, who was also occupying the village. Each night I
attempted to get through his lines without being observed, but failed.
On the fourth day my sergeant was killed at my side by a shell. On the
fifth day I was rescued by our troops while I was unconscious. During
this time I had had nothing to drink or eat, with the exception of
about a pint of water.

“At the present time I am subject to dreams in which I hear these
shells bursting and whistling through the air. I also continually see
my sergeant, both alive and dead, and also my attempts to return are
vividly pictured. I sometimes have in my dreams that feeling of intense
hunger and thirst which I had in the village. When I awaken I feel as
though all strength had left me and am in a cold sweat.

“For a time after awaking I fail to realize where I am and the
surroundings take on the form of the ruins in which I remained hidden
for so long.

“Sometimes I do not think that I thoroughly awaken, as I seem to doze
off, and there are the conflicting ideas that I am in the hospital, and
again that I am in France.

“During the day, if I sit doing nothing in particular and I find myself
dozing, my mind seems to immediately begin to fly back to France.

“A dream that keeps on coming up in my mind is one that brings back
a motor accident I had about six years ago, which gave me a severe
nervous shock. I had, of course, entirely forgotten about it, except
when in a motor, when I always thought of it.

“Of the fifth day I have absolutely no recollections.”

This is the one instance in which a man has dreamt the experience of
hunger and thirst in addition to battle experience.


Olfactory dreams: Hysterical vomiting.

=Case 345.= (WILTSHIRE, June, 1916.)

A lieutenant in the infantry (mother, of a nervous disposition) had
been at the front for 3½ months when he started vomiting everything he
ate.

He was transferred a fortnight later to a base hospital as “gastritis.”
Physical examination proved negative, but the man complained of his
nerves. He slept badly owing to trench-life dreams, from which he would
wake in a sweat. He was quite unwilling to refer to these dreams.

In point of fact he had had to supervise the burial of many decomposing
bodies, after which he had been haunted “by that awful smell of the
dead.” Then developed states of abstraction, in which he went over and
over the burying experience. He cried by himself.

It seems that the vomiting was secondary to hysterical hallucinations.

_Re_ affections of smell and taste, Roussy and Lhermitte remark that
they are rare following shock or trauma in war. Medical suggestion may
produce a hemiageusia or a hemianosmia. Mott’s case above (344) showed
unusual dreams with hunger and thirst. For another olfactory case, see
Case 510 (Rivers) in the Treatment Section of the book, a case in which
Rivers was able to find no redeeming feature upon which to ground his
re-educative suggestions.

_Re_ vomiting, Roussy and Lhermitte state that this relatively common
condition is diagnosticated readily enough but that pyloric ulcer and
other organic causes must be eliminated. They remark that there is
no tendency to spontaneous cure of neuropathic vomiting, and commend
strict dietetic régime and psychotherapy. They ally the condition in
its nature and genesis with so-called false or hysterical incontinence
of urine in soldiers. Wiltshire’s case early received the diagnosis
“gastritis.” It is remarkable how little emaciation need follow such
vomiting.


Shell-shock: Amnesia; dreams of falling. POST-ONIRIC
suggestion--surprise produced fear of falling.

=Case 346.= (DUPRAT, October, 1917.)

A man was subjected to shell-shock August 11, 1916, at the Somme. He
lost consciousness for five hours and was picked up stuporous with
verbal amnesia, which soon passed leaving only a difficulty in getting
the right word promptly. He began to have frightful dreams of falling
into a hole and of exertions to avoid falling, whereupon he would awake
with a feeling of anxiety that would last some time. Treatment caused
the dreams to disappear.

There remained, however, a powerful _post-oniric_ suggestion. Any
slight surprise would cause the fear of falling to reappear. There was
a sort of derived phobia, against any military act that would need to
be performed upon sudden order. He developed a blind anger against any
commanding officer who gave a brusque order. After the crisis of anger
he would fall into tears and a feeling of profound depression coupled
with precordial anxiety. There was also a chronic aortitis physically
determined. The man himself had a vague idea of the relationship of his
fear of surprise to the old nightmares.

_Re_ persistence of fear and its relationship to nightmares, see
remarks under Case 342 (ROWS).


Four months’ SERVICE IN THE REAR: Depression; war HALLUCINATIONS (not
based upon actual experiences); psychasthenic symptoms.

=Case 347.= (GERVER, 1915.)

A Russian lieutenant, 32, arrived at the front in November, 1914, but
never served on the front line, or had occasion to visit the line or
the trenches. Toward the close of February, mental symptoms appeared,
which caused the man’s evacuation to the interior.

He was a tall, well-built, well-nourished man, who was physically
normal except for sharp twitching movements of the tongue, eyelids, and
face; tremors of extended hands, occasionally spreading to the whole
body; well-defined dermatographia (in places, stereodermatographia);
exaggerated tendon reflexes; tenderness of skull and spine;
hyperesthesia of chest; pulse 120.

Mentally, the patient was markedly depressed, irritable, at times
lacrimose. His complaints were of a psychasthenic tinge. He feared
incurable disease. He feared to go to the front, and was terrified at
what he might do there. He feared crowds of soldiers; he was afraid
of forests and mountains; the Germans were going to break through and
capture him; shells were about to burst over his head. He was also
disturbed about his family, regarding his wife and son as helpless,
sometimes even as dead. Suicidal thoughts at times.

At night, though he had never been at the front, he had hallucinations
of shots and the voices of soldiers, as well as those of his wife
and son. He smelt an unpleasant corpse-like odor. He was unable to
distinguish these hallucinations in any respect from reality. He
complained of general weakness, headaches, palpitation of the heart,
vertigo, and insomnia, and of a variety of pains.

He was non-alcoholic and non-syphilitic, and had been in perfect health
before the war.

_Re_ war hallucinations with service back of the line, compare remarks
of Régis (see under Case 333).


A case of hysterical astasia-abasia develops “big belly”
(“catiemophrenosis”), perhaps by hetero-suggestion from a ward neighbor.

=Case 348.= (ROUSSY, BOISSEAU and CORNIL, May, 1917.)

A farmer, 22, of the foot chasseurs, who had been in various hospitals
with a variety of diseases before his injury, was evacuated June 2,
1916, for “contusion of back,” to the temporary hospital at Bussant,
from which he was evacuated to Pontarlier for “contusion of back and
cerebellar shock” and thence, July 21, to Besançon for “internal
contusion and cerebellar shock”; thence to four other hospitals from
July 31 to February 17, 1917; finally to the Hospital at Veilpicard
with “functional disorders, paraplegia, trepidant astasia-abasia.”

It seems that he had lost consciousness for fifteen days and had
thereafter been paraplegic with retention of urine. The abdomen
had then increased in size in such wise as to be termed a nervous
pregnancy, _grossesse nerveuse_. The evolution of this pseudotympanites
was probably related to the presence of the same so-called “big belly”
of a patient who had been in a neighboring bed from May, 1916, onwards.
The feet were in equine position with toes flexed, suggestive in all
ways of hysterical paraplegia. The abdomen looked like that of a woman
six months pregnant and measured 78 centimeters in a plane passing
through the anterosuperior iliac spines and the umbilicus. The abdomen
was hard, tense, swollen, and on palpation, gave out a low, tympanic
note. When the diaphragm was mobilized progressively and slowly, the
tympanites could be made to disappear. Slow pressure on the abdomen
with flat hands effaced the swelling for the time being; but upon
release of the hands the abdomen would swell up again as before.
Pressure on the abdomen produced a contracture of the recti. Forced
flexion of thighs on pelvis (as suggested by Denéchau and Matrais) also
caused the swelling to go down. Faradization of the phrenic nerves
in the neck caused respiratory movements with a slight diminution
in the volume of the abdomen. There was an obstinate constipation
requiring daily lavage. Respiratory movements were short and rapid and
of the thoracic type. Abdominal compression caused the respiration to
assume almost a normal rhythm. X-ray examination of the abdomen, after
50 grams of bismuth carbonate had been taken in three spaced doses
the evening before, showed the intestine to be distended by gas in
such wise that the lower border of the liver became clearly visible,
as after insufflation of the stomach. The bismuth was found in the
large intestine. The splenic angle filled with bismuth was low. On
compression the splenic angle was raised with the diaphragm.

The main features of this disease are the large abdomen, simulating
what has hitherto been found chiefly in females under the name of
nervous pregnancy, but also suggesting a tuberculous peritonitis (one
patient was actually evacuated to a hospital for tuberculosis with this
disease); gastro-intestinal disorder with aerophagy, aerocoly, and
obstinate constipation (one case also showed almost daily vomiting).
The genesis of the condition appears to be a contracture of the
diaphragm in a low position of forced inspiration. The condition may be
termed a diaphragmatic neurosis.

Psychotherapy was applied, the patient was requested to walk, and
the movements made in walking required such an intense respiration
that the diaphragm was forced to function, whereupon the “big belly”
disappeared. The digestive disorders then rapidly disappeared. These
authors suggest the name of _catiemophrenosis_.


War stress; collapse going over the top: Neurasthenia (hereditary
taint; alcoholism).

=Case 349.= (JOLLY, January, 1916.)

A German soldier, 35, of a nervous make-up (his mother was nervous, and
he had been nervous and tremulous and easily excitable, and alcoholic
to the extent of at least 5 glasses of beer every night), was called
to the colors in September, 1914. He got through his training well;
in May, 1915, was on very strenuous duty in a very exposed position,
had frequently to stand up under heavy shelling, had a number of
frightful experiences, was surrounded by corpses and mutilated bodies,
and frequently took part in storming attacks. His nervousness came
to a head with some suddenness; just as he was about to “go over the
top,” he had no strength for the effort and collapsed. Thereafter he
could no longer stand shelling, could not speak, and was inattentive to
surroundings. When he was examined by a physician he fell asleep in his
presence, although sleep had latterly been almost impossible on account
of the shelling. He was immediately put on the hospital train and taken
to the reserve hospital in Nuremberg, where he presented an appearance
of extreme exhaustion, wept, seemed much fatigued, and trembled all
over whenever he started to do anything. He was very easily excited and
especially sensitive to noise. There was a fine tremor of the whole
body and especially of the head; the knee-jerks were increased; there
was a moderate vasomotor reddening of the skin after stroking; his
tongue was heavily coated; but there was no other evidence of internal
disorder. His pulse was strong and not rapid.

The patient got well gradually, complained at first of bad dreams, and
was given to weeping. The tremors slowly improved. The patient grew
better in a hospital at home.

As to the diagnosis of this case, Jolly regards it as one of nervous
exhaustion. The remarkable feature is the tardiness with which the
symptoms developed under the stress of war. Such a patient would
probably never develop a neurasthenia under normal peace conditions.
After recovery these patients may be sent back for garrison duty or
for other work not directly connected with the firing line. As for the
tendency to desire a pension, this wish, according to Jolly, must be
strenuously opposed, both in the interest of the state and that of the
patient. If there is no will to get well, some of these patients are
found vibrating from garrison service to furlough and to hospital.

The above case is one of the simplest observed; yet there is evidence
both of hereditary taint and of alcoholism. According to Jolly, the
majority of the severe exhaustion states of a neurasthenic nature
have been, in his experience, distinctly nervous before the war, and
frequently show hereditary taint as well.

_Re_ neurasthenia, see views of Babinski relative to differentiation
from hysteria (under Case 340).


Series of battles: Sudden mania followed by confusion with fixation of
mind upon war experiences, possibly hallucinatory; general analgesia.

=Case 350.= (GERVER, 1915.)

A Russian private, looking much older than his years (35), had been
in a number of battles without mental disorder. Where he was posted,
however, there was a heavy artillery fire in the last of the battles.
Suddenly the man became excited and leaped upon his comrades’ shoulders
crying, “The devil is here! This is hell and murder, and here are
the devil’s imps!” The commanding officer accordingly ordered him to
the rear. His regiment had suffered severe losses in a succession of
attacks upon a certain strategic height.

Upon evacuation to the field hospital and thence to the interior, his
excitement did not lessen. He went about with a lost look, trembling,
talking a great deal and gesticulating. His talk was incoherent and
pointless. After every few phrases, he would repeat, “Don’t ride there!
That’s hell! Murder is being done. Devils and unholy powers are beating
and killing people.” As he said this, he would tremble, and hands and
feet would stiffen with a suggestion of catalepsy. There was general
anesthesia to pain; no response was made to deep pin-pricks. The pupils
were dilated and failed to react, either to light or to pain. The
tendon reflexes were exaggerated. No contraction of visual fields. The
man was disoriented for time and place and much confused. No paralysis.
No wound or contusion.

_Re_ analgesia, we may only say that hysterical anesthesia appears in
a variety of forms; sometimes (_a_) in the form of a classical stigma
of hemi-anesthesia; (_b_) in a segmentary form; again (_c_) in isolated
patches; (_d_) in a very rough way approximating the peripheral nerve
distributions. Babinski gives an unpublished note by Lasègue, in which
he states that hysterical patients not enlightened by the doctor’s
investigations do not make mention of anesthesia. But in case 350 a
psychotic factor may have entered.


Ten months of military service (several battles) without reaction;
then, hot machine gun battle: Mania with disorientation and war
hallucinations.

=Case 351.= (GERVER, 1915.)

A Russian private, 24, in a scout company, entered the war on
mobilization and took part in several battles without reaction. May
11, 1915, he was sent with the scout party into a hot encounter, hand
to hand with machine-guns. After the battle, the man began to yell
incoherent phrases at the men around him, started to climb over the
top, and shot off his gun without permission. He was accordingly sent
to hospital, where he was under observation for a week, during which
he had occasional flashes of excitement, jumping out of bed and making
movements of cutting or shooting, and then in a few minutes subsiding
into inactivity.

He was a short but well-built and well-nourished man; the pupils
responded rather weakly in accommodation; there was a small fibrillar
tremor of the face, eyes, and tongue. The skin reflexes were
diminished and there was a general hypalgesia; considerable mechanical
overexcitability of muscles; no other neurological disorders. The
mental state was one of confusion. Although he was in one of the corps
hospitals, he said he was in a dug-out; the doctors were lieutenants;
the attendants were privates in his company. Answers to questions
were irrelevant or incoherent; there were a number of delusional
expressions. He was to be shot because he had not himself shot enough
Germans. If he were not to be shot, anyhow the soldiers would poison
him. Rather than this he should be allowed to go into an attack. He
would take a German fort and the Czar would name him a colonel. His
regimental commander was saying to him, “You will be a hero, you will
soon get a company.” His hallucinations sometimes included the voices
of Germans saying, in broken Russian, “We will hang you and cut your
belly open!” There was considerable amnesia for dates and even his last
battle.


Numerous attacks and counter attacks in one day: Sudden incoherence
with disorientation and the rapid development of war hallucinations of
a scenic type. Suggestion of catatonic phenomena.

=Case 352.= (GERVER, 1915.)

A Russian lieutenant, 28 (no mental disease, non-alcoholic), was in
battle August 14, 1914, on which day his company attacked and was
itself attacked several times. An officer who observed the lieutenant
said that he came to him and informed him that the Germans must first
be burned and then fought with. Thereafter the lieutenant began to
speak loudly and incoherently, sometimes yelling incoherent orders.
He was accordingly removed from the battle-field to the hospital back
of the line. Upon examination, he was found to be of middle height,
with dilated pupils, responding weakly to light and not at all to
accommodation; twitchings of face, eyelids, and tongue, digital tremor,
marked dermatographia, general analgesia, tendon reflexes somewhat
exaggerated, cataleptic tendency in feet and hands.

Mentally, the patient was in a stupor, sitting or standing in one
place, without initiative; uncomplaining but occasionally uttering deep
sighs or occasional isolated phrases. He answered no questions or only
after a long pause. He was disoriented for time and place, but gave
evidence of delusions and hallucinations. He thought, for example,
that he was the chief of staff and had brought with him a squad of
captured Germans who were standing nearby. Some wanted to be fed and
let go; others were yelling and saying they would burn down the house.
Sometimes the patient would hear shots and shells bursting, at which
he would shudder and turn away. Apparently he would see his comrades
falling under the shrapnel hail. However, he stood his ground and
commanded the rest of the soldiers to go forward to the attack. Now
and then he was negativistic, flexing the hands upon request to extend
them, refusing food and drink. He was still apathetic on evacuation to
the interior.


Shell-shock after two days in trenches: Hysterical STUPOR seven days.
Cure in three weeks, barring amnesia for stuporous period.

=Case 353.= (GAUPP, March, 1915.)

F. S., in civil life a wreath-binder in a flower shop, and from
childhood very nervous and excited, subject to frequent nosebleeds and
fainting spells (_e.g._, at sight of blood), enlisted at 22, November
3, 1914, as a reservist. January 18 he went into the field.

The wreath-binder was only two days in the trenches before going
unconscious under the whistling and exploding shells. Physically
uninjured, he was received in reserve hospital C in a deep stupor,
January 22. He was unresponsive at first, once however saying, lost in
a dream, “When will mother come?” His gait was unsteady and he had to
be led and held. He slept a good deal in the daytime.

He became somewhat more active mentally, January 24 (remarking that
he had slept well), and made his toilet, but he did not yet have
bearings and wanted to go to his place of business. The next day his
condition was similar. Asked what troop he was with, he said, “In
the flower business.” January 26 he was much better, telling of the
army training and a little about the war, and wrote a postcard to his
parents. The stupor disappeared after January 27 and the patient became
mentally normal. Amnesia persisted for the time, January 20 to 26.
Headaches. February 9 he was well, except for the limited amnesia still
persisting. He was eventually sent back to garrison duty, cured.

_Re_ stupor, Grandclaude remarks that stupor is probably the most
frequent of the mental symptoms of Shell-shock, and that it may
last from a few moments to a week. During the stupor the patient is
asthenic, stertorous, and staring. Upon recovery from the stupor, a
condition of dulness with amnesia and disorientation ensues. There may
be a third phase of a more hyperkinetic character, with hallucinations
and delusions concerning the war. These stuporous cases are among
the most serious of the conditions found, as some of the victims may
even suggest dementia praecox from the persistence of childishness
and silliness. As in Gaupp’s case, Grandclaude finds that headaches
and amnesia persist. Relapses are frequent on the basis of a kind of
sensitization.

_Re_ amnesia and Shell-shock, Roussy and Lhermitte speak of amnesia
as ordinarily a phenomenon of confusion. Amongst the mental disorders
of the Shell-shock psychoses, these authors describe a group due
to inhibition or diminution of mental activity, including the rare
narcolepsy, or pathological sleep, and the confusional states proper.
Simple confusion involves slowness in thinking, and amnesia often
anterograde from the moment of the shock. Simple confusion ought to be
distinguished from so-called “obtusion” or torpor, in which there is a
disorientation for time and space, such as was shown in Mallet’s case.
Chavigny has described an aprosexic form (with “birdlike” movements).
More common is the amnestic form of torpor. The amnesia may not merely
be anterograde from the moment of shock, but may extend to a prolonged
period prior to the accident. Sometimes the amnesias are selective,
producing phenomena of pseudo aphasia.


Amnesia, monosymptomatic. Progressive recovery.

=Case 354.= (MALLET, January, 1917.)

An infantryman, 36, arrived without information at a psychiatric
center, March 15, 1916, looking confused and knowing little more than
his name, believing himself in a distant town. The disorientation
lasted to March 21, on which day the man recognized the doctor as such,
knew that he was at a hospital, but felt that he had just left home
and wife. From this time on, he began to pick up his surroundings,
evidently not knowing that there was a war or that he was a soldier.
He did not recognize one of his own company. It was not until March 31
that the first memory of the war reappeared, namely, a memory of the
call to the colors, drums, bells, and crowds. April 11 he recollected
that he was a soldier and that his wife was in the country, where he
had left her on the eleventh day of the mobilization. In the next few
days, memories came back bit by bit. He had been at first a little thin
and showed a slight fever, oliguria, and poor digestion. All these
symptoms now lapsed, and the man became apparently perfectly well.

Such states, according to Mallet, are relatively frequent in soldiers,
both in epilepsy, and in infectious deliria,--more than in the deliria
of exhaustion.


Aviator shot down: Organic mental symptoms.

=Case 355.= (MACCURDY, July, 1917.)

A Canadian, 20, of normal makeup, in 1915 lost part of his left foot in
a railway accident, but, notwithstanding, was finally commissioned in
the Royal Flying Corps. He enjoyed the nine months of English training
greatly. In France he made several successful flights over the lines,
but was shot down and crashed to the ground within the British lines
after two weeks of service. He got black eyes and bruises and lost
consciousness for about four days, though a week later he was still
hazy about recent events and was not quite sure in what hospital he
lay. After another week he arrived in a London hospital.

Here he would not answer questions, but stared at the examiner, finally
shouting: “I want to get up.” He said he was in a certain suburb of
Toronto, which, however, he insisted was a part of London not far away.
He wanted a taxicab to go thither. He pondered, but seemed content
when told that Rosedale was across the ocean. A superficial machine
gun wound of the hip the patient said must be the mark of a hospital
in France; it was a secret mark, meaning that he could return to the
line and fight whenever he wanted to and that he could use the lavatory
whenever he wanted to. He sometimes uttered brief phrases after
questioning. Asked if he dreamed, he looked up cunningly and said,
_e.g._, “I down the Boche. I am a live wire.”

Next day it was clear that he had gained a good deal of information
from the nurses, and the day after he had become oriented for time and
able to recognize the physician, though still confused about hospital
names and his recent movements. The 7 from 100 test he did slowly
and made several bad unrecognized mistakes. He was over-fatigueable,
complained of foggy eyesight, showed haziness and redness and obscure
margins in the optic discs, with the remains of one hemorrhage, and
presented nystagmus on looking to the extreme left. Two weeks later
he complained less of his memory and said that he was beginning to
remember what had happened during the last day of his fighting; the
chase by the German airplane and the maneuvers. He worried about being
sent back to France by a medical board, which would not realize that he
was incompetent to fly again. The left pupil was slightly larger than
the right.

In this case there were no neurotic symptoms and according to MacCurdy
the difficulties here are strictly those of organic type.

_Re_ organic cases of traumatic psychosis, Lépine sums up the
subjective phenomena as follows: There is (_a_) a cephalea, often
a feeling of weight, varying at different times of the day; often
frontal; often subject to marked alteration on movement. There may be
(_b_) a number of visual phenomena like those mentioned under Case
355, part and parcel of a sort of absence, suggesting an epileptoid
effect. Sometimes (_c_) there is vertigo, but this is rare. There are
also congestive attacks. The patients are unable to work, and have
strange head sensations when they attempt to work. The memory disorder
is not as a rule markedly accentuated. This amnesia is usually a
disordered fixation of current events, but there is also a retrograde
amnesia. Insomnia and impulsiveness are also found, and more rarely
is a depressed and melancholy state suggesting that which Case 355
exhibited. Lépine has tried to define the traumatic psychoses (not
_neuroses_) on the basis of phenomena found in trephined cases. He
remarks upon the extreme analogy, not to say identity, between the late
sequelae of trephining and the syndrome of _commotio cerebri_.


Daze with relapses; mutism--following shell fire and corpse work.

=Case 356.= (MANN, June, 1915.)

A soldier lost his voice apparently from two factors: shell fire and
the emotional shock of helping to fill the big common graves. The man
could never tell for certain (retrograde amnesia) whether he went from
corpses to shell fire or from shell fire to corpses.

Several weeks of daze followed in which he hardly reacted to outward
stimuli, but occasionally said “It smells!” “Leave me still!”

He recovered gradually from the daze. But merely hinting at his
experiences, especially the smells, sufficed to throw him into another
daze.

The loss of voice lasted for some time after he had wholly stopped
lapsing into the dazed states.

There was some alcohol in the previous history of this case, which is
the only case among twenty-three Shell-shock cases reported by Mann
which had a psychiatric disorder of any lasting nature due to shell
fire.

_Re_ mutism and the two factors of shell fire and emotion spoken of by
Mann, compare the views of Babinski to the effect that emotion alone is
unable to cause such a hysterical manifestation as mutism.

_Re_ the corpse work, see remarks under Case 342.


Mine explosion: Mental confusion. Amnesia effected through Y. M. C. A.

=Case 357.= (WILTSHIRE, June, 1916.)

A sapper, 21, was admitted to a base hospital semi-stuporous, unable
to answer questions and mistaking the identity of persons about him.
At first he slept, but next day found he was in hospital. His mind was
“all of a blur.” He did not remember coming to France; “It all seems a
mist.” He felt he was ill and was afraid of becoming insane. There was
no physical sign of disease except coarse tremor of hands.

At intervals over a period of about half an hour, helped by questions,
he was able to get out the following with much emotion:

    “Joe, don’t go--Give me my rifle, Joe--Ten killed. Poor old
    Taffy--Dreamed last night--Saw Harry Edmands with all his ribs
    broken--when we had the explosion--5000 bombs or two and a half
    tons of explosives blew up.--Joe--Clay said he would never
    live three weeks,--Glasses blown in.--Taffy killed by shell
    in stomach--S-- L-- All privates blown off him--Just after
    leaving workshop.”

Between the above statements, the patient might go off into short
trance states, staring and pointing out of the tent.

Next day he was found in a condition of cheerful emotion, saying that
he was ever so much better; an orderly had “saved him!” This orderly
had taken him to the Y. M. C. A. recreation tent, played the piano to
him, and made him play himself. His whole emotional state suddenly
changed over. He now had a good memory for everything previous to
his reaching France, and remembered simply that there had been an
explosion. He remembered two names that he had mentioned, but he could
remember nothing about their fate in France. He did not know where they
were but he was not anxious about them.


Shell-shock: Hallucinations; alternations of personality.

=Case 358.= (GAUPP, March, 1915.)

A soldier, 29, a helper in a wholesale house, came to a hospital by
hospital train, uninjured, directly from the field, having become
completely deranged under shell fire. He arrived at the clinic January
11, 1915, in deep emotion, anxiously excited, and looking tensely
and suspiciously at the bystanders. He seemed to hear very badly and
shouted his statements like a deaf person. Led to the sick section,
he shouted out of the window, “Frenchmen!”; then he went willingly to
the bath and was put to bed, unresisting. He lay in bed on his elbow,
listening in the direction of the window or the wall, answering loud
questions with a quick, yelling voice after a pause. He gave his
name correctly. He seemed to think he was in the trenches and to see
hallucinatory pictures of battle.

In the examining room he immediately sat down, back to the wall, taking
the chair at the desk and leaning it against the wall. Asked why he did
so, he said with a horrified expression, “The shells, they are coming
over! Whew! they are shooting all the time.” He ducked, imitating the
hissing and whistling of the shells. Asked if he had been struck, he
said, “There are two dead and one’s head is off.” He declined to be
told where he was, and when he was told that he was no longer in the
enemy’s country, but in Württemberg, he said, “No, no; they don’t
come so far. No, the Frenchmen don’t come so far.” He was very easily
frightened and started at every touch as if wakened from a dream.
Sometimes his whole body would tremble with anxiety. He would not allow
his pulse to be taken, at first. He would suddenly shout, “That’s the
Krupp now flying by. Now it has struck.” He cast his eyes along the
ceiling as if to follow the course of the shell. Asked what he was
doing, he said he was in the trench on the mountain.

He was able to tell about his family, his marriage in Berlin, and his
child, and he could tell time by the clock. Then he would suddenly
shout: “The shells, they are shooting everything; they are shooting
like another earthquake.” Gaupp stepped up to him, in uniform, and
asked if the patient knew him. He examined Gaupp suspiciously from top
to toe, looked at the shoulder-straps, and then quickly cried loudly,
“Physician.”

At another time he described the shell havoc with evidence of extreme
anxiety. He would take food only when one broke off a piece and ate
of it before him. He would not drink out of ordinary drinking-glasses
but only out of his field cup, examining it carefully. He denied he
was on patrol duty at Soupis. His comrade was merely asleep just
now. A civilian physician in his long coat was termed by the patient
“a baker” after careful examination. There seemed to be no pause in
the man’s behavior, which looked absolutely genuine and dominated by
strong emotion. He had the look of a man in immediate danger of death,
exerting himself to escape shell fire.

This dream-like disorder of consciousness with war delirium persisted
for a number of days. There was no marked motor excitement. He would
remain for the most part quietly in bed, absorbed in his thoughts,
watching and listening, sometimes looking about in astonishment but not
getting his bearings. Gradually his emotions declined and he developed
a certain confidence in the nurse. She was able to convince him that he
might be in a hospital, although he objected that there were no wounded
there. (He was in a mental section where there were no bandaged men.)
All the while he was very hard of hearing and shouted loudly in speech.
For twelve days he could not be convinced that he was in Germany. The
fact that the Sister was speaking German was met promptly by the fact
that in France the physicians and Sisters spoke German too.

An extraordinary change came over him January 27 (sixteen days after
admission). He went into the garden, apparently deaf and shouting
his answers, accompanied by Sister Margarethe, whom he always called
“Sister Anna” and whom he thought came from Lichterfelde. While
walking with the Sister, his condition suddenly disappeared. He began
to hear; he spoke in a normal tone, in fact, rather low, and began to
address the Sister by her right name, Margarethe. He was astonished at
the snow in the garden, and asked the Sister whether she noticed that
the artillery had just stopped firing. Gradually getting his bearings,
he wondered whether he had been in the hospital since the day before.
He certainly was not ill, he thought.

This normal state lasted for a half hour. The patient then relapsed
into anxious semi-consciousness, becoming deaf again and shouting his
words. During the next few days and weeks he had frequent changes of
state like the above described. The changes to a normal state would
take place spontaneously in the absence of apparent occasion, but
the relapses into semi-consciousness took place when there was some
outer irritation, especially some noise. Every fright would cause a
relapse. Once a small cannon fired at a great distance off caused such
a relapse; again, a sudden shouting at the patient.

During the clear state there was a complete amnesia for the period of
illness. He did not want to believe that he had been in the hospital
for weeks, declaring that he must have been in the trenches two days
before.

Gradually the semi-conscious states decreased in length; the deafness
and loud speech returned with the semi-consciousness. With the return
of orientation, the man looked entirely normal, speaking in a low voice
somewhat shyly. He was rather suspicious and could find his way about
with difficulty. His memory broke off with the last days of December,
1914, at which time he was in the trenches under intense shell fire.
His wife had received no word from him since December 26. Even at the
beginning of February he grew anxiously tense when the word _shell_ was
mentioned.

February 4, Gaupp presented him in clinic as entirely clear. He
mentioned that his relapses to semi-consciousness occurred on the
occasion of a loud noise or word spoken. His face was contorted at
Gaupp’s remark but there was no other change in him. The next day,
however, he told the Sister that Gaupp had shouted out once to “get
him away.” He said he had then heard artillery fire for a moment,
but pulled himself together though he had almost gone off, and had a
violent headache afterward.

These states of alternating normality and semi-consciousness continued
until about February 10. During a clear spell, the patient was quiet,
reserved, taciturn, a little ill-tempered and seclusive, occasionally
writing his wife a rather empty letter. In the semi-conscious state
he was emotional and restless, seeking cover from the enemy. These
states stopped altogether about the middle of February. He then
became somewhat more open, though he had no idea of the gravity of
his condition. He was angered by the window-bars, and offended by the
opening of a letter to his wife, declaring that he would never write
a word again, as it was just like a prison. These outbursts passed
quickly by. He wanted to go home and believed he would soon be able to
go to his comrades in the field.

At the time of the report, Gaupp felt that he could not be discharged
for a number of weeks. He was pallid, gave the impression of being
exhausted mentally, complained of restlessness and internal irritation.
His memory gap covered at the end of March a period of about five
weeks: from the end of December, 1914, to the beginning of February,
1915.


Frostbite; thrown into water by horse; horse shot under its rider who
becomes: A HORSE IN THE UNCONSCIOUS.

=Case 359.= (EDER, March, 1916.)

A private in the Royal Engineers, 25, went through Gallipoli without
injury and without fears. He was sent to the hospital in Malta,
December 18. When observed by Eder, February 7, the frostbitten finger
of the right hand was well although there was some loss of grip. He
was suffering from insomnia, terrifying dreams, shaky hands. It seems
that December 6, a horse started and he was thrown into the water from
a bridge. The next day his horse was shot under him. A few days later,
a finger was frostbitten. Then his hands began to tremble and the
insomnia set in, with severe headaches.

This patient was a jovial, thickset, farmer’s son, with a diffuse
enlargement of the thyroid gland, a high blood pressure, lymphocytosis,
a fine tremor of the hands, irregular and rapid pulse, and anginal
attacks. Extremities were cold and blue; the palms perspired markedly;
there was hypersensitiveness to sound; there were occasional attacks of
dizziness, with a feeling of suffocation; there was frequent desire to
micturate.

The patient’s dream was always the same: He saw a Frenchman digging
a knife into his horse, getting off a cart to do this somewhere in
Serbia. Occasionally he had this dream in the form of a vision in the
daytime. It seems that he had actually seen a French soldier plunge a
knife into a mule to make it go. He had been busy with horses since
childhood: as stableboy and groom. He thought that the sufferings of
the mules in Gallipoli were worse than those of human beings. According
to Eder, this farmer’s son was the horse of his dreams; instinctive
fear had to emerge; he was pitying himself. According to Eder, “That
the person should become a horse in the unconscious would not startle
one who has dipped into the totems and taboos of the lower races.”


Shell-shock; gassing; fatigue: Anesthesias.

=Case 360.= (MYERS, March, 1916.)

A stretcher-bearer, 44, eleven years in the service and two months on
French service, was seen by Lt. Col. Myers eight days after reporting
sick and admission to a base hospital.

While he was under cover in a cellar, three days before reporting sick,
a shell had jammed the door and the fumes came in. Later in the day,
in another cellar, he had been blown off his seat by a shell and six
other men had been laid out. The shelling continued that day and two
following days. He had worked on the wounded without any rest.

On lying down he found his left arm numb and cold. The numbness then
spread to the legs, especially to the left leg. There was continual
tingling in terminal joints of fingers of left hand; hypalgesia over
both forearms and hands, especially on left side; total analgesia over
left dorsum.

Two days later, the patient could feel articles and reported that the
numbness occurred only in the early morning and was followed by a
tingling as the numbness passed off. On the same day, the hands and
forearms showed a total loss of sensibility to pain, except for a small
area on the flexor surface below the elbow joint.

_Re_ spread of anesthesia and alternation of sensory symptoms in
this case. Babinski, of course, believes, that the majority of these
conditions are the product of medical suggestion, but Babinski meets
any critique by pointing out that any other sort of suggestion may
produce such results. The heterosuggestion need not be medical.
Thus, the sight of a comrade with paralysis or anesthesia, organic
or hysterical, may suggest such to the soldier. Léri remarks that
these may also be produced by autosuggestion alone. “From a tired
feeling in a limb to a loss of power in it, there is but a small
step. Another step leads to paralysis and anesthesia. The neuropathic
temperament takes these small steps in perfectly good faith.” Léri
has found no case in which he could exclude the influence of auto- or
heterosuggestion.


Shell-shock; burial; somnambulistic state: Amnesia. Recovery of memory
in hypnosis.

=Case 361.= (MYERS, February, 1915.)

A healthy-looking man, with flushed face and large dark eyes with
wide pupils, complained of pains in abdomen, back, and limbs, chiefly
in knees and ankles, and of visual impairment. This corporal said
that his sight had been very indistinct since he was buried, and that
if he looked at an electric light, he could see nothing for five
minutes afterwards. He was admitted to the Duchess of Westminster’s
War Hospital at Touquet, December 11, 1914, having been buried for 48
hours, December 8, when a shell blew in the trench where he lay. He
said he could remember nothing until he found himself in a dressing
station, lying on straw, in a barn. He was at that time unable to see
and fell over something when he tried to walk.

He had gone out August 13, and had been in the last two days at Mons
and then at La Bassée. He had slept badly and had taken a good deal of
whiskey. He had led a fast life and had had domestic worries recently.

It appeared that his vision had improved since the day of the
explosion; though he could read for a short time only when things
became blurred, and only with the type close to the eyes. Bowels had
not opened for five days. Vision in right eye was 5/60; left eye, 2/60.

Tested for smell, he failed to smell peppermint, ether, iodin tincture,
and carbolic acid 1-40. Sugar was tasted only after tongue movements
were permitted, as was also a strong solution of salt. Acid tasted
salty like alum. The patient complained that he did not sleep, though
in point of fact he slept well.

The patient was treated by suggestion, both in hypnosis and without,
when he was transferred on the 31st of December, to the London
Temperance Hospital, whence he was discharged. The treatment by
suggestion occurred daily. At the second trial and thereafter,
light hypnosis was easily induced, but the deeper stages, with
hallucinations, anesthesia, and post-hypnotic anesthesia, could not be
reached. The lighter stages brought about sleep, a gradual restoration
of memory, and later an improvement in visual and olfactory acuity; in
near vision, in visual fields, and in color sensibility.

The stages in the restoration of memory are as follows: December 22,
he was able to describe how he was buried, how Sergeant L. dug him
out, how men of another regiment than his own took him to a dressing
station, whence he was packed off by the M. O. to the dressing station
of his own regiment. Capt. S. had spoken to him and given him a drink.
Post-hypnotic suggestion caused him to remember this latter fact after
he had come out from hypnosis.

December 23, even before hypnosis, he could remember a big hospital
with a stove in the center of a big square room, and gave a fragmentary
account of struggling in the trench after being buried, and of going to
sleep and enjoying himself at home, when somebody started messing him
about. In hypnosis, he gave further details of his dreams after falling
asleep in the buried state.

December 26, further details were remembered before hypnosis, such
as a ride in the motor ambulance, offers of tea, cocoa, sweets, and
cigarettes, a bad headache, and the like.

December 27, in hypnosis, he was able to describe with apparent
accuracy the position of the trenches and their appearance. He said:

    “The explosion lifted us up and dropped us again. It seemed as
    if the ground underneath had been taken away. I was lying on
    my right side, resting on my right hand, when the shell came.
    I got my right hand loose but my wrist was fixed behind a
    piece of fallen timber. At last I dropped off to sleep and had
    funny dreams of things at home. One thing in particular I have
    thought of many times since, I have not been able to make out
    why I should dream of the young lady playing the piano. I don’t
    know her name and I don’t think I have seen her above twice.”

According to Myers, it is questionable how far the patient’s memory
can be trusted; and there is considerable doubt whether the man had
remained in the trench for more than an hour after the shell had burst.
A comrade said that the doctors at the barn thought the man off his
head. Another soldier, familiar with the positions of the regiments in
question, gave information suggesting that the patient had wandered in
a somnambulistic state from the trench, past his own dressing station
to that of another regiment.

_Re_ Shell-shock and burial cases, compare remarks of Grasset and of
Foucault concerning the feeling as if dead on the part of certain
buried persons. Somnambulism is a natural sequel to such feelings. For
somnambulism, compare cases of Milian (364, 365, and 366).


Shell-shock; minor injuries: Somnambulistic “carrying on”;
fatigueability, physical and mental.

=Case 362.= (DONATH, July, 1915.)

A lieutenant of infantry, 31, threw himself down on the earth September
9, 1914, as a shell was passing over him. The shell exploded and
seriously injured a soldier one meter away. The lieutenant got up and
ran for cover about twenty meters distant. Only six and a half hours
later did he perceive that there was a small skin lesion between his
thumb and index finger, caused by a shell fragment, as well as a
superficial burn on his right temple. Neither wound bled or had to be
dressed. He carried on, aware that they were marching toward the River
D.; but only two or three days later did he find they had already
marched to the other side of K., had rested there and spent the night
in various places in between. During this whole period the lieutenant
led his battalion and held a piece of woods without anyone’s noticing
anything striking about him. These dazed states were twice repeated,
for periods of ten and twenty-four hours respectively, and finally he
was brought behind the firing lines unconscious.

The physician found him to be in a state of exhaustion, pulse 108, and
had him brought to the nearest station. There Donath found increased
tendon reflexes, some dermatographia and increased fatigueability of
mind and body. He was especially fatigued by walking, though he had
always been a good mountain climber. He was now unable to concentrate
on reading, writing or calculating, though he had been accustomed to
dictate letters and calculations in his official work in peace times.
He had seizures of crying and trembling on September 10 and October 27,
both quieted by bromides. There was diminution of sexual power.

Rest, lukewarm baths, cold compresses to the head, and psychotherapy
improved his status rapidly.

This patient had never been epileptic or hysterical, subject to dazed
states of any sort, was weak, delicate and anemic (three sisters
leukemic), but had before the war been well.


Emotion of captain who saw men burned by bomb: Stupor “as if dead”;
awakening “as if a German prisoner.” Recovery.

=Case 363.= (RÉGIS, May, 1915.)

A captain, one day seeing some of his men hit by incendiary bombs,
felt the deepest kind of emotion. He threw his coat over one of his
men and succeeded in smothering the fire. Of a sudden, he completely
lost consciousness, only regaining contact with the outer world two
days later, in the sanitary train. He did not know where he was, but
thought himself a prisoner surrounded by Germans. The disorder of
consciousness lasted three days, and the memory of what happened during
those days never returned. In fact, the captain declared that he felt
as if he had been dead during that time. His dreamlike state lasted for
some time, and for several weeks he did not sleep without disturbing
nightmares. It was always the same night attack, with the burned men
and the anguish of feeling that his men were not about him and that
he was alone in the skirmish. He later recovered entirely and made
preparations to start for the front.

_Re_ feelings “as if dead,” see remarks of Régis under Case 293.


Emotions over battle scenes: Spontaneous hypnosis or SOMNAMBULISM
lasting twenty-four days.

=Case 364.= (MILIAN, January, 1915.)

Upon recovery from a state of apparent hypnosis described below, the
victim wrote, in part, as follows:

    “After marching two days we reached a Breton village near
    Virtou. Next day we were in a battle that lasted from seven in
    the morning to eight in the evening. I was somewhat troubled by
    the first balls and bullets that whistled by, but felt I had to
    get used to them and we marched on, under our brave captain’s
    orders. Then we really got under fire. It was sad to see my
    comrades falling under the murderous bullets, and the captain
    was soon mortally wounded; but we had reinforcements and went
    on and chased the enemy from his positions. During the battle
    I kept thinking of my old mother and father and I felt that
    I should die without seeing them again. Little things about
    the family came to my mind. I saw my father’s roof, and his
    favorite garden seat, and I saw my mother weeping over her only
    son, her only ambition in old age. The return from the battle
    was very sad for me. Night began to fall on the frightful
    field. I saw on the bare earth the bodies of poor comrades
    whose joys and sorrows I had shared. There they were, cut down
    in all the strength of youth, leaving their parents in trouble,
    their widows in despair, and their poor orphans. I wanted to
    carry them off and I could not. We had to march over their
    glorious remains. I was able to give a word of encouragement
    to one of my comrades who now probably is no more. We then
    retired. Although I was very weary, I was unable to get any
    rest. My mind was occupied with the frightful things I had
    seen. I thought of the comrades over there and that no one
    could help them. I remember I drank coffee the next morning and
    talked with my relative. Then that is all. From that time I do
    not know what happened.”

The writer was an infantryman, 20, who had been employed in civil life
in the Crédit Lyonnais, and was brought August 24, 1914, to the Saint
Nicolas Hospital in a state of hypnosis.

Once placed in the standing position he kept balancing back and forth,
with head motionless, eyes fixed and directed to the left side. He
did not speak in reply to a request for his name or facts about his
life, but as soon as the battle was talked of he began an expressive
pantomime, speaking in a very low voice a few words interrupted by
sighs. “What were you doing in the fight?” He extended his arms,
described a half circle with his hand, as if to show the extent of the
field, thrust his hands forward with a finger outstretched, saying,
“Zi, zi,” as if to indicate whistling bullets; plunged forward with
hands in front of his chest, as if holding a gun in charge bayonet
position, saying “Prussians, Prussians,” and threw himself down in a
kneeling posture, saying, “Trenches, trenches.” “Do you remember the
battle?” “Belgium, Belgium. Germans pushed back,” making a sign as if
chasing them. “Captain dead. Two hundred men dead.” With a suitable
gesture he sighed, and tears ran down his face.

August 28 the mutism was still almost complete, but he could say his
name and lay stretched out on the bed.

September 4 the hypnosis was less, but the delirious state was more
active. He got up in the night and tried to escape to help the wounded.
In the daytime, if he saw a man lying down resting he went to him and
unbuttoned his coat to see whether he was wounded. Upon seeing the
physician he would cry, “Major! Wounded! wounded!” and then pull the
physician by his coat. He could hardly be stopped from these maneuvers.
He had to be fed like a child, but went alone to stool.

He began to be employed about the hospital a little September 14,
in sweeping the room and in guarding another patient in complete
somnambulism, over whom he watched as over a child, leading him by the
hand and keeping him from bumping into objects.

September 16 he awoke suddenly. Some one had talked to him about his
own village and his relatives. He was astonished to find himself
in a hospital. He wrote out, on request, the above account of his
recollections. The man was 177 cm. tall, well proportioned; showed a
slight facial asymmetry and a few other facial features of a dystrophic
nature, such as an adenoid appearance. There was no stigma of hysteria.


Putative loss of brother nearby in battle: Spontaneous hypnosis or
somnambulism; mutism, except “Mamma, Mamma.” Sudden awakening after
twenty-seven days.

=Case 365.= (MILIAN, January, 1915.)

A man, 22, was brought to the Saint Nicolas Hospital in a sort of
coma August 24, 1914. He lay on the bed, eyes closed as if asleep,
insensible to excitation, irresponsive. Flies crawled upon him with
impunity. He did not wink. The arms raised fell back inert. The corneal
reflex was absent on the left side, diminished on the right. The
knee-jerks and the skin reflexes were normal.

Next day he had to be fed like a child and looked after. Lifted from
bed, once on the ground he stood up with flexed legs, as if to crouch.
It seemed as if he was about to fall, but he did not.

The next day he was in the same immobile state. Upon removal from bed
he again made as if to fall, but got his balance. He kept his legs
flexed, his head lowered in a fixed posture, with his eyes on the
ground. He would walk quickly without falling, if taken by the hand,
feet dragging, and even holding back with a certain amount of force.
His walk suggested that of a somnambulist. He was left in a standing
posture by his bed throughout the medical visit. After a few minutes
he began to flex his legs progressively and slowly. The attendant
cried out, “He is going to fall.” Instead of falling, he sat down upon
the floor near the bed. He was in the same immobile, somnolent state
September 1, eyes half open, hidden under long lashes. Flies walked
over his eyes and lids, but he did not wink. He would rise only when
pushed and walk only when pulled, but had begun to eat a little better.
To all questions he replied, from between his teeth, “Mamma. Mamma.”

The next day there was a bit more spontaneity in his walking.

Lumbar puncture showed a slight hypertension. There were traces of
albumin and very few lymphocytes.

September 6, he was able to eat soup alone, but kept the same immobile
posture, with eyes fixed on the ground, eyelids not winking, in a
posture suggesting Parkinson’s disease, but without rigidity. He still
replied only, “Mamma. Mamma.”

September 19 the patient suddenly waked up completely. Douches and
external irritations had not served to wake him up, but a soldier told
him upon this day that his brother was not dead, as he believed, but
was alive and he then began to speak, opened his eyes, and began to
talk. He told how he had been by the side of his brother in battle.
Germans had taken them in the flank and opened machine guns upon them.
Two men had fallen by his side, and, catching at his garments, kept
him from retiring when the order was given. He got loose, looked for
his brother among the corpses, could not find him, thought him dead,
and from that point forward had been without memory. He shortly became
perfectly normal.


Shell-shock; slight trauma; windage felt; fall; loss of consciousness;
wandering, conscious, over night; shrapnel burst: Spontaneous hypnosis
or somnambulism, lasting four days. Return to the corps.

=Case 366.= (MILIAN, January, 1915.)

An infantryman, 20, boxer by profession, was brought with other
wounded, in the night, to Saint Nicolas Hospital and was seen next
morning, August 24, in bed, lying motionless on his back, eyes open,
fixed, eyelids not winking. No reply was got to questions. The arm
lifted fell back upon the bed, although slowly and not heavily as in
apoplexy. There was no catalepsy. The patient was taken from his bed
and put upright. In this position he remained immobile, hands at side,
head bent forward, eyes fixed on the ground. The eyelids did not move
upon approach of the finger or a lighted candle, unless there was a
fine beginning of movement. If he was pushed, he made two or three
steps forward, with eyes fixed on the ground and head bent forward. The
only spontaneous movement was carrying the left hand back to the side
as if to take the bayonet. He got into bed alone.

Next day the patient could walk better and began to talk, but preserved
the same absorbed attitude. He told, in monotonous voice, of the shells
that his squad had received and of the dead that he saw about him.
August 27 he woke up and was unable to tell how he had come to the
hospital. He told how the regiment had been bombarded for a time and
how a shell burst near him; how he got a splinter in the buttock (of
which the contusion was still visible); and how he had been thrown down
by the windage of the shell. His sack had been torn from his shoulders.
He had lost consciousness, he thought, for a short time, anyhow he
could not find his regiment. He passed the night near Longuyon and
next day looked for his regiment again. Shrapnel burst near him, and
from that time forward he had lost memory. August 27, at his express
request, he started back for his corps. There was no stigma of
degeneration or hysteria.


Burial; struck in head by beam; overcome by gas: Tremors, convulsive
movements, confusion, flight toward enemy.

=Case 367.= (CONSIGLIO, 1916.)

An Italian private, 28, of meager build (infantile eclampsia; brother
epileptic) was buried by a shell explosion and overcome by gas. After a
month’s leave he went back to the trenches.

But now, whenever a shell burst, he fell into irresistible terror and
made convulsive movements which he forgot afterwards. He could not
sleep. The mere memory of the scene would throw him into terror. He
was tremulous, developed asymmetrical innervation of his face, was
generally hypesthetic and mentally blocked.

In the midst of convulsive tremors he fled towards the enemy. He was
stopped and brought back, and remained for two days confused and
hallucinated.

In the original accident he had been struck in the head by a beam.

_Re_ this Italian’s flight toward the enemy, see various cases of
fugue. Clinically and medico-legally, Roussy and Lhermitte remark that
these confusional escapades are of great interest, and that many cases
are encountered near the front line, put under trial by court-martial,
and handed over to specialists. The dream is being lived through. Such
a case as this of Consiglio recalls the hystero-emotional psychoses
of Claude, Dide, and Lejonne. The relation of oniric delirium to
mental confusion is still a matter of polemic. According to Régis,
however, the common oniric delirium of toxic or infectious origin
is nothing more than a sort of somnambulism. The retrograde amnesia
which follows toxic delirium is the same in principle as that which
follows hysterical delirium. Régis pointed out that suggestive hypnosis
could bring back the memories in both types of disease, as well as
from the toxic delirium as from the hysterical somnambulism. However,
the differential diagnosis between onirism and hysteria is not easy.
Alcoholism and actual brain trauma need to be excluded.


Shell-shock; windage; unconsciousness: Carried on with fugue
tendencies. Variety of hysterical symptoms. Fit for garrison duty four
months from explosion.

=Case 368.= (BINSWANGER, July, 1915.)

A non-commissioned officer, 22, entered service at 20, went into the
artillery and had been advanced repeatedly. There was no heredity; the
man had been a moderately good scholar. It appears that he had had at
17 a febrile angina with delirium.

September 25, 1914, a big shell load for a cannon was exploded by
the enemy. All the men about the cannon were thrown to the ground by
air pressure, and the officer became unconscious. On awaking, he had
headache, dizziness, and vomiting. There were many corpses lying about
him.

He resumed work at once, but in the evening his headache and dizziness
increased and there was “a feeling inside as if he had to run away.”
This feeling appeared to come from the heart; it was an oppressive
feeling, running to the head. On the next day he did gun duty,
noticing, however, that every shot he fired caused him a sharp pain.
He was relieved from work at 11 A.M., and was declared ill by the
physician. His comrades told him that he had often been noticed trying
to run away, but about this he himself declared he knew nothing.

He was received at the Jena Hospital, October 9, 1914, a very strongly
built and well-nourished man. Neurologically, he showed a marked
dermatographia; knee-jerks were obtainable only on reinforcement;
Achilles jerks somewhat more marked; there was a weakly positive
Oppenheim reflex. The abdominal reflex on the left side was greater
than that on the right; and this was also true of the cremaster reflex.
Percussion of the head was extremely painful; and there were painful
points on pressure of the spine and head.

Touch was poor on the entire left side of the body; but there was no
diminution of sensibility to pain. There was a fine static tremor
of the hands. The strength of both hands appeared to be decreased
(dynamometer). Gait was unsteady and stiff; Romberg sign was positive;
the patient fell over backward. Hearing was greatly diminished,
ordinary speech being heard only close to the ear.

Toward evening of the second day after admission, there was a marked
attack of dizziness while the patient was lying on his back in bed.
During this attack the face was very red. It lasted two or three
minutes. Hearing was remarkably improved on the left side for some
time after the attack. The ear clinic examination, October 19, showed
much disturbance of hearing on the right side (direct injury of the
vestibular apparatus in both ears).

Headaches continued, radiating from the orbit to the top of the head,
and sensitiveness to pressure at the exit point of the upper branch of
the right trigeminal. The whole of the forehead was somewhat red and
swollen (neuralgia of the frontalis). The patient wore dark goggles on
account of his marked photophobia.

Improvement was gradual; there was a transient slight swelling and
a venous hyperemia of the nasal mucosa, which was treated in the
nose clinic. The impairment of hearing was quite gone in two months’
time, though buzzing was now and then heard in the right ear. The
supersensitiveness in the right upper trigeminal region vanished also.
The patient was discharged January 21, 1915, fit for garrison duty.
Later he went into the field again.


Burial: Dissociation of personality.

=Case 369.= (FEILING, July, 1915.)

The following are some stories told by a “lost personality” under
hypnosis.

The patient, aged 24, was a bandsman in the Second Battalion Wiltshire
Regiment, who sometime near the end of October 1914, was buried in a
trench near Ypres. This is his account:

“I was dug out at night and taken to a dressing station; it was cold
and dark. Then I went on to a hospital at Ypres; it was really a
convent, and there were a lot of nuns about, dressed in dark robes with
white hats; some of them spoke English. I stopped there for a night and
a day. There were a lot of wounded there. Then I was sent on by train;
I lay down all the way on a seat in the carriage; we took the whole day
to get to ----, and kept on stopping at stations. I was at ---- about
ten days; I don’t know what hospital it was, but there were English
doctors and nurses. It was near the harbor. We came over to England in
a hospital ship, the _Arethusa_; I went straight on to Manchester by
train. The hospital there was really a school turned into a hospital.”

Here is a brief account of a scrap with some Uhlans.

Q. Did you see any Uhlans? Yes.

Q. What are they like? They’ve got no guts. One time 30 of them were
against 8 of us infantry, and they “done a bunk.” Their horses were not
bad. They wore helmets with a double eagle on the front.

He was asked to describe the country round the trenches and to give
some account of the fighting there:

“It’s agricultural land, ploughed fields. There were two farms in front
of us. One day we saw an old cow between our trenches and the Germans,
and we all had pot shots at it. Once the Germans rushed our trenches;
we killed hundreds, bayoneted them mostly, and hit them over the heads
with the butts of our rifles. It was hellish. The British were all
shouting. I saw a German officer behind with a sword and a revolver.
I saw a lot of French soldiers, too; they wore long coats with the
corners turned back; some had blue and some had red trousers. The
French dragoons are like Life Guards, with big steel breastplates and
brass helmets with a long plume; they carried swords and rifles and a
few had lances.”

He was asked to mention some of his impressions in Belgium and what he
thought of the manners and customs of the French and Belgians.

“We cut off all our buttons and gave them to the French girls. The
French cigarettes are muck; you buy them in little blue packets; the
tobacco is rather dark and strong. When we bivouacked on the march at
night we were not allowed any lights, but you could smoke by digging a
hole in the ground with your bayonet and smoking into that.”

The following are some of his remarks about his stay at Gibraltar.

“Gibraltar’s like a great big rock; the steep side looks toward Spain.
I was in barracks there, and used to spend a lot of time in the
band-room practicing. Sometimes we bathed in the sea. I went to Spain
two or three times and saw some bull-fights; they were very exciting,
but rather too cruel for my taste. They used to kill six or seven bulls
a day. The horses got fearfully cut about.”

This bandsman showed what Feiling calls dissociation of personality.
There was an amnesia of such degree that all conscious memories of the
patient’s life, as well as all memory of letters, objects, and life in
general, were suppressed. The patient was brought, after the burial
above noted, to the hospital for epilepsy and paralysis at Maida Vale,
January 21, 1915. After his experience, he had been transferred to the
Second Western General Hospital, Manchester, where he spoke sensibly,
understood and was able to remember things since the burial. His mind
was a complete blank for all previous experience. He was unable to
recognize his own father or relatives. He was slightly deaf for a time
but this defect disappeared.

At Maida Vale he showed a nervous twitching of eyelids and facial
muscles; otherwise he was neurologically and physically normal,
dreamless, without complaints, and straightforward about all
experiences since coming to himself in the hospital at Manchester. He
took his parents on trust. “I don’t know if I ever went to school.” “A
bayonet is like a knife; you see soldiers with them on their rifles. I
have never seen a bullet.” His memory for recent events was also not
good. He once recognized a single tune played at a concert.

Suspected of malingering, he was tried out in various ways. He was told
that an elephant was a little furry animal and shown a little 6 inch
toy sample. On going to the zoo he was greatly astonished at seeing a
real elephant. He did not know what the war was about and he had no
interest therein.

March 10 he was hypnotized and proved an easy subject. Powerful
suggestions that lost memories would return were unavailing. The next
day, during hypnosis, it was found that his previous experience could
be readily tapped, and a history of his family, schooling, running
away, and eventual enlistment was told. He had been at Gibraltar when
war broke out. He was at the first battle at Ypres, and was for ten
days in severe trench fighting, and was finally buried in the mud and
débris of a trench blown in by a high explosive shell. He had been
buried for about 12 hours, was dug out at night, and (according to his
father) remained unconscious 24 hours, and deaf and dumb three days. He
was transferred to another hospital and then to Manchester, where he
came to himself.

Only during the first few sittings did the patient lie with eyes
closed. Later, during hypnosis, he behaved exactly like a normal
person. The fact came to light that when hypnotized the patient
returned to the personality that possessed him just before awakening
in Manchester, and accordingly during hypnosis, he had to become
acquainted again with his hypnotizer. Maida Vale astonished him, as it
should have been Manchester. Thus there were two personalities: No. 1:
The personality since the date of the Manchester awakening; No. 2: The
personality containing all the memories of the past life as well as the
more recent Flanders memories. In State No. 1, the manner was jaunty
and cocksure. In State No. 2, the man was more modest and less loud.
Moreover, though in State No. 1 he spoke with a Lancashire accent,
in State No. 2 his speech was in the West Country dialect--a strange
observation, confirmed by several observers. He was asked to write down
the answers to questions, and on awakening from hypnosis was shown the
things written; whereupon he laughed and said, “Why, that’s not my
writing.” On writing out the same sentences again, various minor points
of difference were apparent. Hypnotized in the presence of his father,
in whom in State No. 1 he took no great interest, he showed every sign
of joy, causing his father to think that in State No. 2, his son had
“come all right again.” In State No. 2 he could play a euphonium better
than in State No. 1; but after practicing in State No. 1 he rapidly
became as expert as in the hypnotic state.

If the patient were left for some time before being awaked by a
previously-arranged method of counting three, he would experience
disturbed dreams, with clenched hands, snarling lips, and muttered
phrases, “Give it them,” etc.

Twenty-five hypnotic sittings were given but no improvement took place
and the patient was discharged May 5. May 25 there had been no further
change and he remained in State No. 1, in which state he was invalided
from the service by a medical board, May 28.


Ear complications and hysteria.

=Case 370.= (BUSCAINO AND COPPOLA, 1916.)

An infantryman, 22 (father and mother quite normal; patient showed
slight convulsions, attributed to worms, from which he actually
suffered; was malarial from 9 to 15; had otitis media and lost hearing
completely at 11; had suffered from 9 onwards with joint pains; as an
adult had no convulsions), was called to arms August, 1914, and sent
to the front May 2, 1915. About the end of August, in a water-filled
trench by Monte San Michele, he was covered with mud from a shell
explosion, lost consciousness, and in some way got back to the second
line. He was told that blood had flowed from the right ear, and on
recovery he found himself unable to hear with that ear, although it was
the left in which he had had otitis. There were continual noises in
the ear. He was, however, sent back to the front line. By mistake, one
day, he got with companions in the midst of the enemy’s barbed wire,
saw sparks from the guns, heard no shots, saw comrades fall, and threw
himself instinctively into the wire network. Leaving the food kettles,
he finally got back to the trenches. He was sent to the hospital at
Legnano for his ear pains, and was treated by leeches, which he could
not feel. He began to hear a little more. Flies walked on the left
cheek without being felt. This anesthesia had begun a few days after
the shell explosion. He was transferred to a military hospital at
Florence.

One day he wedged a toothpick in cotton into his left ear and was
charged with simulation, though he had been absolutely deaf in his left
ear since childhood. From the moment the military surgeon told him he
would be denounced for simulation, he lost his memory. Reports indicate
that he had headache and delirious dreams (October 30), and suddenly he
became furious (October 31), about three hours later going into severe
collapse, for which camphor injections were given.

November 1 he had battle dreams and lumbar puncture had to be given
up as he was in the midst of an attack. A hypodermic injection was
interpreted by the patient as a wound, and he cried as if he were
being abandoned on the battle-field. At one point he woke up from
his hallucination and asked where he was and shortly relapsed into
stupor. November 2, the patient was slightly bewildered and felt pains
where the lumbar puncture needle had been tried the previous day.
November 5, he was disoriented, thinking himself still at Legnano.
The pupils were throughout dilated. November 6, confused and dreamy;
November 7, he soiled his bed, was somewhat disoriented, immediately
corrected himself; oculo-cardiac reflex 64 full compression, 62 during
compression. November 11, headache; November 12, a slight bewilderment
reappeared; November 13, remembered for the first time having been
stunned by shell explosion, and this day got up and wrote home.
November 14, complained of pains in muscles and weariness. Pupils still
dilated. November 16, pulse 86; a gradual increase from 50 to 60 during
previous days. November 17, patient had begun to remember facts that
preceded the dream syndrome. November 18, pulse standing 88; November
20, pulse standing 120. This day cried when he remembered having been
suspected of simulation. November 22 and 23, aches in joints and
intense otalgia; pulse 86. November 24, diarrhea; deafness somewhat
diminished; 26, diarrhea; looked as if he were about to have a new
hallucinatory episode. This, however, did not come about until December
1, when he heard cannonading and knew the regiment was near. Next day
he had forgotten the cannonading. December 14, the patient had become
entirely tranquil and lucid and was able to give his entire history.
December 16 and 17 he was given a systematic neurological examination,
which showed on the left side complete anesthesia, hyperesthesia to
pressure, thermanesthesia, analgesia, loss of bone, tendon, and muscle
sensation. Vision was diminished more on the right side than on the
left, and the visual fields on this side were more contracted. During
examination, the fields became still more tubular. There was complete
deafness, anosmia, and ageusia on the left side. On the right side
there was a slight diminution of hearing. The pharyngeal reflex
was abolished; the cremasteric reflex was somewhat less on the left
than the right; and the defensor reflexes of the left leg were less
marked than those of the right. There was no clonus or Babinski. The
dynamometer grasp on the right was 37; on the left 18; and on this side
there was a limitation of voluntary movements.

                               CHART 10

                        ETIOLOGY OF SHELL-SHOCK

    WOUNDS                                                14 of 150

    PHYSICAL
      EXHAUSTION FROM EXPOSURE, HARDSHIP (all neuropaths)  3 of 142
      CONCUSSION                                          52 of 142

    CHEMICAL--SHELL GAS                                    3 of 150

    PSYCHIC
      GRADUAL EXHAUSTION, PREDISPOSING    (43 neuropaths) 51 of 132
      SAME, ACTING PER SE   (patients chiefly neuropaths)
      SUDDEN SHOCK
        HORRIBLE SIGHTS                                   51 of 142
        LOSSES OF COMPANIONS
        FRIGHT NEAR EXPLOSION             (one neuropath)
        SOUNDS                         (a few neuropaths)

    RELAPSES (41 of 150 observed, three-quarters neuropaths)

                                                    After Wiltshire



C. THE DIAGNOSIS OF SHELL-SHOCK

    Chè non è impresa da pigliare a gabbo
      descriver fondo a tutto l’universo,
      nè da lingua che chiami mamma e babbo.

    For to describe the bottom of all the universe
      is not an enterprise for being taken up in sport,
      nor for a tongue that cries mamma and papa.

                             Inferno, Canto XXXII, 7-9.


In the course of our study of psychoses incidental in the war (Section
A) and especially of Shell-shock’s nature and causes (Section B),
we have naturally met most if not all of the major diagnostic
difficulties. In the present Section we shall study cases for the light
they may throw on the more technical troubles of the diagnostician.
Who would _à priori_ have felt that such diseases as tetanus, rabies,
malaria, would produce practical difficulties in clinical diagnosis in
the field of Shell-shock?

Mayhap there was no need to emphasize further the values of lumbar
puncture fluid examination. Yet the admixture of “functional”
and “organic” symptoms in numerous puzzling cases can hardly be
over-emphasized.

But the interpolation, through the ingenious inquiries of Babinski,
of a new or but vaguely suspected series of “reflex” (“physiopathic”)
troubles between the organic neuropathic disorders on the one hand and
the hysterical psychopathic disorders on the other--the result of these
observations, sampled only in Section B, is given more in detail in the
present Section. What a split in therapeutic method a recognition of
this new group of “physiopathic” disorders might entail is seen also in
further cases in the Section that follows this (Section D on Treatment
and Results).

A number of simulation cases has been added.

                               CHART 11

              ETIOLOGICAL GROUPING OF WAR PSYCHONEUROSES

      I. NEUROSO-ORGANIC ASSOCIATION (NO CAUSAL NEXUS)

     II. REFLEX NEUROSES (LESION DISPROPORTIONATELY SLIGHT BY
         COMPARISON WITH PSYCHONEUROSIS)

    III. NEUROSO-SOMATIC ASSOCIATION (TRENCH FOOT, NEURITIS,
         RADICULITIS)

     IV. FATIGUE OR EMOTIONAL PSYCHONEUROSES (CONSIDER EFFECTS OF
         PSYCHIC CONTAGION, EDUCATION)

      V. PSYCHONEUROSES ON ANTEBELLUM BASIS

                                                      After Grasset

                               CHART 12

                          WAR PSYCHONEUROSES

                          SYMPTOMATIC GROUPS

      I. EMOTIONAL (HYPER- HYPO- PARA-)

     II. CONFUSIONAL (ATTENTION AND MEMORY DISORDER, DREAM STATES;
         DELIRIA)

    III. CONVULSIVE AND PITHIATIC (HYSTERICAL)

     IV. NEURASTHENIC AND PSYCHASTHENIC

      V. SENSITIVOMOTOR AND SENSORIMOTOR--_e.g._, LIMITED PARALYSES,
         CONTRACTURES, DEAF-MUTISM

     VI. COMPLEX

    VII. PHYSIOPATHIC (BABINSKI)

                                                      After Grasset


Value of lumbar puncture.

=Case 371.= (SOUQUES and DONNET, October, 1915.)

A colonial soldier arrived at Paul-Brousse Hospital with a hospital
ticket showing that ten days before he had had _commotio cerebri_.
He was dull, had a fixed stare, held his head in his hands, was
disoriented for time and place, and had lost memory for everything that
had happened for eighteen months. There was no sign of wound. There
was no motor disorder save that walking was a bit slow and uncertain.
Perhaps the right knee-jerk was stronger than the left. Percussion
of the right Achilles tendon produced tremor. The plantar reflexes
were flexor on both sides; flexion lasted longer right than left. The
cremasteric and abdominal reflexes were a little weaker on the right.
Arm reflexes were lively. Sensations proved normal. Complaint of
headache, frontal and vertical.

Lumbar puncture October 7, that is, on the thirteenth day after the
shell-shock, yielded a transparent, slightly greenish fluid, with 92
cells per cm. (lymphocytes with one or two large mononuclear cells and
a few sometimes degenerated endothelial cells) and hyperalbuminosis.

October 9, the clouding of consciousness was less marked. The headaches
and amnesia were constantly complained of; the reflexes were normal.
October 12, there was less headache. October 25, another lumbar
puncture showed but 14 or 15 lymphocytes per cm. and hyperalbuminosis.
There was now no longer any clouding of consciousness. The amnesia,
retrograde and anterograde back to May 9, 1914 (date of his daughter’s
birth), and up to September 25, 1915, persisted. The man did not
remember the declaration of war, or the mobilization, or his regiment,
and the like. Meantime, the man’s judgment and reasoning powers were
normal.

If there had been no early spinal fluid examination of this patient, he
might well have been considered an hysteric or even a simulator.


Meningeal and intraspinal hemorrhage: Lumbar puncture.

=Case 372.= (GUILLAIN, May, 1915.)

A gunner from Morocco, who lost consciousness for an hour March 28,
1915, upon the explosion of a large-calibre shell in his trench, was
carried to the ambulance. He complained of headache and generalized
pains. His status was scarcely modified during five weeks, and a
generalized contracture of the body developed whenever movements were
attempted. In horizontal decubitus, the muscles of the limbs and neck
were of a normal tonicity, but the head went into hyperflexion if
the patient was asked to sit. The eyes turned upward, and Kernig’s
sign developed. The patient could walk only with short steps, with
legs apart and arms held away from the body, the head in a sort of
tetanoid dorsal hyperflexion. There was a right-sided hemiparesis with
trepidation and the Babinski sign.

Lumbar puncture assured the diagnosis of something organic. The
fluid contained blood cells and a marked lymphocytosis. The symptoms
evidently depended upon hemorrhages in the meninges and the nervous
system, affecting particularly the right pyramidal tract.

_Re_ hypothesis of organic changes in hysterical cases, Roussy and
Lhermitte remark in comment upon albuminosis in the cerebrospinal fluid
that the albumin is perhaps due (in cases of camptocormia) to the
effect upon venous and lymphatic circulation of the spinal curvature.
It was Sicard’s claim that camptocormia, or bent back, was due possibly
to anatomical changes in the spinal column, that is, that camptocormia
was in one sense a spondylitis. In other cases the camptocormia might
be due to a ligamentous or muscular change; that is, to a syndesmitis
or a psoitis. His idea was that the curvature was in a sense antalgic;
that is, a response having the purpose of avoiding pain.


Slight hyperalbuminosis.

=Case 373.= (RAVAUT, August, 1915.)

A farmer, 32, in the 66th Infantry, was lying in a dug-out March 5,
1915, when a bomb threw him on the ground and covered him with earth.
He was picked up unconscious, and remained so for an hour. In the
ambulance it was found that he could hardly stand, could not speak,
and appeared to be completely confused. There was no sign of wound.
The next day he recovered consciousness and complained of a violent
headache. He was completely deaf in the left ear, and vision was also a
little impaired on that side. The puncture fluid was clear, and there
was a very slight excess of albumin by the heat test. The next day the
headache had entirely disappeared, the left ear was absolutely deaf,
but the patient complained of buzzing. Lumbar puncture the following
day showed a normal amount of albumin.

March 16 the patient was evacuated to the rear presenting no abnormal
symptom except deafness.

_Re_ the spinal fluid, Armstrong-Jones considers that a shock directly
sustained by the spinal apparatus through sudden impact to the
surrounding cerebrospinal fluid, ought to be felt more by the anterior
horn cells than by the spinal root ganglia, since the latter are
shielded by the sheath in the intervertebral spaces. Motor symptoms
would, naturally, then be more frequent than sensory symptoms. He also
believes that the controlling neurones in the intermedio-lateral tracts
that have to do with the sympathetic system, would be affected just as
anterior horn cells are. Accordingly, the dilated pupils, rapid heart,
dyspnoea, and a variety of precordial pains and disorder of the viscera
would ensue. The jar would thus be communicated to the neuronic cells
of origin of two types: spinomuscular and preganglionic, leaving the
gangliospinal neurones relatively intact.


Paraplegia, organic: Lumbar puncture.

=Case 374.= (JOUBERT, October, 1915.)

A gunner, 23, was thrown to the ground, according to his story, by the
explosion of a large-calibre shell, at eight o’clock in the morning of
September 10, 1914. He could not get up but thought he had not lost
consciousness. September 13, he arrived at hospital, looking like a man
with dorsolumbar fracture of the spine. There was, however, no external
injury. There was a marked paresis of the right upper extremity, with
diminished sensibility, weakened reflexes, numbness, formication. The
right lower extremity was subject to complete flaccid paralysis, with
lost reflexes, and anesthesia in all respects reached to the belt
level, and stopped sharply at the median line of the abdomen. The left
leg, also, was paretic but the muscles could be contracted weakly;
the knee-jerk was exaggerated; there was a tendency to epileptoid
trepidation, and the sensations were only slightly diminished. There
was a Babinski reflex on the right side; the abdominal reflex was
absent on the left side; both cremasteric reflexes were present.
The feet at times gave formication. Rectal, bladder, and sphincter
paralysis. Dark albuminous urine, with a few blood cells, was obtained
on catheterization. There was an early sacral decubitus; consciousness
was somewhat clouded. The man made no requests except for something to
drink, and seemed apathetic.

Lumbar puncture, September 14, yielded hemorrhagic fluid. Three days
later, the upper extremity regained its powers and sensations, but the
paraplegia had become complete, with abolition of reflexes on both
sides, and absolute anesthesia. The feet yielded formication at times,
however. Sacral decubitus increased and healed not. The temperature
varied between 38 and 39. The patient died September 24, in coma, with
anuria and Cheyne-Stokes breathing.


Gunshot wound of spinal column; no penetration or injury of dura mater:
At first quadriplegia; later cerebellospasmodic type of disorder.

=Case 375.= (CLAUDE and LHERMITTE, July, 1917.)

A soldier, 22, sustained a gunshot wound in the neck about the level
of the fourth cervical vertebra. He immediately became quadriplegic.
He recovered arm motion in two months and some weeks later ability to
stand and walk.

Three months after the injury, station was difficult, better on a broad
base. Rombergism, even with eyes open. Cerebellospasmodic gait. There
was no weakness of leg muscles, but there was a certain degree of
weakness of the upper extremities, especially in finger flexion. There
was hypertonia of the muscles of all the extremities and the hands
showed the signs of Raimiste, of Klippel and Weil, and of Dejerine.
Static equilibrium was preserved to the will, but the kinetic balance
was affected, and as much in the upper as in the lower extremities.
Ataxia, tremors, dysmetria, adiadocho-kinesia, and disorder of combined
movements in thigh and trunk flexion were all in evidence. Meantime,
there was no disorder of sensation whatever except that the ulnar
border of the right hand showed a hypobaresthesia, and there was a
disturbance of tactile discrimination and absolute astereognosis in
the hands. The deep reflexes were everywhere increased, and ankle and
patellar clonus were easy to excite, especially on the right side.
Bilateral defense reflexes. Bilateral Babinski sign. The hypertonia and
ataxia ebbed away during the following three months. Walking became
normal, and there was little sign of difficulty except astereognosis of
both hands, combined with slight disturbance of deep sensibility and
poor response to compass test in palm.

We here deal with a case of spinal column injury without injury to the
dura mater. This cerebellospasmodic form of the superior cervical type
of spinal concussion is less frequent than a quadriplegic form with
Brown-Séquard syndrome. It is striking that both types of concussion
may recover.


Spinal column trauma, with local signs: Later, hysterical anesthesia
and contracture of back muscles homolateral with the trauma.

=Case 376.= (OPPENHEIM, July, 1915.)

A musketeer, wounded August 20, 1914, by a shell splinter in right side
of vertebral column, fell unconscious, but was able afterward to crawl
on all-fours out of the firing line. Severe vomiting and epistaxis
followed. August 23, there was pain in the small of the back; the last
two ribs were painful on right side; and the muscles were slightly
swollen up to the iliac crest. August 30, a slight rise of temperature
(at first it had been above 38) still persisted, but the muscular
swelling was diminished. Treatment by aspirin and baths. No further
rise of temperature after early in September.

On October 9, patient was permitted to get up, whereupon he showed a
peculiar curved attitude of the body, reduced almost completely by
passive straightening. Swelling of the longitudinal muscles. Radiograph
negative, except that one picture showed a change in left twelfth rib,
near the transverse process. Pains in left lumbar region.

November 19, on examination, pulse 112. November 23, after massage,
vomiting. Temporary use of plaster corset.

On admission to the nerve hospital December 22, the musketeer was
unable to extend the trunk, and the long muscles of the back were
on the stretch, often as hard as wood, especially those of the
left (longissimus dorsi). Patient lay on right half of pelvis.
Hemianesthesia and hemianalgesia, left side. Tachycardia. Formerly the
patient had done hard work, especially carrying heavy bags. He declined
to be examined under general anesthesia. He seemed to be of unreliable
character, and his trouble did not prevent him from returning from
leave of absence, on one occasion, drunk.


Mine explosion: Combined hysterical and lesional effects.

=Case 377.= (DUPOUY, September, 1915.)

A lieutenant, 23, was in a mine explosion June 23, coming out in
complete torpor, with mutism and retention of urine. He was brought
to hospital June 26, with jactitation, irregular pulse, markedly
exaggerated tendon reflexes, absent skin reflexes, sluggish, dilated
pupils, especially right, and general anesthesia. The spinal fluid
contained an excess of albumin, altered blood cells and many
lymphocytes.

Several hours after puncture he suddenly demanded where he was, thought
it was the year 1911 when he was in the Dragoons, talked about his
camp, and was confused, irritable and stereotyped in questions. There
was no verbal amnesia. Speech was hesitant, explosive and scanning,
suggestive of multiple sclerosis. Next day there was still retrograde
amnesia. He clung to the belief that it was July, 1911, and asked
wearisome, stereotyped questions. The words, “German house” caused a
jactitation, stiffening and relapse into a _second état_, out of which
he came with hiccoughs and sighs, and amnestic for this conversation.
There was general hypesthesia and muscular weakness especially of legs.
The reflexes were as before.

The morning of June 28, he heard the hum of an airplane, whereupon
his memory returned. It seems that he had himself once ascended. The
memory gap was now limited to the time immediately preceding the
mine explosion and the days following, up to the time of hearing the
airplane. He told about his military life and also about incidents
immediately preceding his blowing up. He complained of malaise and of
pains in the vertebral column and limbs.

There was a quadriparesis, more marked, however, on the left; walking
with falls to the left; astasia with left foot; double facial paresis;
inability to whistle and to close eyes completely; intestinal and
bladder paralysis; nocturnal emissions non-pleasurable; partial
anesthesia of right leg, of arm and of hand, with hyperesthesia
of thigh, of forearm and of the posterior aspect of the upper arm;
anesthesia of the left side, including thorax and abdomen, excepting
that the arm was hypesthetic only. Face hyperesthetic. Complete
anesthesia of nipple and testis; hypesthesia of neck; anesthesia of
tongue, nose and vertex; plantar, cremasteric, abdominal reflexes
absent; exaggerated tendon reflexes; pupil reflexes normal; painful
heat flashes and profuse sweating on the slightest movement; vertigo
and tendencies to syncope after effort; explosive, scanning speech;
intermittent convulsive movements of the arms. Palpation and X-ray show
separation of the spinous processes of the third cervical vertebra.

Improvement was marked and progressive in motor, sensory and reflex
fields. At the time of report three months later, there was a definite
paresis of the left leg, with anesthesia and absent plantar reflexes,
and slight paresis of the orbicularis palpebrarum, scanning speech
and syncopal tendencies. Here, then, due to diffuse, non-systematic
lesions, with superadded hysterical manifestations, were probably some
effects of a permanent nature due to destructive processes.

_Re_ combination of functional and lesional effects, Sollier and
Chartier state that in Shell-shock hysteria, physical causes
and conditions are the chief factors; that in the so-called
hystero-traumatism of Charcot, the psychic and physical factors are of
virtually equal importance, and that in ordinary cases of hysteria, the
psychic is the chief genetic factor.


Shell explosion: Hysterical and organic symptoms.

=Case 378.= (HURST, 1917.)

A champion heavy-weight boxer, 29, was unconscious for two days after
being knocked over by the explosion of a shell in December, 1914. He
found at first that he could not move the right arm or left leg; and
after power had returned to the limbs, he had forcible involuntary
movements in the left leg whenever he tried to stand. Examined, April
1, 1915, he answered questions slowly and with slow words; the right
arm was weak. When the left hand was clenched, an associated movement
took place in the right hand, but not vice versa. There was, however,
no diminution in the girth of the muscles. The man was unable to
localize light tactile stimuli accurately. Movements of the left leg
were somewhat weak, the left knee-jerk was slightly brisker than the
right; ankle clonus could be obtained on the left side and Babinski
second sign (paralyzed leg rising higher than the normal leg in
combined flexion of thigh and pelvis). When the man tried to walk, the
left leg moved rapidly from side to side round the point of contact of
the toes. When the right leg moved forward, the left dragged behind in
irregular movement.

Every effort to cure the patient by means of suggestion during
hospital care for a month entirely failed. Although the man was easily
hypnotizable, he could not be made to move his leg under the deepest
hypnosis. The first whiff of ether hypnotized him, so that the method
of etherization could not be used in the endeavor to control the leg
movements. Over a year later, July, 1916, the patient had greatly
improved mentally but was otherwise in precisely the condition that is
above described.


Gunshot wound of buttocks with injury to cauda equina: Urinary
disturbance; decubitus; anesthesia. Superimposed paraplegia, regarded
as functional and cured by psychotherapy.

=Case 379.= (OPPENHEIM, July, 1915.)

A German grenadier, October 11, 1914, was wounded in the left buttock
by a missile that passed out through the right buttock. Pains in the
abdomen and legs followed. The man had to be catheterized on the
battle-field.

October 23, he suddenly fell down with total paralysis of both legs.

November 3, numerous small furuncles appeared on the buttocks, and
bedsores developed. The patient lay helpless in bed, was unable to sit
up without support, or to turn from one side to the other, and had
areas of anesthesia.

During November and December, there was persistent high temperature,
between 38 and 40; but January 3 the temperature stood at 36.6.

January 7 the patient was admitted to a nerve hospital. At this time
he was able to pass urine unaided, though with tenesmus and pain,
sometimes nausea and a tendency to vomit. He complained of pain in
the back and pelvic region; the legs lay as if paralyzed. No active
movement whatever was performed. There was a marked increase of tendon
reflexes (even including the semi-membranosus). The muscles were
relaxed through disuse but there was no atrophy. The patient moved
his legs about with his hands. Sensibility was preserved except in
the region of the pubis. The plantar reflexes were absent. Electrical
reactions normal.

The diagnosis was functional paralysis of the legs (previous gunshot
injury of cauda equina).

Treatment with psychotherapy met with prompt results; within a few
days, the patient learned to move his legs and to walk with support,
though making enormous efforts which threw the pulse up to about 160
and made the face congested. The bladder disturbance and the sacral
anesthesia persisted.


Spinal concussion with spinal cord lesion: Thermanesthesia and
analgesia of right leg and side.

=Case 380.= (BUZZARD, December, 1916.)

An officer was hit in the back by a shrapnel fragment, fell paralyzed,
but after a few minutes was able to walk more than a mile to the
dressing station. Eventually arriving in London, he had nothing to
complain of except the wound, as the foreign body had been removed in
France. The wound healed and the patient went to a convalescent home.

However, when taking a bath he could not feel the temperature of the
water with the right leg. Muscular power was perfect; reflexes normal;
but the heat, cold and pain sense was lacking in the right leg and the
right side of the body from the seventh costal cartilage downwards.


One may make a wrong diagnosis of “Shell-shock.”

=Case 381.= (BUZZARD, December, 1916.)

In August, 1915, an officer was blown many yards by a shell, lay
unconscious a while, could find no bruises, and carried on for
twenty-four hours. Then, finding legs unreliable, he reported sick
and was sent home as “Shell-shock.” He remained “Shell-shock” until
February, 1916, then being able to walk five or six miles on smooth
ground. Going downstairs he took the step with left foot rather than
with right, and the right was apt to turn in. The sense of position and
movement in regard to the right foot proved to be faulty. He could not
balance himself on the right foot, nor could he appreciate tuning fork
vibrations as well on this foot as on the other.

An X-ray examination showed a slight fracture, without deformity, in
the left post-Rolandic region near the median line. His helmet had been
bashed in at this point, and the bruised brain yielded symptoms even
eight months later.


Retention of urine after shell-shock.

=Case 382.= (GUILLAIN and BARRÉ, November, 1917.)