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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.)

An infantryman underwent shell-shock December 19, 1915, from the
explosion of a torpedo nearby. He arrived at the ambulance, unable
to speak, and next day had a confusional crisis of convulsions with
contractures. He had not urinated since the accident, and two liters of
clear urine were withdrawn by catheter; after which, the patient rested
quietly and gradually regained consciousness. He was catheterized again
in the evening and clear urine withdrawn. He remained unable to urinate
spontaneously until December 25, and was catheterized accordingly.

There was no motor, sensory, or reflex disorder in this patient. Lumbar
puncture yielded a normal fluid; the pupils were normal, and the only
appearance was that of a marked asthenia.

Three months after his shell-shock, in March, 1916, the soldier was
once more examined and still complained of headache, weakness, and
inability to walk more than four or five hundred meters without a
certain trembling of the legs. The reflexes remained normal and no
further bladder trouble had supervened.

_Re_ anuria, Babinski remarks that, in days of yore, hysteria was
supposed to be able to produce anuria as well as albuminuria, and even
such organic changes as vesicles of the skin, ulceration, hemorrhages
in the skin or of the viscera, fever, and even gangrene. He remarks
that of late years no single identifiable case of this sort proved
to be hysterical, has been reported. This is aside, of course, from
such superficial and quickly passing vasomotor disorders as erythema
and dermatographia. Anuria and albuminuria have consequently passed
from the textbooks on hysteria, just as Babinski believes that
hysterical edema and hysterical exaggeration of the reflexes are bound
to pass. Hysteria cannot imitate everything; it cannot reproduce the
characteristic phenomena of organic paralysis.


Retention of urine after shell-shock.

=Case 383.= (GUILLAIN and BARRÉ, November 1917.)

An infantryman, 27, underwent shell-shock August 16, 1916, at
four o’clock, from the nearby explosion of a big shell. He lost
consciousness for a period of ten minutes, was sent to the regimental
aid post, and twelve hours later brought to a hospital center, in a
state of profound muscular weakness. He could not walk although he
could make every movement of the legs. There was a marked diffuse
cutaneous hyperesthesia. The reflexes were normal; the pupils were
unequal, the right myotic. The lumbar puncture yielded a clear fluid
under normal pressure, but with an excess of albumin. For three days,
retention of urine was absolute, requiring the catheter. There was
neither sugar nor albumin in the urine withdrawn. On the fourth day he
was able to urinate spontaneously; the asthenia and other symptoms had
disappeared in two or three weeks.


Incontinence of urine after shell-shock and burial.

=Case 384.= (GUILLAIN and BARRÉ, November, 1917.)

An infantryman was subject to shell explosion and burial May 10, 1917.
He lost consciousness for a few hours and spat blood for two days. He
was carried to an evacuation hospital and thence to the neurological
center at Amiens. Incontinence day and night lasted from the period of
shock up to May 29, when the patient was transferred again, to another
hospital. The man had never, either in childhood or adult life, had
incontinence. He showed a slight tendency to latero-pulsion toward the
left. Puncture fluid normal.

Guillain and Barré report but 12 cases of sphincter disorder following
shell-shock without external wound among hundreds of cases, and
among 12 instances of sphincter disorder there were but three of
incontinence, of which the above is one example. Incontinence lasted
longer in these cases than retention. Guillain and Barré are unable to
assign a cause for the findings.


Struck in back by shell splinter: Crural monoplegia; absence of plantar
reflex.

=Case 385.= (PAULIAN, February, 1915.)

An infantryman, 20, was struck by a shell fragment in the small of the
back while lying in the firing position, about 2 P.M. August 22, 1914,
at Eth in Belgium. He felt as if he had been struck by the butt of a
gun in the lumbar region. He was unable to get back with his comrades.
His sack had been cut. He was without ammunition, and getting to a
bridge he was able to jump a distance of about 8 meters. He fell and
fainted. On coming to himself, his left side felt bad and he could not
move his left leg. He dragged himself to the relief post which was
being bombarded just as he arrived, and he got a bullet in the left
frontal region.

He was evacuated to another ambulance and decided to go back to
France. Supported by his Lieutenant, he walked all night making about
35 kilometers on foot. He arrived at Charancy and got by train to
Mont-Midi. On alighting, he could not walk. He said he was bent in two,
and shuffled on in this position.

The “bent-back” lasted about a month, when he began to stand up
again. He passed through various hospitals and was evacuated to the
Salpêtrière. He then walked with the left leg in extension on the thigh
and the foot in external rotation. He was hardly able to stand on
either foot, and especially fell if he tried to stand on the left foot.
He made no resistance to passive movements of the left lower extremity.
The reflexes were normal except that the left plantar reflex was
abolished. On the right, the plantar reflex was normal, and an attempt
to elicit this reflex was followed by strong defensive movements. There
was a tactile, thermic, and pain anesthesia of the foot and leg as far
up as the lower third of the thigh. Above this anesthesia, there was a
zone of hypesthesia. Position sense was also abolished in this region,
and there was a bony hypesthesia likewise. A slight muscular atrophy (2
cm.) affected the lower leg and thigh.

There were no hereditary or acquired features of importance in the case
except that there had been at 14 a chorea for a year. In particular
this man appears not to have been an emotional person.

The point in the case is the abolition of the plantar reflex on
the left side, in association with a functional paraplegia and
hemianesthesia.

_Re_ plantar reflex modification in hysteria, Babinski believes that
the same law which holds that hysteria is not in line to alter either
the tendon reflexes or the pupil reflexes, is true for the skin
reflexes. Dejerine brought forward three cases which appeared to him,
however, to demonstrate absolutely that functional anesthesia might
abolish or greatly diminish the skin reactions of the sole of the foot,
that is, the plantar reflexes and movements of defense. Case 385 was
alleged in support of Dejerine, as also were cases of Jeanselme and
Huet, and of Sollier. Babinski’s critique of Dejerine’s cases ran to
the effect that two of them showed contractures, and accordingly were
not pure cases in which to demonstrate plantar reflexes or movements of
defense. In the third case, Babinski at a meeting of the Neurological
Society, himself obtained definite flexion of the little toes by
stimulating the planta. According to Babinski, therefore, Dejerine’s
cases, far from proving that hysterical anesthesia could abolish the
plantar cutaneous reflexes, proved that hysterical contracture might
mask reflex movements. Hysterical contracture, therefore, may be as
important a factor to consider _re_ reflexes as voluntary muscular
contracture itself. As Babinski pointed out, many normal persons can
keep the leg immobile when the sole is stimulated. Moreover, Babinski
pointed out, many cases regarded as hysterical were actually cases of
a physiopathic or reflex nature which had actually undergone trauma.
It will be noted that the above case of Paulian is just such a case of
trauma.


Shell-shock; unconsciousness: Crural monoplegia; sciatica (neural
changes).

=Case 386.= (SOUQUES, February, 1915.)

A reserve lieutenant, September, 1914, was blown up by a shell and
lost consciousness for an hour. On coming to, he felt pains in the
loins, right thigh, knee and heel, and found himself unable to move
the right leg at all. Urinary incontinence lasted three or four days.
Violent pains lasted weeks, now and then actual crises (sleep only with
hypnotics).

The pains then passed off. The flaccid crural monoplegia lasted. There
was a hydrarthrosis of the right knee and a sciatica (physical nerve
changes?) and a crural monoplegia without trophic, electrical, reflex
or vesico-rectal trouble. Lumbar puncture showed no lymphocytes or
excess of albumin. It would, of course, be difficult to tell whether
this case was hysteria or simulation.

_Re_ hysterical monoplegia, Babinski inquires whether a hysterical
monoplegia can automatically appear as a result of emotion without any
intellectual element whatever. Emotion produces sweat, diarrhea or
erythema, without any intellectual intermediate. Can emotion--that is,
emotional shock--produce a monoplegia in the same way as it produces
an erythema? The narratives of patients might indicate that emotion
can do such things. But according to Babinski there is no genuine case
of monoplegia or paraplegia directly produced by emotional shock. One
must be careful in this discussion not to confuse emotional shock and
emotion of a gradual nature. Babinski wishes to define emotion as a
violent affective change as a result of a sudden mental shock upsetting
physiologic or psychic balance during a usually brief period. As for
the more gradual affective states or emotions, there is obviously so
much of the imaginative and intellectual compounded therewith, that
plenty of opportunity exists for the production by suggestion of such
phenomena as monoplegia, paraplegia, hemi-anesthesia.

_Re_ sciatica, see remarks above under Case 329.


Functional paraplegia and internal popliteal neuritis.

=Case 387.= (ROUSSY, February, 1915.)

A Zouave was taken out from under a trench shelter beam, the night of
December 21, 1914, at Tracy-le-Mont. The beam had fallen upon eight
men, killing one, and striking the Zouave in the hypogastrium. He was
pulled out two hours later, unable to take a step. He was evacuated
on his back, to Paris; stayed a month in the hospital at Croix-Rouge,
bedfast. According to the patient, he was entirely anesthetic in the
legs. He went to Villejuif, January 22, with the diagnosis of spinal
contusion and hemiplegia. He could then walk on crutches, leaning on
the left leg. He felt a sharp pain at the level of the spinous process
of the first lumbar vertebra and all along the sacrum. Spontaneous
movements of the left leg were possible, but they were slow and weak.
The hypesthesia rose to the navel. There was a suggestion of a cauda
syndrome. The knee-jerks were normal, but on the left side the Achilles
jerk was absent. There was a partial R. D. in the posterior muscles of
the left leg.

The diagnosis was functional paraplegia plus left internal popliteal
neuritis. The crutches were removed, he was isolated, and given motor
reëducation. In a week he was able to walk alone with ease.

_Re_ popliteal nerve lesions, Athanassio-Benisty remarks that the
external popliteal nerve of the leg resembles pathologically the
musculospiral nerve of the arm, whereas the internal popliteal behaves
like the median. The musculospiral nerve of the arm shows very variable
and usually slight sensory changes. The median nerve more than any
other nerve in the arm yields painful sensations during its recovery
from section.

_Re_ differentiation of peripheral neuritis and hysterical paralysis,
Babinski gives as signs peculiar to neuritis, and never found in
hysterical paralysis, the following: (_a_) diminution or loss of
bone and tendon reflexes; (_b_) muscular atrophy (except for slight
amyotrophy exceptionally found in hysteria); (_c_) the reaction of
degeneration (only of value after eight or ten days); (_d_) hypotonus;
(_e_) distribution characteristic of peripheral motor sensory and
trophic disorder.

_Re_ diagnosis of organic paraplegia as against hysterical paraplegia,
the latter is to be recognized chiefly by the absence of the organic
signs, as (_a_) alteration of tendon reflexes, (_b_) the Babinski
sign (toe phenomenon), (_c_) exaggeration of defense reflexes (dorsal
flexion of foot on sharp pinching of dorsum of foot or leg), (_d_)
muscular atrophy with R. D., (_e_) sphincter disorder, (_f_) skin
changes, such as decubitus.


Bullet in hip: Local “stupor” of leg.

=Case 388.= (SEBILEAU, November, 1914.)

A Moroccan sharpshooter, 20, was wounded September 27, at Soissons.
One bullet scratched the left thigh. A second entered below the
anterosuperior iliac spine at least 6 cm. outside the femoral artery
and emerged above the ischiotrochanteric line, 2 cm. above and 4 cm.
behind the upper extremity of the great trochanter, thus passing
through the tensor of the fascia lata and without breaking a bone.

There was a complete paralysis of the left leg. The man had to walk
with a crutch and a cane, dragging the leg like a weight. There was
no active or passive movement of thigh, lower leg and foot muscles,
except that there was a slight tendency to abduction of the toes, from
innervation of the dorsal interossei of the foot. The iliopsoas was
also involved, as well as the gluteal and pelvic trochanteric muscles.
There was a certain amount of muscular tone preserved, so that the bony
elements of the skeleton were held together. The foot did not fall
and the leg did not elongate, as it might have in a case of paralysis
of the sciatic nerve. Electro-diagnosis showed an early reaction of
degeneration according to one examiner, but Sebileau believes that
there was no R. D. There was anesthesia of a large part of the leg,
which stretched over the anterior and internal aspects of the thigh,
covered the entire territory of obturator and crural nerves but did not
stretch above the fold of the groin. The region of the femorocutaneous
nerve was slightly sensitive and the posterior aspect of the thigh and
buttock was sensitive. There was a slight sensation on the external
aspect of the lower leg. Foot and toes were entirely insensitive.
The anesthesia was for all forms of common sensation. No vasomotor,
thermic or trophic disorder. The reflexes were all abolished, except
for a tendency to cremasteric reflex. It is clear that these conditions
cannot be simulated. Possibly they are hysteric and to be explained
on the basis of a kind of autosuggestion or perhaps, according to
Sebileau, the local and nervous apparatus under the mechanical and
caloric effects of the fragment had undergone a sort of local stupor.
No large nerve could have been affected by the injury, according to the
analysis made by Sebileau.

_Re_ stupor, see Case 253 of Tinel. _Re_ such local “stupor” it may
be noted that this case was published in 1914, before Babinski’s
larger publications on reflex disorders. As for the loss of cutaneous
reflexes, Babinski remarks that immersion in hot water may cause the
cutaneous reflexes in the so-called physiopathic cases to reappear for
a time. He regards the loss of cutaneous reflexes in the physiopathic
cases as due to a circulatory disturbance, and recalls the fact that
compression by an Esmarch bandage can cause the tendon reflexes to
vanish for a time, and can even cause pathologically excessive reflexes
to disappear. The cutaneous reflexes have also been caused to disappear
by compression.

According to Babinski, Sebileau’s explanation that such matters as loss
of reflexes could be explained by autosuggestion is erroneous.

_Re_ muscular hypertonus in reflex cases, Babinski remarks that though
it may be very pronounced, it is as a rule restricted in area. _Re_
sensory disorders in reflex cases, pains are found (they were very
slight ones in the present case); hypesthesia has also been found by
Babinski.


Localized catalepsy: Hysterotraumatic.

=Case 389.= (SOLLIER, January, 1917.)

An invalided soldier had been suffering for a year with marked
atrophies and the right knee in extension. There had been a bullet
wound of the upper third of the tibia, which did not affect the joint.
There was a total anesthesia, both superficial and deep, which stopped
sharply at the upper part of the thigh. At the time of the very
first examination, this apparent ankylosis was reduced, to the great
stupefaction of the patient. There was, however, a peculiar phenomenon
in this subject. There was a localized catalepsy of the limb, which
was able to preserve any desired attitude in which it was placed; and
this attitude could be indefinitely prolonged, just as in cataleptic
hysterics. Here, then, was a case of localized hystero-traumatism
precisely imitating the classical hysteria of Charcot except for its
localization.

_Re_ hysterotraumatism, Charcot developed ideas concerning trauma and
localized hysteria in 1886, thereby overthrowing the ideas of Erichsen
concerning the organic nature of “railway spine” and “railway brain” as
developed twenty years before. In a case of local trauma such as the
bullet-wound of Case 388, Babinski’s explanation would be that the pain
and inhibition of movement resulting from the bullet wound at the time
of injury, formed the focus of a process of autosuggestion. According
to Babinski’s figure, the organic factor acts as a _bait_ for the
hysterical symptoms. According to the Salpêtrière experience, hysteria
is incapable of producing a real superficial and deep anesthesia such
as is mentioned for this case. For example, no hysterical patient
in the Charcot clinic, according to Sicard, could undergo a scalpel
operation without some general or local anesthetic. When, therefore,
a true deep anesthesia occurs, Sicard’s conception would be that the
anesthesia is not a truly hysterical one but belongs to the group of
physiopathic phenomena.


Contracture: Hysterotraumatic.

=Case 390.= (SOLLIER, January, 1917.)

A sailor, 41, got hygroma of the right knee in 1915, was operated on in
July, returned to his dépôt a month later, and thence to Vizille Urage
by reason of contracture in extension of the right leg. It was thought
he was simulating (since there was no muscular atrophy), and he was
sent to the neurological center, where under anesthesia the joint was
found free. This man developed, when the knee was bent, extraordinary
cracklings in the joint, and he showed pain unequivocally, making a
defensive movement, partly reflex, partly voluntary, when the leg was
flexed beyond a certain point. There was 3.5 cm. atrophy in the thigh,
a reflex atrophy due to the joint disorder. There were no other signs
of hysterotraumatic contracture.

According to Sollier, the diagnosis of hysterotraumatic contractures
depends upon: first, a characteristic special attitude of the
contractured limb; secondly, the participation of the antagonists as a
group (_global_); thirdly, the superposition of sensory disorder upon
motor disorder (Charcot’s law); fourthly, the segmentary topography
of sensory disorder; fifthly, the extension of the contractured
joint; sixthly, the persistence of the contracture in the same form,
whether at rest or in attempted movements; seventhly, muscular
rigidity; eighthly, normal tendon reflexes; ninthly, normal electrical
reactions (though R. D. is hard to determine in muscles contracted to
the maximum); tenthly, special reactions during attempts to reduce,
such as pains, and equal and regular resistance to changed attitude,
pseudoclonus in cases of foot contracture; eleventhly, immediate
reproduction of the contracture after reduction under chloroform;
twelfthly, co-existence of various hysterical stigmata.


Crural monoplegia, tetanic. Recovery.

=Case 391.= (ROUTIER, 1915.)

An ensign was wounded by a shell splinter in the right scapular region
September 25, 1915. A large hematoma was drawn off and drains inserted.
Antitetanic serum was given 24 hours after the trauma. The wound looked
well. The patient complained merely of the heaviness of his arm, and
after September 27, the temperature fell to normal. Magnesium chloride
solution was applied every other day, and progress was so good that
evacuation was ordered.

However, October 8, the patient suddenly began to complain of a sharp
pain in the right thigh, which next day became intolerable and threw
the muscles into a slight contracture, the adductors being extremely
stiff. Headache developed in the course of the day, with slight
stiffness of neck, exaggeration of reflexes in the right leg, and
ankle clonus. Temperature: 37.6 morning, 38.5 evening. The patient was
isolated and given chloral.

October 10, paroxysmal crises of pain, more marked stiff neck,
and lumbar stiffness appeared, with nervousness, photophobia, and
hyperesthesia to noise. The wound seemed to be doing well. Chloral was
given.

Slight trismus developed October 11. The tongue became dry and the
patient drank little. The condition held and the same treatments
were repeated up to October 15, when the temperature fell and the
contractures and pains were diminished. The chloral was continued.
There were still a few cramps in the neck. October 22, however, the
patient was practically well.

We are here dealing with an instance of local tetanus of monoplegic
form, developing a fortnight after the wound (there is an early group
developing, as a rule, from the fifth to the tenth day, and a group of
later development, after the twentieth day; the interval in this case
was of intermediate duration). According to Courtois-Suffit and Giroux,
the differential diagnosis is not easy, since, besides tetanus, must
be considered tetany, spastic monoplegia of cerebral or spinal origin,
partial hemiplegia, peripheral neuritis, contractures due to bone,
joint, muscle or tendon lesions, strychnine intoxication and hysterical
contractures. Three cases out of six described by Routier were fatal.

_Re_ differential diagnosis of tetanic conditions, see Courtois-Suffit
and Giroux in the _Collection Horizon_. The cases as a rule appear in
subjects that have had serum treatment, and may occur in subjects in
whom no trismus ever develops (the above case showed slight trismus).

The recognition of localized tetanic contracture is based upon (_a_)
the intensity of the contracture, which causes the limb to feel wooden
(in one case the foot, leg, and thigh were welded to the pelvis like an
iron bar); (_b_) paroxysmal contractions resembling those of tetanus,
confined to one limb, and started by a variety of external causes,
forming the principal symptom in the disease; (_c_) contracture of
comparatively brief duration (hardly ever over two or three weeks). A
slight fever may help in the differential diagnosis.


Wound of left leg: Local spasms, later contracture, and painful crises
(these associated with suppuration), the whole treated as tetanic.

=Case 392.= (MÉRIEL, 1916.)

An infantryman was wounded by shell fragments September 28, 1915, at
Virginy and was given a first dressing an hour later and a second at
the ambulance, where antitetanic injection was also made. October 3,
the patient arrived at Foix, showing a superficial wound of the left
frontal region, a penetrating wound of the upper third of the left
thigh, and another in the lower third of the left lower leg.

The evening of October 8, the man began to feel pain in the left leg,
though the wounds looked well and there was no fever. October 9, sudden
involuntary contractions of the left leg developed, and these increased
in amplitude if the limb was touched. The other extremities were
normal. Temperature 38.2; pulse 102. Restlessness at night.

Next day 10 c.c. of antitetanic serum was administered and more on
the 11th, with chloral and isolation; but on the evening of the 11th,
with the contractions still completely localized to the left lower
extremity, came an extremely painful crisis interfering with sleep and
at last requiring morphine. Up to the 15th the antitetanic injections,
chloral and morphine were continued, but on the 15th the contractions
were replaced in part by a contracture affecting the muscles of the
posterior aspect of the thigh. In the meantime, the patient howled with
pain, especially in the night. Chloral and morphine were given.

During the next five days the contractures and pains became still more
violent, and on the 21st the antitetanic injections were begun once
more and kept up through the 26th in 5 c.c. doses.

The patient began to urinate in bed and to be delirious. The
contractions now disappeared, but the contracture persisted.
Antitetanic serum was given every other day from October 28 to November
2; every third day from November 4 to November 19; every fourth day
from November 22 to December 3; and every fifth day from December 3 to
December 17. The chloral was diminished from 15 to 5 grams per diem and
by the 20th of December all administration of chloral had ceased. The
morphine was given up December 25.

The tetanic symptoms of the left leg now gradually diminished. The
leg, which had been flexed at a right angle, began to extend little
by little, and the toes, which had been strongly flexed, reassumed
their normal position. The wounds suppurated freely during the tetanic
crises, but then healed. In January the man could get up and walk,
dragging his leg somewhat, and January 20 a complete recovery had
been obtained. There was no hysteria in the history of this patient,
although the man was subject to “professional” alcoholism, being carter
for a wholesale wine dealer, drinking 5 liters of wine a day.


Shell-shock by windage: Hysterical paraplegia, flaccid type, develops
10 days later, after strain, capture, privation, recapture. Paraplegia
at first complete. Recovery by suggestion (one séance).

=Case 393.= (LÉRI, February, 1915.)

A corporal, 21, told how at Goselmind, during the Sarrebourg retreat,
August 20, 1914, a shell burst a meter behind him, flattening his
knapsack, throwing him to the ground, blowing him forward (as he
said, by the pressure of the air) seven or eight meters, leaving him
stunned though conscious for about twenty minutes. Uhlans fell upon
him but did not trouble themselves further with him as he could not
walk. He crawled along on elbows and knees about a kilometer and a
half to some Frenchmen in a wood. He now found himself able to walk a
whole day supported by two comrades, making about 12 kilometers. He
got by carriage to Gerbéviller, but here fell again into the hands of
Germans, who left him nine days in the corner of a barn without care.
Gerbéviller was retaken, and he was evacuated to Bayon.

He had now had for some time pains in the kidney region below the point
struck, some difficulty in turning his head, and some numbness and
jerkings in the legs; and the legs that had carried him 14 kilometers
were unable to move at all, even in bed. It was only 8 days later
that he could perform the slightest movement, and two months followed
before he could go a few steps on crutches. December 14, three months
and a half after his accident,--he was demonstrated as “spinal
contusion.” Upon examination, however, there were no reflex disorders,
no sensory disorders, and the muscular weakness was equal in all parts
of the lower extremities and trunk. On crutches, he lunged the trunk
forward, painfully dragging his legs one after the other, the right
foot in external rotation, never passing the left foot, toes scraping
ground,--a functional flaccid paraplegia, completely dissolved by
suggestion at a single sitting.


Scalp wound; probably no loss of consciousness: Quadriparesis, later
paraplegia; tremors; profound sensory disorders, some apparently
hysterical; cataleptic rigidity of (anesthetic) legs on passive
movement. Diagnosis?

=Case 394.= (CLARKE, July, 1916.)

A soldier, 40, got a scalp wound but probably did not lose
consciousness. However, when observed three months after the injury,
though fat and well-looking, the patient could not stand or walk, and
his hands and arms were feeble. He complained of headache, insomnia
and anorexia, and remained in a state of mental inertia. All efforts
to read and write produced fatigue. Memory was bad both for remote
and for recent events. He was able to feed himself slowly, execute
a few movements of arms and hands, and raise his feet from the bed.
Upon passive movement, there was a sort of spastic state, which
did not amount to a true rigidity. Now and then a clonic spasm was
induced by such passive movements. After the repetition of those few
voluntary movements which were possible, the muscles passed into a
flaccid condition. There was a tremor of a type called swooping; the
tremor resembled that of Friedreich’s disease, such as is thought to
occur in cases of marked loss of muscular sense. The deep reflexes
were exaggerated. Concentric narrowing of the visual fields was
easily induced by testing them. There was a general slight dulness of
perception on sensory tests. There was astereognosis, and apparently an
absolute loss of position sense. Movements of the large joints through
an angle of 90 degrees were, however, vaguely recognized. Although the
patient could not touch, for example, his left forefinger with his
right, yet, if he had once seen the position of a limb and it was not
moved, he could remember its position and touch it after some time.
His localizing sense was from two to four inches out in the hands, the
localization being generally of points proximal to the point tested.

Two months later the patient was somewhat less dull and apathetic.
His memory had improved. He was able to read, and he was successfully
making a rug; but the legs were worse, having become anesthetic to
touch and pain. When the legs were placed in any position, they would
assume a cataleptic rigidity, and remain rigidly fixed in any position
for some time. The patient could sit up in bed. The muscles were well
nourished and the electric reactions were normal.

_Re_ catatonic rigidity, see Case 389 (Sollier).


Shell explosion; pitched in air: Spasmodic contractions of sartorii,
persistent in sleep.

=Case 395.= (MYERS, January, 1916.)

A private, 23, was admitted to a casualty clearing station and the next
day told the examiner, Major Myers, that the Germans had been sending
whizz-bangs and coal-boxes over, and the last he remembered was being
on guard and then digging himself out of fallen sandbags. His comrades
told him that he had been pitched in the air, but this he did not
remember. He remembered running to the shell trench, but finding this
“too hot,” he returned to the firing trench, noticing on the way that
he could not see well. He lay in the dug-out, flinching at each shell,
and “trying to get into the smallest possible corner.” He tried to do
guard duty that night, but, when some one noticed involuntary spasmodic
movements, he was ordered to go back to the dug-out, was helped to the
regimental aid post by two men, and was sent to hospital. He had been
in France eight months and had been shaken up somewhat four months
before, when bombs threw dirt in his face. At that time, his hands and
handwriting had become tremulous, but he had not reported sick. He
was depressed and wanted Major Myers to make him well. It seems that
he had shrugged his shoulders and made leg movements, diving beneath
the bedclothes, and bringing his knees to his chin. When Major Myers
examined him, the leg movements were due solely “to strong periodic
simultaneous contractions of the two sartorius muscles, the rate of
contraction of which varied from 60 to 70 per minute, increasing to 90
during the excitement of examination.” There were special changes of
sensibility in the right leg and arm and right side of the face and
chest, not involving the abdomen. The patellar reflex was exaggerated;
plantar reflexes could not be obtained. The legs were tremulous,
especially when the patient lifted them, whereas the hands and tongue
were only faintly tremulous.

Under light hypnosis, events in the amnestic period were recalled, and
details as to the shell’s direction, process of lifting up, and fall.
Under deeper hypnosis, the sartorius contractions diminished but did
not disappear. Appropriate suggestion was made, and upon arousal from
hypnosis, the movements ceased, the headache disappeared, memory was
recovered, and the unilateral disturbances of sensibility had vanished.

As to the possibility of malingering in this case, Major Myers calls
attention to the disorders of sensibility which he believes could
hardly have been simulated, to the persistence of spasmodic movements
during sleep, to their confinement to the sartorii, and to the spastic
condition of legs, such that when the thighs were passively raised the
knees remained extended.

_Re_ persistence of hysterical phenomena in sleep, Ballet felt that
he could prove that some hysterical contractures persisted during
sleep, and Sollier has written a special article to the same effect.
Ballet’s case had a contracture developing after an operation on the
first metacarpal bone. The contracture which followed would be then
probably, upon Babinski’s analysis, a reflex contracture and not a
hysterical one. Duvernay, Sicard, and Babinski himself have noted the
persistence of reflex contractures during sleep, to say nothing of
their persistence under an advanced stage of chloroform narcosis. In
fact, these reflex contractures are exactly as fixed and persistent as
contractures of clearly organic origin. It is probable that Babinski
would define Myers’ case (395) as a physiopathic one; yet against this
diagnosis would be the disappearance of the movements after hypnosis.
As against hysteria, it will be noted that the patellar reflex was
exaggerated, and that the plantar reflexes could not be obtained.


Shell-shock: Brown-Séquard syndrome, hematomyelic?

=Case 396.= (BALLET, August, 1915.)

A soldier, 24, went to the front November 12, 1914, and June 1, 1915,
had a shell burst near him in the trench, on the occasion of which he
felt a violent shock, as if a blow in the kidneys. He felt suddenly
paralyzed in both legs. He was crouching at the time of the shell
burst. His legs felt dead, and he had such violent pain in the thorax
as to make breathing difficult. He was carried to a shelter. After a
few hours, the left leg began to move again.

He was carried to the ambulance, remaining there five days, unable to
walk, though able to move and turn in bed, slightly constipated, with
persistent pains in back. He was then carried to Auxiliary Hospital
231, at Paris, and a bullet (!) was found superficially lodged in the
region of the left scapula. Neither patient nor physicians had hitherto
observed the bullet, which could have had nothing to do with any spinal
lesion.

The pains, in the course of a month, grew less, and at the end of two
or three weeks he began to walk and was sent to the psychoneurosis
service at Ville-Évrard, July 10. He then complained of pain in the
right thorax, especially on movement or after sitting up some time. He
could hardly bring himself to the sitting posture from the bed, and
found difficulty in raising the right leg therefrom. In walking, the
_right leg_ was dragged behind. The reflexes were increased on the
right side. There was ankle clonus without Babinski sign. Anesthesia
to touch over the whole of the _left leg_. Anesthesia to pin prick and
temperature as far as the umbilicus. Cold was not felt on the left side.

The water of a bath seemed lukewarm on the left side and warm on
the right. The left side of the scrotum and the left half of the
penis showed the same disorder of sensibility. There was a zone
of hypesthesia on the _right_ side of the thorax in the region of
the lower ribs. The patient compared his sensations while at rest
and without contact to a sensation of painful pressure occurring
intermittently, or rather in paroxysms, not advancing beyond the median
line of the back. Here was a question of Brown-Séquard syndrome,
probably due to a slight hematomyelia, but associated with no external
lesion or any injury to the vertebral column.

_Re_ Brown-Séquard’s syndrome, see Athanassio-Benisty with respect to
spinal cord symptoms associated with lesions of the brachial plexus. It
appears that the combination of spinal cord and brachial plexus injury
is not uncommon. Note in this case that a bullet was found in the left
scapula region. According to Ballet, this bullet could have had nothing
to do with a spinal lesion.


Violence to back: Dysbasia. Antebellum injury.

=Case 397.= (SMYLY, April, 1917.)

A man (also injured in 1906 by the fall of a heavy weight on his back)
went to France in 1914 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.

Upon return home the patient went from one hospital to another, for the
most part unable to walk, suffering from agonizing pain in head and
eyes. Insomnia and waking dreams.

He was able to bring himself to an upright position and to rush a few
steps. He has now acquired considerable control of the feet by the aid
of crutches. Insomnia persisted.


Dysbasia: Psychogenic (cerebellar nucleus (?))

=Case 398.= (CASSIRER, February, 1916.)

On March 9, 1915, a shell wounded a man slightly, and burned off some
of the hair of his head. He was unconscious two days, and on waking
vomited for a time. Shortly after the injury difficulties in standing
and walking set in, with headache, noises in the left ear, difficulty
in the intake of ideas, excitability, and poor memory. Then, slight
improvement. About the middle of June he was no longer closely confined
to bed and could take a few steps with two canes; but the gait was
still unsteady and the left leg tended to make abnormal-looking
movements. There was nystagmus, rapid, though constant, on looking
to the left,--more in the left eye; and nystagmus on looking to the
right,--more in the right eye. Adiadochokinesis absent. Vestibular
nerve somewhat excitable. Deviation outward in finger-pointing test.

According to Cassirer, this case is one largely of psychogenic origin,
with possibly an organic cerebellar nucleus. The knee-jerks absent
(even up to March 31). W. R. negative.


Shell-shock; unconsciousness: Dysbasia, in part hysterical, in part
organic (?).

=Case 399.= (HURST, May, 1915.)

A private, 29, was knocked over by a shell explosion December, 1914. He
was unconscious two days, found that he could not move either right arm
or left leg, got some power back shortly, but, if he tried to stand,
experienced involuntary violent movements in the left leg.

April 1, 1915, response to questions was slow and speech slow. The
right arm and grip were weak. If the left hand was clenched, there was
an associated movement of the right hand; but on clenching the right
hand, no associated movement was produced in the left. The musculature
was equal on the two sides, and the tendon reflexes of the arms were
brisk and equal. Light tactile stimuli were hard to localize. Movements
of the left leg were somewhat weak, though the musculature was equal on
the two sides. The knee-jerks were brisk, the left slightly brisker.
Sometimes a well-marked ankle clonus could be obtained on the left
side, but sometimes not. The plantar reflex was constantly flexor.
Babinski’s second sign (combined flexion of thigh and pelvis) was well
marked on the left side.

On attempts to walk, the left leg would move rapidly from side to side,
round the point of contact of toes with ground. When a step forward
was taken with the right leg, the left one dragged, and made irregular
movements.

This gait seemed obviously hysterical. The patient was kept in hospital
for a month. He was very easily hypnotizable, but even in deep hypnosis
leg movements could not be controlled when he was told to walk. The
first whiff of ether hypnotized but did not cure him.

On the whole, upon review, Hurst believes that there may have been
organic brain changes, which (_a_) the associated movement of the
paralyzed hand when the normal hand was contracting, (_b_) the slightly
increased left knee-jerk, (_c_) tendency to ankle-clonus, and (_d_)
Babinski’s second sign, may show.


Peculiar walking tic.

=Case 400.= (CHAVIGNY, April, 1917.)

A soldier was found with a peculiar walking tic. He would rest a
good deal longer on the left leg than on the right. He would make a
sudden movement of the right leg forward, as if on a spring. At the
same time, the man’s head would give a violent movement to the right
just as the right leg was receiving the weight of the body. The idea
of this movement seemed to be that the center of gravity would be
shifted and the work of the right leg would be relieved. This peculiar
walk was naturally very slow. If the walk was slowed down, it became
quite normal. There was no pain at the basis of this walk. If the man
hopped, he hopped no more painfully on the right leg, nor with greater
difficulty, than upon the left.

This man was guilty of desertion in the face of the enemy, and of
desertion in the interior in time of war. He said he could not walk
well and that he needed to take care of himself at his mother’s house,
as he was not considered sick in his regiment. He had been wounded
with two bullets, September 28, 1914, which struck him on the internal
aspects of the knees. He was treated in hospital from October to the
end of November, 1914; was held at the dépôt of his regiment from
December to August, 1915. He was then put in hospital a month, and
returned to his dépôt for three more months. He was examined by three
physicians in August, 1915, and the commission decided that he was fit
for service, and a simulator.

Thorough examination, including electrical and X-ray examinations,
showed no lesion. Chavigny observed the patient for a long time, from
the 21st of November, 1916, to January 5, 1917. Shells dropped near the
hospital, December 2, and, following orders, the patients were taken
into a vaulted cellar, and they ran thither very rapidly; but this
patient could not hurry. He walked slowly, with the same tic. Surely
the tic would be rather a difficult one to imagine, and a somewhat
more probable set of symptoms would ordinarily be chosen. The man has
not the unstable nature of the ordinary victim of tic. On the contrary,
he has rather the invincible obstinacy of a hysterotraumatic. On being
shown that he could walk properly without these “para” movements, he
would reply, “I can’t do anything else,” and he shook his head upon
being told that he could be cured.

Reëducation of his anesthetic areas (there was a zone of diminution in
sensibility to pin-prick in the knee region, and a complete anesthesia
of the sole of the foot, with abolition of the plantar reflex),
reëducation by appropriate gymnastics, and mental reëducation, might be
attempted in a special neurological hospital.

_Re_ disorders of gait, Laignel-Lavastine and Courbon divide functional
gait disorders into three groups: (_a_) A group called dynamogenic;
(_b_) an inhibitory group; and (_c_) a group showing both forms of
disorder.

Roussy and Lhermitte have attempted to divide the gait disorders into
two groups: (_a_) A group termed by them basophobic, in which there is
a marked psychogenic and emotional basis; and (_b_) a dysbasic group,
the basis of which is suggestion rather than emotion. Following is a
skeleton of their classification:

1. Astasia-abasia and dysbasia group.

    Astasia-abasia.
    Pseudo tabetic dysbasia.
    Pseudo polyneuritic dysbasia.
    Tight-rope walker’s gait.
    Scrubber’s gait.
    Choreiform dysbasia.
    Knock-kneed gait.
    Walking as if on sticky surface.
    Bather’s gait.

2. Stasobasophobia group.

3. Habit limping.


Mine explosion; unconsciousness: Camptocormia. Hospital rounder twenty
months (bedfast five months) without complete neurological examination.
Cure by persuasive electrotherapy in one hour.

=Case 401.= (MARIE, MEIGE, BÉHAGNE, February, 1917; SOUQUES and
MÉGEVAND, February, 1917.)

A man became a hospital rounder to all points of the compass in France
during a period of twenty months, with such diagnoses as myelopathic
disorder, complex spinal trouble, ataxic phenomena.

As a matter of fact he was a camptocormic: trunk bent, knees
semi-flexed, legs in external rotation. He used two canes in
locomotion, made a bowing movement with each 20 cm. step, then another
bowing movement, and another little step with the other foot. Made to
lie down, his legs would elongate, the right completely but the left
with some difficulty, the feet going into hyperextension, with the big
toe raised, others flexed; the feet externally rotating, plantae turned
in. In horizontal decubitus, there was only slight lumbar discomfort,
but the legs stiffened and gave quick convulsive jerks. Taking the
posture several times in succession would diminish these phenomena.
Kneeling, he could bring his heels within 10 cm. of the buttock,
whereas in spontaneous flexion of the leg on the thigh, the knee
remained a distance of 40 cm. from the buttock.

A complete examination showed no joint disorder or any diminution in
muscular strength, or any reflex disorder except that all the tendon
reflexes were rather powerful. There was a question of possible X-ray
demonstration of lesions and ankylosis of the fourth and fifth lumbar
vertebrae, and there was a question of some incontinence of urine. On
the basis of these phenomena apparently, this camptocormic patient had
been saddled with the diagnosis of myelopathic and ataxic disorder
for a period of 16 months. A neurologist was at last consulted, and
on his advice, it proved possible to get the patient evacuated to a
neurological center in a period of four months. Facts of this species
are unfortunately still too common, state Marie, Meige and Béhagne,
February 1, 1917, despite the remarkable and rapid cures obtained in
camptocormia by Souques. In point of fact, no complete neurological
examination had been performed upon this man during a period of 20
months.

This particular patient was given to Souques for treatment (Souques and
Mégevand). His cure was completed by persuasive electrotherapy, in an
hour.

It appears that the man was buried in a mine explosion, June 5, 1915,
lost consciousness and came to twenty hours later, able to rise and
take a few steps, but bent in two with a sharp dorsolumbar pain. The
pain grew more violent and generalized during the next few days, and
he began to lose all power in his legs, so that he could walk with the
greatest difficulty. He was practically bedfast for five months. He
then tried to rise and walk, but suffered so much that he could not get
up except in a camptocormic position. It was in fact only January 23,
1917, at the Salpêtrière, that the diagnosis of camptocormia was made.
The man complained of pains at the lower dorsal and lumbar regions
of the spinal column with slight irradiation sidewise. The following
diagnoses had been made:

June 8, 1915. Severe contusion of chest and back.

July 9, 1915. Multiple contusions, commotio spinalis; lesions and
ankylosis of the 4th and 5th lumbar vertebrae (X-ray examination).

Sept. 3, 1916. Lumbar intervertebral arthritis with compression of
roots.

Nov. 4, 1916. Myelopathic disorder.

Dec. 5, 1916. Old complex spinal disorder.

Souques remarks that these diagnoses show that knowledge about
camptocormia has not penetrated into most of the sanitary formations
(1917).


Astasia-Abasia.

=Case 402.= (GUILLAIN and BARRÉ, January, 1916.)

A soldier was evacuated to the 6th Army neurological center for
paraplegia with tremor. He had been in various hospitals _for a period
of a year_. The tendon reflexes of the arms appeared increased; there
was a suspicion of patellar clonus and of foot clonus, and it had been
proposed to invalid the man for spastic paralysis. In point of fact,
the man was suffering from an epileptoid trepidation of the foot and of
the patella. When he was lying down, his motor disorders practically
passed away, though they had been very marked when he tried to stand
upright or to walk. He had much trouble in walking, but could readily
stand for some time on one leg.

The man was forthwith treated by persuasive methods. It is important
to find out the organic lesion which in all probability served as a
starting point for the functional disease, and important to remove or
abolish this lesion however minute if a complete and lasting cure is to
be obtained.

_Re_ astasia-abasia, writers have remarked that it is one of the
commonest hysterical syndromes in the war, though somewhat rare in its
complete form. Roussy and Lhermitte state that it usually follows the
explosion of a large calibre projectile and has a rapid onset. It is
often an isolated phenomenon, without emotional or other Shell-shock
complications. The victim has been thrown to the ground and rolled into
a trench or hollow. Sometimes the victim gets back to the first-aid
post, only to find himself on arrival at the ambulance wholly unable to
walk. The legs, however, are drawn along inertly, as in paraplegia, or
a pronounced contracture interferes with walking.

Astasia-abasia is classified with hysteria major, hysterical
hemiplegia, hysterotraumatic brachial monoplegia, glossolabial
hemispasm, hysterical mutism, and rhythmic chorea, as so characteristic
that differential diagnosis is superfluous. According to Babinski,
no functional spasm and no organic disease can reproduce hysterical
astasia-abasia.


Multiple shell wounds, with persistent slight suppuration of thigh:
Abdominothoracic contracture, tetanic, four months after original
injury.

=Case 403.= (MARIE, 1916.)

A soldier, 31, was wounded in the left arm January, 1915, and received
10 c.c. antitetanic serum; was wounded again July 10 in the face,
scalp, upper part of the thorax, left arm and left leg by shell
fragments, and again received, two days later, 10 c.c. antitetanic
serum. July 13, at the ophthalmological center at Rouen the left eye
was enucleated on account of a shell wound, and four days later a
fragment was removed from a phlegmon of the forearm. Later a number of
operations were made for blepharoplasty. The wounds all healed well
except for an apparently insignificant, small suppuration of the thigh.
November 10, four months after the shell wounds, while apparently in
perfect health, the man began to complain of lancinating, intermittent
pains in the abdomen, thorax and lumbar region. With these pains was
associated a persistent abdominolumbar contracture.

On the suspicion of an abdominal form of local tetanus, chloral was
given; but the condition grew worse. The sudden contractions spread
from the waist to the feet, from November 20 onward, and were felt by
the patient as electric shocks. The arms were not affected. Trouble
with breathing supervened on the night of December 3. Sometimes there
were respiratory pauses for as long as 15 seconds, followed by a slight
polypnea. December 6 the man presented an intense contracture of the
lower part of the trunk. The slightly retracted abdominal wall was of
marbly hardness, but quite painless. Analgesic muscular rigidity took
the place of the former crises of pain. The dorsolumbar contracture was
so marked as to make an appreciable hollow in the back. The patient
could pick up an object from the ground only by flexing his knees to
the maximum, as the trunk could not be flexed. There was a very slight
trismus, but he could open his mouth, drink, eat and talk without
difficulty. There was no trace of neck stiffness or of Kernig’s sign.
The tendon reflexes, normal in the arms, were exaggerated in the lower
extremities, especially on the left (wounded) side. The skin reflexes
were also more marked on the left side, especially the reflex of
the tensor of the fascia lata. There was no longer any evidence of
suppuration of the wound of the left thigh, which had been dried up for
a fortnight. The pulse was somewhat exaggerated (92) and there was a
general hyperidrosis, especially of the face.

Forty c.c. antitetanic serum were given without reaction, and 4 grams
of chloral; five days later, 30 c.c. more serum. After ten days the
abdomen remained hard, though there was a trifling improvement of
the lumbar contracture. There were no longer any spasmodic crises or
respiratory disturbances. There was a slight serous exudation from the
wound. X-ray showed a small shell fragment 6 cm. below the orifice of
the wound.

The third injection was given December 27 to prevent mobilization of
the bacilli at operation, and on the 28th, the projectile was removed
under local anesthesia from a small, walled-off, old pus pocket, from
which were cultivated bacillus perfringens and other organisms.

December 31 a distinct improvement set in and January 13 there was
little or no trace of previous disease, except that testing the plantar
cutaneous reflex on the left side produced an exaggerated contraction
of the tensor of the fascia lata. February 15 he was reëxamined and
found quite normal.

This case of tetanus limited to the abdominothoracic muscles (except
for a very mild contracture of the masticators) had as its locus of
origin, doubtless, a wound of the thigh from which the toxin rose along
branches of the lumbar plexus to impregnate the corresponding level of
the spinal cord. Although there was no stiffness of the wounded leg,
yet there was an exaggeration of the tendon reflexes thereof. The first
phase of painful contractures and spasms with respiratory disorder was
succeeded by an analgesic phase of characteristically tetanic rigidity.
The nonfebrile nature of the disease and the preservation of good
general health are worth noting.


Shoulder blade unslung in knock-down by shell splinter: Hysterical (!)
paralysis of arm with anesthesia. Recovery by electricity, massage, and
reëducation (dislocation remaining).

=Case 404.= (WALTHER, December, 1914.)

A soldier was struck September 27, near Berry au Bac, by a shell
fragment in the right scapular region and was thrown, according to
his story, 15 meters. Upon entrance at Val-de-Grâce, October 13, the
shoulder-girdle was found intact. There was a very painful point in the
spinous process of the scapula, suggesting a fracture; but the bone
was proved intact on X-ray. The scapula was very mobile, as if unslung
from the thorax. The arm was paralyzed. On raising the arm the scapula
followed its movements and detached itself completely from the thorax,
dislocating upwards with lively pain. The fingers could be pushed under
the anterior surface of the scapula, and its internal border proved to
be entirely free of attachment. Pressure along this internal border was
very painful. It seems as if there had been a tearing of the rhomboid
and serratus magnus muscles and probably a part of the latissimus
dorsi under the influence of the violent shock conveyed by the shell
fragment, which had pushed the scapula forward and upward without
injuring the skin.

There was also a complete paralysis of sensation. Paralysis of motion
was complete except for the extensor longus of the thumb. This motor
paralysis had come on progressively three days after the accident. A
radicular paralysis from an evulsion of the plexus was suspected.

Babinski, however, made the diagnosis of psychic paralysis, finding the
muscles reacting perfectly to percussion. After a few electric tests
with the faradic current voluntary movements were obtained in all the
muscles of the arm and hand.

Treatment was then continued by electricity, massage and reëducation,
so that all movements soon regained strength. The patient can now
himself, by raising his arm, still produce his dislocation, which still
provokes a lively pain.


Gunshot wound of left forearm: PARALYSIS of the arm gradually
INCREASING IN DEGREE and extent and associated with pains and
anesthesias.

=Case 405.= (OPPENHEIM, July, 1915.)

A reservist sustained, October 2, 1914, a gunshot wound of the left
forearm from a distance of about 1400 meters. He fainted, lost much
blood, and was treated surgically, October 7, in hospital (at this time
no complete paralysis of the arm).

In November, however, an incomplete paralysis at first developed.
November 12, the patient was able to flex his thumb but showed some
anesthesia.

Transferred to nerve hospital in December, the patient said that at the
first change of dressings, October 10, he had not been able to move his
arm, and said that pains and paresthesia had existed in the arm ever
since the injury. There was still some evidence of suppuration at the
exit orifice of the bullet. The left arm was now completely paralyzed
and atonic, and hung down in walking, without swinging. The supinator
phenomenon, though present on the right side, was absent on the left.
The triceps reflex was present. The shoulder acted like a flail joint.
On passive elevation of the left arm, the deltoid seemed to contract
slightly at first; later it failed to contract. Fibrillary tremor of
the left thumb.

Suggestive therapy was unsuccessful. There was an anesthesia of the
left arm and the left trunk. The disorder diminished proximally,
being most severe in the hand and the arm. The legs were normal. The
electrical irritability of the left arm was only slightly diminished.
There was a well-marked hypertrichosis of the left forearm, the skin of
which was slightly purple and discolored. The patient himself made an
attempt to burn his arm with a lighted cigar, to see if he could feel
the pain. He showed the scar but had felt nothing. The pectoralis major
muscle did not contract. If the left arm was started actively swinging,
it kept on swinging inertly. The left hand showed hyperidrosis. The
small hand muscles were emaciated but electrically normal.


Glass wound of wrist: Differential glove anesthesias (cold to mid
forearm, pain somewhat higher, touch as far as elbow).

=Case 406.= (_Romner_, March, 1915.)

A German soldier, 37, wounded his right wrist in the glass of a door.
The hand was put up six weeks long with very few changes of the bandage
on account of suppuration, and he noticed that the arm was getting
weaker and weaker, that he was losing feeling in it, and that it was
beginning to sweat a good deal, so that now and then drops of sweat
would stream off. The right hand was found markedly congested and 1.5
cm. larger in circumference. The fingers and hand were especially weak.
There was a marked tremor of the arm. Electric excitability normal. The
sensory disorder was in glove form. Hypesthesia to touch reached the
elbow, analgesia to a point three fingers’ breadth below the elbow,
and anesthesia to cold to a point two fingers’ breadth still lower, a
sort of stepwise dissociation of sensibility resembling what is found
in spinal lesions. The case was presented as one of local traumatic
hysteria.

_Re_ hysterical anesthesia, the rule is that it obeys no definite rule;
that is, it may be a hemianesthesia, a segmentary, an isolated, or even
a pseudo-peripheral anesthesia. It is a question whether Babinski would
attempt to explain Romner’s case on the basis of medical suggestion,
hetero-suggestion, or autosuggestion.

Myers has had a few instances in which anesthesia spread gradually, and
in which analgesia increased after its onset.

_Re_ reëducation of cutaneous sensations, Chavigny recommends the
faradic current in successive applications, marking the extent of the
zone of anesthesia with ink upon the skin. Each time the current is
applied, the inked limits of the area are lessened. By this form of
suggestion, not only does the anesthesia disappear, but very often the
accompanying paralysis also.


Hysterical contracture, edema and vasomotor disorder.

=Case 407.= (BALLET, July, 1915.)

For some unknown reason, a soldier developed a contracture of the
right upper and lower extremities at a time when a basin of water was
offered to him for toilet purposes. Three days later, this contracture
disappeared in the leg but persisted in the arm at the radiocarpal
joint and in the finger joints. There was also an anesthesia to touch
and pain and temperature which ran up the arm to the shoulder. The
tendon reflexes were normal. On the whole, there seemed to be no doubt
that the case was one of hysterical arm contracture. Associated with
this contracture was a white edema of the hand. On account of the
chances of simulation, the hand was done up and sealed in such wise
that the seals would have been broken if the splint had been lifted
down during the night. The bandage was in place from June 25 to June
29. Upon its removal, there was no edema, but the contracture was
still there. The arm was put up upon a cushion so that the hand would
drain to the forearm. The edema was found capable of returning when
the hand was placed below the level of the shoulder, disappearing when
the hand was raised. The contractured hand was warmer than its fellow.
According to Ballet, we here have an anesthetic instance of contracture
associated with edema and vasomotor disorder.

_Re_ edema, Babinski states that no case of hysterical edema has stood
the test of scientific critique. Sometimes a case turns out one of
tuberculous synovitis. Sometimes the patient is shown artificially to
have brought about the edema. The hysterical “blue edema” of Charcot
has not been proved to exist. Some during the war have been found due
to voluntary constriction. Some of these constriction edemas even
become relatively permanent. Babinski regards the above case of Ballet,
as well as cases of Lebar and of Raynaud, as not true cases. Raynaud’s
case was probably vascular.

_Re_ vasomotor disorders in Ballet’s case, the Babinski school, of
course, holds that hysteria cannot cause such disorders.


Hemiparesis with syringomyelic dissociation of sensations.

=Case 408.= (RAVAUT, August, 1915.)

A road-laborer, 42, in the 268th Infantry, had a bomb burst about
a meter away, March 4, 1915. Three men nearby were killed, and two
wounded. The laborer himself was turned over, covered with earth, and
stunned. He could hardly get up. He was carried to shelter and found
paralyzed on the left side, and unable to speak.

Next day, he was carried to the ambulance, and hemianesthesia was found
to exist in addition to the hemiplegia. He could now speak with some
difficulty and stammered. Vision and hearing were also impaired on the
left side. Reflexes weak; no sign of wound. There was a convulsive
crisis of some sort during the day, and afterwards the man complained
of a violent headache, whereupon a lumbar puncture showed a clear fluid
and a marked excess of albumin by the heat test.

The following day, March 6, the patient had much improved; his
hemiplegia was less marked and the arm paralysis had almost entirely
disappeared. He still stammered.

Upon the next day, vision and hearing were normal, and the sensation
was practically normal. A second lumbar puncture, March 8, showed a
diminution in the amount of albumin, although it was still supernormal.

March 9, leg contractured in extension; stammering.

March 12, there was no evidence of disease. March 13, albumin was very
slightly increased over the normal in the puncture fluid. March 16,
there was a slight trace only of weakness in the left leg. The urine
was throughout normal. The patient wrote _Bavo_ April 12, and May 7 he
was well but still felt heaviness and pulling sensations.

July 15 it was reported at Tours that he was not yet well, presenting
a left-sided hemiparesis, especially in the leg, with a syringomyelic
dissociation of sensations, with atrophy of the quadriceps and
diminution of reflexes on the left side. The patient had had a
hematomyelia (Laignel-Lavastine).


Brachial monoplegia, tetanic.

=Case 409.= (ROUTIER, 1915.)

A soldier sustained a penetrating wound of the back of the thorax
on the left side and received an injection of antitetanic serum. A
few days later, May 18, 1915, he came on hospital service very sick,
with high temperature and marked suppuration. The next day he had an
anxious facies, temperature of 40 degrees, and sharp pains in the left
arm. This arm May 21 was still very painful and then began to make
involuntary movements in the shape of incessant clonic contractions.
The forearm would suddenly flex upon the upper arm, and the upper arm
itself would violently push itself forward and outward. Meantime, the
wrist and fingers were not involved in the contractions. The movements
were continuous, but paroxysmally increased in extent.

Babinski, called in consultation, confirmed the diagnosis of an
anomalous form of tetanus. Next day trismus, pleurosthotonos, and stiff
neck developed. Antitetanic serum and chloral had been given from the
beginning, with morphine at night. The patient, however, died with
asphyxia June 3.

_Re_ brachial monoplegia, the hysterotraumatic form first observed by
Charcot has an anesthesia with the shoulder of mutton distribution,
slightly affecting the thorax in front and behind, in addition to the
paralysis.


Paralysis of right leg: Hysterical? Organic? “Micro-organic?”

=Case 410.= (VON SARBO, January, 1915.)

A Lieutenant, aged 28, lost consciousness September 6, 1914, as
the result of a shell explosion. When consciousness returned in
the hospital, he could not remember what had happened. The last he
remembered was that he had been pushing forward with his troop. There
had been no psychic shock whatever. Examined September 15, he showed
a right-sided hemiplegia with stiffness of the right lower extremity
so that it could not be even passively flexed. It was with difficulty
he could walk and he dragged his right foot. Patellar reflex could not
be elicited on the right. Oppenheim and Babinski were absent. There
was a slight nystagmus on looking to the right. Pupils normal. Tongue
deviated to the left. Speech was slow and the man had to think a little
over some expressions. He could not feel touch so well on the right
as on the left and this hypesthesia grew more marked distally. He was
greatly bothered because certain words did not come to him readily,
especially names.

The absence of the Babinski and Oppenheim reflexes was against an
organic hypothesis and the absence of hysterical stigmata and the
non-characteristic sensory disorder, as well as the absence of any
psychic shock in the history, spoke against hysteria. The hypoglossus
paralysis spoke in favor of the organic nature of the disease.

According to von Sarbo we must look for the background of so-called
functional nervous disorders, hysteria and neurasthenia, in structural
changes of the nervous system, the changes that Charcot called
molecular. But the lesions, he believes, do not lead to a degeneration
of neurons. Accordingly we get only the external form of organic
paralysis without concomitant symptoms, such as Oppenheim and Babinski
reflexes. Von Sarbo terms his hypothesis that of “microörganic”
changes. To prove the hysterical nature of a condition we must show
first that the symptoms have taken their rise on a mental or moral
basis.


Shell-shock and momentary burial: Muscular weakness, followed (third
day) by complete paralysis (save neck and head). Diagnostic hypotheses.

=Case 411.= (LÉRI, FROMENT and MAHAR, July, 1915.)

A big shell burst October 3, 1914, a little over 3 meters from a
soldier crouching in a shallow Saint Mihiel trench. The shell made a
hole two meters in diameter and 1.5 meters deep, and covered the man
with loose earth, from which he was readily released. During the next
few days, the man found difficulty in following his comrades on short
marches (1 to 4 kilometers). He was unable to buckle on his knapsack.
The patient was himself not alarmed at his condition.

Up to the time of his accident, this man, a farmer, had never had
any motor trouble, nor was there any nervous disorder in any of his
relatives. He had been in several conflicts, August 24-25, September
4-6, in the Argonne and in the Haute Meuse, and he had never found it
hard to keep up with his comrades. In fact, once in the Haute Meuse,
he took part in an exceedingly difficult and hasty retreat, and only a
week before the shell-shock above described he had put in a very long
march. Thus a man, perfectly normal before the shock, had fallen into a
general state of slight muscular paralysis.

On the third day very suddenly this paralysis became complete. The
wounded man, while sitting in the trench, found that he could not stand
up either with or without the use of his hands. Now, that very morning
he had marched three kilometers from his cantonment to the trench. He
was supported on the way to the relief post, hardly 200 meters away,
and was then sent to the hospital at Bar-le-Duc. At this time he was so
weak that he had to be fed like a child.

For a period of three weeks he lay, unable to rise or sit up. There was
one exception to the generalization of the paresis: the movements of
the head and neck were normal. A general muscular atrophy set in during
the three months, but gradually diminished in amount. The diagnosis of
myopathy was made, based upon the evident degree of lumbar wasting,
kyphosis, the man’s attitude, gait, manner of rising, galvanotonic
contractions.

The history was, of course, rather against the diagnosis of myopathy,
as well as the marked atrophy of the hands and the existence of an
incomplete R. D. Moreover the fact that he improved may be regarded as
rendering the diagnosis of myopathy doubtful.

Other diagnoses, less likely than that of myopathy, may be
considered,--hematomyelia, recurrent traumatic poliomyelitis affecting
the anterior horns, polyneuritis.

Without making decision as to the nature of this case, Léri proposes
the question whether there is a shell-shock myopathy and whether there
is a myopathy due to gas or to hemorrhage?


Shell-shock: Right hemiplegia with contracture and mutism. Cure by
isolation and suggestion. Question of the relation between plantar
areflexia and (_a_) anesthesia (hysterical) or (_b_) contracture.

=Case 412.= (DEJERINE, February, 1915.)

A territorial infantryman, 36, of a nervous and impressionable
temperament (father alcoholic), was blown up by a bomb October 3,
1914, between Bapaume and Arras. He was evacuated forthwith to the
relief post. According to his own story, he spat blood, could not talk,
and felt his right side weak. He was three weeks at a hospital in
Paimpol, with the diagnosis of right hemiplegia with contracture and
mutism. At Guingamp, an electrical treatment was followed by a gradual
disappearance of the arm contracture.

Examined by Dejerine, January 2, 1915, he was found to be a tall,
stalwart man with right leg contractured in extension, foot in
equinovarus, heel raised. He walked, dragging the leg, which trembled;
the trembling then extended to the rest of the body. In dorsal
decubitus, the leg lay in adduction and internal rotation. He could
lift the leg only 5 cm. above the bed, could only slightly flex leg on
thigh, and could not at all flex thigh on hip. The leg could not be
bent at all if he was requested to hold it stiff. Ankle joint movements
were impossible from contracture. The equinovarus was in contracture
which could not be corrected. Right hip movements were limited and
painful. Muscular atrophy absent.

Whereas on the left side plantar stimulation produced not only the
normal flexor reflex but also the classical defense movements of
flexion of leg on thigh and thigh on hip,--on the right side neither
a needle nor a match, nor any other form of stimulation of the sole,
produced any kind of reaction on the part of the toes, the fascia
lata, or any leg muscles. Tested every day for some weeks, the result
was always the same. The cremasteric reflex was weak on the affected
side. Abolition of the plantar reflex and of the defense movements
on the right side was associated with an anesthesia and a hypesthesia
of the right side of the body, involving complete anesthesia below
the knee and hypesthesia of superficial and deep sensation above the
knee. The buccal and lingual mucous membranes were also hypesthetic.
The bony sensibility was lost in the foot and lower leg, and was
diminished in all of the bones of the right side of the body. There
was no contraction of the visual fields. The right corneal reflex was
diminished. There were no other sensory defects.

The man was also aphonic, being unable to utter a word or a sound
except a jerky whistling sound like the letting off of steam. He was
able to write out his history intelligently. He was very emotional,
wept, and trembled all over when talking of wife and children. The
spinal puncture fluid was in all respects normal. A laryngoscopic
examination showed that the vocal cords were functioning normally. The
long _a_ could be pronounced distinctly, at the expense of great effort
so that the larynx would finally be blocked. The laryngeal reflex was
abolished. The laryngeal mucosa could be touched with a probe without
producing the slightest pain or coughing reflex. By way of treatment,
this case of hysterotraumatism was given isolation and psychotherapy
for two months without effect. But about the middle of March he began
to get better, the symptoms rapidly faded, cure was effected at the end
of March, and the man was evacuated to his dépôt.

_Re_ reflexes and contracture, see the views of Babinski reproduced
under Case 385 of Paulian.


Shell-shock: Tic VERSUS spasm.

=Case 413.= (MEIGE, July, 1916.)

A soldier was bowled over in a trench by a big shell that burst nearby.
He lost consciousness and was carried to the ambulance. But he came to,
and was so absolutely well with a few hours’ rest that he took part in
a lively attack shortly thereafter and got a wound in the left arm,
affecting slightly the ulnar nerve. He was sent to the Salpêtrière for
this ulnar nerve affection, when certain movements of his scalp were
incidentally noted.

The scalp movements were quick, affecting the fronto-occipitalis
muscles as well as the auricular muscles. The displacement was from
behind forward, and then from before backward, with slight oscillations
of the ear; and at the same time, the forehead wrinkled or became
smooth. The movement was involuntary and more convulsive than the
somewhat similar movements that many persons can execute with scalp
and ears. The phenomenon appeared after the shock for the first time.
He had not noticed it himself but the physician at the ambulance had
called his attention to it. The soldier was not disturbed by the
matter, either at that time or later.

The diagnostician would consider, on the one hand, tic, and on the
other, spasm. According to Meige, the man was a victim of tic. No
case of such limited spasm appears to have been observed previously.
However, the sudden development of these movements without previous
history of tic renders the diagnosis somewhat doubtful. There was also
a complete anesthesia to pin-prick in the present case over the whole
right side of the scalp, face, and neck, even passing below to involve
the chest, shoulder, back, and upper part of the right arm, with
hypesthesia decreasing toward the nipple and the elbow. The soldier
was quite ignorant of this sensory disorder and had never before been
examined for sensations. The examination was made with due precautions
to avoid suggestion. The question of anastomosis between the facial
nerve and the auriculo-temporal branch of the trigeminus and the
auricular branch of the cervical plexus, and of their relations to the
anesthesia and tic of this case, is raised.

_Re_ pathological movements such as tremors, tics, and choreiform
movements, Roussy and Lhermitte divide the tremors (see also under Case
337) into typical and atypical.

The atypical ones are either limited, or more usually generalized
when they are merely parts of the Shell-shock syndrome. Sometimes the
tremors are paroxysmal, aggravated by noises. Now and then, a condition
of tremophobia appears (see Case 225). As for the typical tremors, see
classifications under Case 337.

_Re_ tics, the tonic or postural tic is, according to Roussy and
Lhermitte, much less common than clonic or spasmodic movements,
which are Shell-shock phenomena like tremors and usually yield to
psychotherapy if treated early. These tics are usually observed in and
about the head, involving the sternomastoid, trapezius, and platysma
muscles to produce clonic contractions of the neck. Other tics involve
coarser head movements, nodding, eyelid and facial spasms, bilateral
or unilateral, and shoulder movements. Babinski has suggested that
some of the tremors are possibly due to organic disease, in view of
the fact that they are not readily influenced by psychotherapy. Meige
has suggested that some of the tics may also be in some sense organic.
As for the differential diagnosis of tremor and tic, according to
Roussy and Lhermitte, the Shell-shock onset may be an indicator. The
non-rhythmic and irregular nature of the tic movements, and their
exaggeration on voluntary movement, may be of some importance. Most
of the tremors appear to be attended by a certain degree of permanent
contraction of the muscle groups concerned. Tremors cease when these
contractions disappear.

A point in treatment is that complete muscular relaxation should be
obtained by having the patient open his mouth and breathe deeply.

_Re_ diagnosis of neurasthenia in this case, it may be inquired whether
the term is properly used, and whether there is not some confusion
here betwixt neurasthenia and hysteria.

_Re_ hyperalgesia, Myers states that about 25 per cent of his
Shell-shock cases have shown a variety of disorders of the skin
sense. Hyperesthesia and over-reaction is one phenomenon in the list,
but is far less common than hyperesthesia. According to Myers, the
hyperesthesia was more relative than absolute, and was probably due to
increased affective response.


Shell-shock; unconsciousness: Tremors, anesthesias. Recovery by
suggestion.

=Case 414.= (MOTT, January, 1916.)

August, 1915, between Ypres and Flamentières, a Jack Johnson exploded
one day about three o’clock in the morning near an experienced gunner,
who had been on service in the R. F. A. for 15 years, and in France
during the present war 10 months. He came to in the military hospital
at Chatham, two weeks later, and was told he was lucky to be there
at all as the shell had killed many comrades. He was transferred to
Colchester, and thence to the Fourth London General Hospital.

Sitting in a chair, the man showed continuous rhythmic movements of
legs, hands, and jaw, exaggerated when he was spoken to. The tremor
was almost a clonic spasm. Every now and then, the patient would start
and look sidewise and upwards, as if a shell were about to drop.
Hyperacusis was such that the firing of the guns as far off as Woolwich
alarmed him. In telling his story, he would repeat the same words over
and over. He dreamt of shells bursting. His sleep was disturbed with
groaning and moaning. The face was flushed, and the palms sweating.
Because of the constant tremor, he could not stand or walk without
assistance, and it was difficult to test reflexes. The tremor somewhat
resembled the intention tremor of multiple sclerosis. He was unable
to feel the prick of the needle on legs, left arm, or hand. He could
not feel vibrations of the tuning-fork on feet, legs, or hands, though
he could on the forehead. The fork was heard quite well six inches
from the ears. There was some difficulty in recognizing colors. Bitter
fluids could be tasted, but vinegar, salt, and various fluids, could
not be recognized. He could not recognize tincture of assafetida, attar
of roses, or oil of cloves, though nitrite of amyl, ammonia and glacial
acetic acid were recognized.

Major Mott felt that, though this prolonged severe disease in a
long-service man might possibly be related to some organic change in
the brain, he might well treat him by suggestion. Major Mott told him
that the careful examination just made showed that there was no organic
disease, and made it certain that he would recover. In a fortnight,
he sat in a chair without tremors and with a profound belief in Major
Mott.


Hysteria as appendix to traumata.

=Case 415.= (MACCURDY, July, 1917.)

A private, 25, something of a liar and of rather a low personality, had
enlisted in the regular army in 1911, but deserted to become a football
player. He reënlisted, and went to France in September, 1914, enjoying
the first six months. He broke his ankles by falling into a deep
dug-out, and got frost-bite. After three or four months in England, he
found that he did not wish to go back to France. He was two months in
barracks, and then went up the line in a good deal of a panic. Soon
after, he was wounded in the thigh and was able to remain in hospital
a fortnight, exposed, however, to shell-fire and given to starting at
noise and occasional war dreams. Sent to his base, he remained jumpy
and was now permanently afraid of the line. After three weeks in the
trenches, he again got wounds, spent five months in England, came back
to France in May, and fought till September, 1916. He tried to convince
the medical officer that he had appendicitis and trench fever.

About the middle of September he saw with horror a man crushed by a
tank, and thereafter was markedly affected by the sight of blood.
Another slight wound sent him to a rest camp for two weeks, whence
he was again thrown into the line, suffering acutely from fear and
horror of blood. In three days he fractured his left collarbone and
wrist. He gave a pint and a half of blood for transfusion purposes,
and in turn was shipped to England. On removal of the splint, he
found “probably not without satisfaction” that the arm was paralyzed.
It remained paralyzed for five months, until treatment in a special
hospital eventually cured the arm; but upon cure of the arm, nightmares
developed,--an indication, according to MacCurdy, of the strong
resistance he felt to the idea of returning to the front.


Neurasthenic hyperalgesia after peripheral nerve injury.

=Case 416.= (WEYGANDT, January, 1915.)

A German volunteer, a sportsman, was under heavy shell fire after the
middle of October, 1914, and was wounded in the upper arm in November,
with an injury to the median nerve that occasioned severe pain.
These strictly localized pains increased upon any sort of physical
or mental strain. If he walked down steps he kept thinking he might
have an accident, and then the pains set in with greater force. He
became apathetic so that he did not eat, drink or urinate. If his head
were touched he felt pain as if from an electric shock. He also felt
the pain when he saw anybody approaching a door to close it, through
apprehension of the noise. Meantime, the wound was well healed. The
pulse was accelerated. The visual fields were only slightly contracted.
The patient wanted to get well and go back to the service.

Weygandt regards this hyperalgesia after peripheral nerve injuries as
neurasthenic.


Military training: Peripheral neuritis in lead workers.

=Case 417.= (SHUFFLEBOTHAM, April, 1915.)

Among fourteen cases of lead poisoning, members of the territorial
forces, largely from North Staffordshire, was a patient suffering from
peripheral neuritis. He had been in the dipping-house. Two years before
going into the service he had been suspended for lead poisoning by the
factory surgeon. Giving up his work at the pottery, he became a general
laborer in a non-lead process factory.

Three weeks after enlistment, the man began to complain of pains,
tenderness in the arms, weakness of the wrists, headache, giddiness,
nausea, and constipation. The bowels were opened by a large dose of
epsom salts. On blood examination the hemoglobin was found diminished
40 per cent; cells with basophilic granules were found to the number
of 500 per cu. mm. The face was characteristically pasty. There was
albuminuria. Alcohol could be excluded. The man had to be discharged.

All Shufflebotham’s cases occurred from three to seven weeks after
mobilization, nor have any cases ever been reported in territorials
after their annual training. Constipation was invariable. In two cases
returned to service, there was a recurrent attack. An epidemic could be
excluded. Shufflebotham suggests that the altered conditions of life,
especially the marching and drilling, caused increased metabolism,
setting free lead compounds from the muscles and organs of the body. It
is true that a glost placer always works very hard with his muscles,
but not with the muscles used by the soldier.


“Peripheral neuritis” cured by faradism.

=Case 418.= (CARGILL, February, 1916.)

A Naval Service man, 20, was thought to have peripheral neuritis. A
long history of pain and numbness in arms and legs, a well-marked
analgesia and anesthesia over the anterior aspects of forearms and
legs, and an anesthetic band across the front of the chest, seemed
consistent with the diagnosis. The calf muscles tightly squeezed
yielded no pain. Pins could be thrust without pain into the anesthetic
areas. When told to say _yes_ when the pin was felt, and _no_ when it
was not felt, the man persistently said _no_ when the areas noted above
were touched. The deep reflexes were normal. Faradism by wire brush
at two sittings yielded a complete cure. It seems that once this man,
after seeing his sister fall in a fit on returning from a funeral,
retired to the garden and had a similar fit himself.

Cargill found in 1052 sailors fifteen cases of total absence of one or
both ankle-jerks; seven of the fifteen were probably cases of tabes.

_Re_ peripheral neuritis and hysteria (see under Case 387).

_Re_ differential diagnosis between peripheral neuritis and reflex
(physiopathic) paralysis, Babinski and Froment offer the following
table:

       _Peripheral Neuritis._                  _Reflex Paralysis
                                               and Contracture._

  1. Motor disorder, degenerative          1. More or less segmentary
     amyotrophy, and sensory disorder         topography.
     corresponding topographically to
     anatomical distribution of nerve
     (neuritic) topography.

  2. Amyotrophy very pronounced,           2. Amyotrophy variable;
     regardless of localization.              ordinarily well-marked
                                              but not so severe as that
                                              of neuritis.

  3. Reaction of degeneration, especially  3. Reaction of degeneration
     weakening or abolition of faradic        absent, never marked
     excitability of muscles.                 weakening of faradic
                                              excitability, which is
                                              often normal and may even
                                              be exaggerated.

  4. Tendon reflexes, corresponding to     4. If reflexes are altered,
     the muscular territory of the            they are as a rule
     nerve, weakened or abolished.            exaggerated and never
                                              abolished.


Multiple wounds; signs of late tetanus 7-8 weeks later: Pain and
contracture of neck, tetanic, 14 weeks after trauma. Dysentery.
Recovery.

=Case 419.= (BOUQUET, 1916.)

A soldier invalided for endocarditis July 8, 1908, went back to the
colors on his own request August 8, 1914. He was wounded at noon
September 6, 1914, in the attack at Abbaye Woods. He lay in the woods,
with several comrades as badly wounded as himself, until September 10,
eating berries and drinking rain water. He had five wounds in all; in
left lower leg, thigh, left external malleolus, right calf, and left
forearm. Moreover, he had dysentery.

He was picked up by the Germans September 10 and carried by them
to the ambulance at Saint André, where he was given belated first
dressing. When the enemy retreated September 12 he was left behind and
finally carried back September 13 into the French lines by a French
physician who had been a prisoner likewise. A second dressing was given
September 14 at Rambluzin. He was then carried in a sanitary train to
Bar-sur-Aube, where, September 15, injection of antitetanic serum was
given. He left Bar-sur-Aube on December 18, 1914, practically cured,
though one of the wounds still needed care. The dysentery was still
present and walking was difficult. He was then cared for at Auxiliary
Hospital No. 102 in Paris.

It seems that about six weeks after his entrance in the hospital at
Bar-sur-Aube he had had some difficulty in opening his jaws, with acute
pains at the temporomaxillary joint. Similar pains appeared a few days
later in the neck, with a sensation of stiffening. The jaws still
opened easily enough December 18, yet the man got pains in his jaws as
soon as he began to speak. The pain and contracture in the neck region
were sharp and permanent. Sometimes the contracture got more marked,
and the board-like muscles could be felt stiffening under the examining
finger. During such crises the patient had to lie or sit down.
Sometimes the pains descended below the shoulders along the vertebral
column. The crises occurred more often in the night, in bed.

The diagnosis of late tetanus was made, and alcohol rubs were given.
The phenomena gradually disappeared. The dysentery also had not yielded
to therapeutics until eight or ten days before the patient left the
hospital. There was still, at the time of report, a certain difficulty
in walking, with a tendency to use the external border of the left foot
rather than the sole.


Shell-shock: Spasmodic neurosis and neurasthenia. Treatment without
great success.

=Case 420.= (OPPENHEIM, July, 1915.)

August 19, 1914, a shell exploded very close to a soldier, whose
bread bag, cartridge container, and field flask were pulled away from
him, but who was not himself wounded. He fell down. Shortly developed
headache, vertigo, palpitation. In running he fell down repeatedly.
Spasms soon appeared in the legs. He had previously suffered from
gastric disturbances, and heavy food did not agree with him.

At the time of admission to hospital he complained of great
irritability, nervous twitching, formication in his limbs, war dreams,
tachycardia. The heart boundaries were normal. The muscles of lower
extremities were attacked by tonic spasms, and felt board-like.
This tonic spasm occurred on each attempt at motion, very gradually
disappearing when at rest. Passive movements also had the same effect.
Fibrillary tremor affected the left quadriceps. On each attempt at
motion, pains were felt in the legs. At first the cramps were so severe
that all locomotion or even standing was impossible.

Treatment: Cold-water pack (Priessnitz), hyoscin injections, magnesium
sulphate injections (5 to 10 c.c. of ten per cent solution), perineural
injections, lumbar spinal analgesia,--all without success. Fibrillary
tremors persisted in the quadriceps and in the extensors of the toes.
The tonic spasms on increased attempts at motion became combined
with clonic twitchings. From the end of November on the patient made
attempts to walk with straddling legs, and under considerable vibratory
tremor. Picture of severe crampus-neurosis, combined with neurasthenia
gravis.

                               CHART 13

    SHELL CONCUSSION

        CAUSE PHYSICAL FROM EXPLOSIVES--AMNESIA FOR SHELL EPISODE
        AND FOR A SUBSEQUENT PERIOD--FOLLOWED BY TRAUMATIC NEUROSIS

    SHELL HYSTERIA

        SHELL HEARD--VICTIMS ALREADY UNSTABLE--RUM ISSUE
        PREPARATORY?--OVEREMOTIONALISM--SENSORY AND MOTOR DISORDER

    SHELL NEURASTHENIA

        HEADACHE, DIZZINESS, INSOMNIA, ANOREXIA, VISCERAL
        PAIN--VICTIMS, OLDER MEN

                                                 After H. P. Wright


(_a_) Bullet-wound of forearm: Combination of hysterical (brachial)
monoplegia, and reflex (physiopathic) disorders. (_b_) Refrigeration:
Combination of hysterical paraplegia and reflex (physiopathic)
disorders.

=Case 421.= (BABINSKI, 1916.)

The forearm of a soldier was pierced in its lower part by a bullet,
which produced no lesion of large nerve trunks or blood vessels. A
complete brachial monoplegia followed. Every movement of the different
segments of the arm was abolished. The hand and forearm were slightly
atrophied, and were of a reddish salmon color. The temperature of the
affected hand and forearm was about three or four degrees lower than
that on the other side. The sphygmometric oscillations of the forearm
were twice as small in the paralyzed limb as in the healthy limb,
but the systolic blood pressure was normal. There was a mechanical
over-excitability of the muscles, and a slight exaggeration of the bone
and tendon reflexes. The paralysis was in part of reflex (physiopathic)
nature. On account however, of the completeness of the monoplegia, and
the fact that the reflex paralyses as a rule affect only the distal
portion of the limb, the diagnosis of hysteria had to be made in
addition to the diagnosis of reflex disorder.

As a result of freezing, this patient had also a complete crural
paraplegia. He showed vasomotor disorders and hypothermia of both feet,
together with mechanical over-excitability of the muscles; and these
latter disorders appeared to be of a reflex nature. The paraplegia,
however, was of a hysterical nature.

_Re_ refrigeration, see Case 309 (Binswanger) of glossolabial spasm.

Differential diagnosis of organic (central) monoplegia and reflex
(physiopathic) contracture and paralysis. (Babinski-Froment.)

    _Organic Monoplegia_                 _Reflex Contracture and Paralysis_

  1. Paralysis often affects the        1. Paralysis almost always partial.
     whole extremity, either arm           In arm paralysis, affects as a
     or leg.                               rule fingers and hand. The leg
                                           is often affected at its origin,
                                           and then only partially.

  2. After several weeks of flaccid     2. Paralysis may remain flaccid for
     paralysis, as a rule contracture      a long time, and frequently
     occurs.                               coexists with contracture,
                                           hypertonicity and hypotonicity
                                           of different muscular groups.

  3. The upper extremity shows flexion  3. The upper extremity in
     with clawhand. The lower              hypertonic cases often shows the
     extremity shows contracture of        _main d’accoucheur_, the _main
     extensors. The patient walks          en bénitier_ (holy-water vessel
     throwing his leg sidewise             hand), the _doigts en tuile_
     (_Démarche helicopode_).              (crowded fingers). The lower
                                           extremity does not exhibit the
                                           sidewise movements.

  4. Tendon reflexes, a few weeks       4. Reflex status variable.
     after paralysis begins,               Hyperreflexia often absent even
     exaggerated.                          in hypertonic forms.

  5. Babinski sign in crural            5. Babinski sign absent. The skin
     monoplegia.                           reflex may be abolished but may
                                           be reproduced on warming the
                                           foot.


Slight bullet wound of hand: Flaccid paralysis with vasomotor and
thermic disorder. A case “non-organic” in the ordinary sense and
non-hysterical, _i.e._, reflex or physiopathic.

=Case 422.= (BABINSKI and FROMENT, 1917.)

Struck by his observations upon the persistence of tendon reflexes
in narcosis in a wounded soldier, Babinski continued observations in
the same general direction in a case which may be termed briefly one
of hypotonia of the extensors of the hand following the passage of a
bullet through the arm without nerve trunk lesion.

This patient had flaccid paralysis of hand and fingers following
wound in second dorsal interosseous space and vasomotor disorder and
local hypothermia in the hand. There was a slight diffuse atrophy
of the muscles of the hand, forearm, and arm; but this atrophy was
not systematized, and there was no R. D. The tendon reflexes of the
extremity were preserved. There were no signs of organic disease of the
central or peripheral nervous system; that is, in the ordinary sense of
these terms.

Was it a question of hysteria or of simulation?

Babinski was struck by the following symptoms:

First, the remarkably intense hypotonia, especially noteworthy in the
thumb, a hypotonia quite equal if not superior to that observed in
paralysis following marked nerve lesions;

Second, mechanical over-excitability of high degree in the muscles of
the hand and forearm, with retardation of the muscular response; and

Third, electric over-excitability of the muscles, with what Babinski
calls “anticipated fusion” of the faradic reactions.

It appears that this patient had been wounded in September, 1914,
and that the paralysis had developed five months later. Before the
development of this paralysis, there had been simply a meiopragic state.

Without perforating the hand, the bullet had remained in the wound,
being excised therefrom three months after the trauma.

In January, 1916,--that is, some sixteen months after the injury and
eleven months after the recovery of the paralysis,--the vasomotor
disorder and the hypothermia, and the faradic, voltaic and mechanical
over-excitability of the hand and forearm muscles, were in evidence.
Hypotonia was marked, permitting an overflexion of the hand upon the
forearm. If the patient moved his forearm, the affected hand would hang
and oscillate inertly; likewise in walking, seeming to obey only the
laws of physics.

In May, 1916, the patient was invalided and found to be still in
possession of the above-mentioned signs. Similar phenomena have been
found in the _main figée_ acrocontracture, and _main d’accoucheur_,
and belong, in the opinion of Babinski, to a group which is neither
hysterical nor organic in the ordinary sense of the terms. Vasomotor
and thermic phenomena are in the foreground of the picture, and are, in
fact, practically constant, though they vary somewhat in degree. They
react abnormally to the temperature of the surrounding medium; there is
undoubtedly a local perturbation of the vasomotor and heat-regulating
mechanism. There is also certain evidence of vascular spasm. The
vasomotor and thermic disorders run parallel with the mechanical
over-excitability of the muscles and the slowness of the response.


Chloroform to demonstrate asymmetry of reflexes.

=Case 423.= (BABINSKI and FROMENT, 1917.)

A soldier, 26, sustained, September 22, 1914, a bullet injury of the
right calf. There was no fracture, as X-ray showed, but healing was
slow, taking no less than three months. The right knee-jerk was a
little stronger and a little sharper than the left, but the difference
was controversial; and the difference between the two Achilles reflexes
was still more doubtful.

Chloroformed October 10, 1915: As the patient was going to sleep, even
before the phase of excitation and motor agitation had passed, the two
knee-jerks and left Achilles jerk had disappeared. They grew rapidly
less marked before disappearing, and none of the tendon reflexes
presented any phase of exaggeration while the patient was going under.
At this point anesthesia was arrested. The right Achilles reflex,
which had not disappeared, was sharply defined. It was even stronger
than in the normal state and polykinetic. During the whole phase
of awaking from the chloroform, the right Achilles reflex remained
strong and polykinetic, without, however, any ankle clonus. Thus, the
difference between the two Achilles reflexes became indisputable; also
the right knee-jerk reappeared before the left, and became stronger
without any patellar clonus. At this time, the difference between the
two knee-jerks was sharp and beyond cavil. This status, in which the
knee-jerk and Achilles reflexes were asymmetrical, lasted about ten
minutes after anesthesia ceased and lasted a little longer for the
knee-jerks than for the Achilles jerks.


Reflexes under chloroform.

=Case 424.= (BABINSKI and FROMENT, October, 1915.)

A soldier sustained a clean-cut wound of the supero-external aspect
of the right thigh without much destruction of tissue or any adherent
scar. He showed marked lameness, September 15, 1915, walking with
his right leg extended and the foot in external rotation. There was
a slight limitation of the movements of the hip joint in respect
to internal rotation and flexion of thigh. The right knee-jerk
was a little stronger than the left, and this condition persisted
several days. After a few tests, the knee-jerk became even slightly
polykinetic. The Achilles jerks were normal and equal. There was no
epileptoid trepidation of the foot, and no patella clonus. There was
a slight hypothermia of right leg, with ill-defined muscular atrophy.
Walking caused pain.

Chloroform anesthesia, September 20, 1915, yielded an exaggeration of
the knee-jerks with a suggestion of patella clonus even before the
phase in anesthesia of motor excitation had set in. As anesthesia
proceeded the exaggeration was rapidly lost on the left side but
progressively increased on the right. In the phase of complete muscular
resolution, when all the other tendon reflexes (such as the knee-jerk,
Achilles jerk on the left side, the radial and olecranon reflexes on
the left side) were abolished, the patella clonus on the right side was
perfectly distinct and could be elicited either by the usual method or
by raising the thigh and letting it fall. On percussion of the patella
tendon, a strong polykinetic reflex was obtained; right Achilles jerk
preserved; right leg in external rotation. Internal rotation could be
passively performed better than in the waking state, but this movement
was still limited. As the man was waking from anesthesia, when reflexes
were reappearing, there was a suggestion of left patella clonus--right
clonus as strong as before. At no time any trepidation of the foot. The
patella clonus on the right side lasted an hour after waking, at which
time all the reflexes returned to their previous state.


Reflexes under chloroform.

=Case 425.= (BABINSKI and FROMENT, October, 1915.)

A soldier sustained a bullet wound, September 22, 1914, in the right
calf. There was no fracture, as X-ray showed. Cicatrization was slow
and took at least three months. He was examined October 2, 1915, at
the Pitié,--not complaining of pains, but lame. There were no pains,
limitation of movement, or joint sounds in the hip joint, and X-ray
was negative. There was a slight atrophy of the limb, 1.5 c.m. less
in circumference on the right. There was a sharply defined local
hypothermia of the right leg up to the knee. The right knee-jerk was a
little stronger and brisker than the left, yet it was difficult to be
sure of this, and there was a still more doubtful difference between
the Achilles reflexes.

The man was anesthetized with chloroform, October 10. As he was going
to sleep, before the phase of excitement and agitation had ceased, the
two knee-jerks had disappeared. At the same time, the left Achilles
jerk vanished, followed by the plantar cutaneous reflexes. Anesthesia
was then stopped. The right Achilles jerk, which had not disappeared
at any time, remained distinct. It was stronger than in the waking
state, and polykinetic. During the waking phase, this reflex remained
strong and polykinetic, but there was no epileptoid trepidation of
the foot. Accordingly, under chloroform, the difference of the two
Achilles reflexes had become very sharp. The right knee-jerk reappeared
before the left and became stronger, though without patella clonus.
This difference was much more striking than in the waking state. This
asymmetry of the patella and Achilles reflexes lasted about 10 minutes
after anesthesia was stopped, and lasted a little longer for the
patella reflexes than for the Achilles reflexes.


Shrapnel wound above clavicle: Brachial monoplegia, partly hysterical,
partly organic.

=Case 426.= (BABINSKI and FROMENT, 1916.)

Babinski speaks of certain symptomatic incompatibilities which emerged
in the study of cases of combinations of hysteria, organic nervous
disease, and the so-called physiopathic disorders. An example of
such an incompatibility might be that of a patient who should, three
months after a sudden hemiplegia, show complete or almost complete
flaccid paralysis and but slight exaggeration of tendon reflexes--yet
the Babinski reflex. Of course, the Babinski reflex would permit a
diagnosis of pyramidal tract disease. Yet a sudden intense hemiplegia
lasting three months, if it were merely a matter of pyramidal tract
disorder, ought to show hyperreflexia of a pronounced degree as well as
contracture. An example from the arm is as follows:

A soldier got a shrapnel wound in the left supraclavicular region,
and had a complete paralysis of the arm, which had lasted more than a
month. Electrical examination showed marked reaction of degeneration
in the muscles controlled by the musculo-cutaneous nerve, as well as
a diminution of electrical excitability in the muscles innervated by
radial branches. On the contrary, in the circumflex territory, ulnar
and median, electrical excitability was normal. There were no vasomotor
disorders. The diagnosis of an association of hysteria and organic
disease was made. Babinski affirmed that electrification would effect a
partial cure; and in point of fact, the patient, after having submitted
to the current for several minutes, was able to use all the muscles
whose faradic contractility was normal or almost normal. Thus, he could
raise his arm, flex the thumb, flex the fingers, close the hand, and
extend the hand and fingers. Flexion of the forearm on the arm was
still difficult, since there was, in fact, a reaction of degeneration
in the muscles of the anterior region of the arm. The fact that the
movements could be partially executed was dependent upon action of the
supinator longus.


Gunshot fracture of upper arm; recovery with motor power in five weeks:
Six weeks later, Erb’s palsy (plus). Hypothesis: “Reflex paralysis”
preferred.

=Case 427.= (OPPENHEIM, January, 1915.)

A reservist, 26, was shot through the middle of the left upper arm,
sustaining an oblique fracture of the humerus, August 26. The external
wounds healed in a month; the fracture somewhat later. The left arm
was at first stiff and motionless, but in five weeks it could again be
moved. Pains disappeared with return of motility.

About the middle of November the arm began to lose power to move again,
especially the muscles of the upper arm. November 20, the patient
showed atrophic paralysis (left deltoid, biceps, brachialis internus,
and supinator longus) suggesting at first glance the appearance of
an Erb’s palsy; but the triceps and the adductor of the upper arm
were also unable to move and there was a slight paresis in the distal
muscles of the extremity. There were no pains or other objective
disorders.

The diagnosis of subacute poliomyelitis was considered. Electric
excitability, however, was found to be normal, both faradically and
galvanically.

When patient walked, the left arm swung helpless without sign of
innervation or any tonus. Abduction of the shoulder could also not be
performed, though a slight flexion of the forearm shortly began to be
demonstrable. If the patient inclined his head to the right, extended
his hand at the wrist, and flexed the fingers forcibly, he could then
flex the forearm somewhat, and a slight tension of the biceps and
supinator longus developed. Sometimes fibrillary tremors developed in
deltoid and biceps.

Of course a transient peripheral palsy can be produced by pressure of
the radial nerve without any change of electrical excitability, but
such a change is not associated with atrophy.

Neuritis and poliomyelitis producing an Erb’s palsy without any effect
upon the electrical reactions is an hypothesis not to be entertained.

Accordingly, the hypothesis of psychogenic or hysterical palsy may
be set up. Yet an atonic atrophic palsy with loss of tendon reflexes
(supinator) is inappropriate. According to Oppenheim, this case falls
into the category of the arthrogenic atrophies. A simple muscular
atrophy may follow disease of joints and bones. However, such cases
have rarely shown a complete palsy, as in Oppenheim’s case.

In short, we return to the old doctrine of reflex paralysis, conceiving
that a stimulus passing from the periphery influences the gray matter
in its trophic functions.

How much effect had the psyche upon this condition? The patient had
stuttered from childhood and had sustained a fracture of the skull at
9, following which his school work, especially mental arithmetic, had
been poor. The lack of psychic inhibitions may play some part in the
situation, but on the whole, the reflex hypothesis is preferred by
Oppenheim, the nerve conceived to be dynamically affected, the muscles
organically.


Paralysis: Hysterical? organic?

=Case 428.= (GOUGEROT and CHARPENTIER, May, 1916.)

A soldier, 20, was wounded May 15, 1915, by a large number of shell
fragments, 15 of which struck the right leg, two producing serious
injuries,--the one, a penetrating wound of the popliteal space followed
by stiffness of the knee, later cured by extraction of the fragments;
the other, causing a deep wound at the internal malleolus. The fragment
was extracted June 3, but osteomyelitis persisted and a fistulous
contraction was developed in January, 1916. There was a slight equinism.

By contrast with these deep bony lesions of the right leg, on the left
side a fragment had struck the dorsum of the left foot at about its
middle point, along the extensors of the fourth and fifth toes. The
fragment was removed toward the end of June, 1915. The wound closed in
a fortnight, leaving a loose 20 mm. scar. The man complained of pains,
which he called electrical, in the third and fourth toes, if one bore
down on this scar, a symptom suggesting that the dorsal nerves had been
injured. Immediately after the wound both legs had been paralyzed,
according to the soldier. He had been able only to drag himself along
on his shoulders. This indeterminate paralysis lasted three days. It
may have been hystero-traumatic, or it may have been a sort of diffuse
inhibition. Just after the injury, the left foot was in contracture,
which gave place a month later to paralysis. Only the great toe was
still able to move a little. In December, 1915, the patient still could
extend and flex the toes on the left side very badly, though he could
execute movements easily on the right side. There was no stiffness of
joints; there were no tendon reflex disorders. There were no trophic
vasomotor or secretory disturbances.

The diagnosis of hysterical paresis seemed warranted, but electrical
examination showed that the troubles were organic. There was an
increase in the faradic and galvanic excitability of the external
popliteal nerve. The response was more sudden than normal, and there
was an increase in faradic and galvanic excitability in the tibialis
anticus. There was a decrease of faradic and galvanic excitability in
the extensor communis of the toes and in the external peroneus.

Thus, this patient after being wounded in both feet May 15, 1915,
paralyzed in both feet for a period of three days, undergoing a
contracture of the left foot for a month, giving place to paralysis
of foot and toes, with slow improvement from the end of July, 1915,
was still in this latter state in March, 1916; though without trophic
disorder, he showed faradic and galvanic over-excitability of the
external popliteal nerve and of the tibialis anticus, _pari passu_ with
diminished electrical excitability for other muscles.


Paralysis: Hysterical? organic?

=Case 429.= (GOUGEROT and CHARPENTIER, May, 1916.)

A man was wounded Oct. 11, 1914, on the back of the right hand. Two
hours later, he was attended at the relief post. At this time, his
hand was straight, with fingers extended. He said that he could not
move his fingers, although there was no pain in them. Three hours
after the wound, the hands swelled and the edema spread as far as
the middle of the forearm. There was a long suppuration, complicated
by lymphangitis. All of the fragments were removed October 26, 1914;
healing was complete in three months. The swelling, however, persisted
to June, 1915, and when the swelling disappeared, the hand began to
show drop-wrist. The wound was sutured between the second and third
metacarpals, and the X-ray showed that the bones had not been injured,
nor had the nerves of the forearm muscles been touched. The situation
was such that the case was catalogued “functional paralysis.”

October 5, 1915, the hand was still drooping, fingers extended, and
middle finger and ring finger trembling. A slight stiffness of wrist
and fingers did not interfere with movements. Extension of the wrist
could be made very slightly above horizontal. Flexion was not quite
complete, nor were adduction or abduction. Extension of the fingers
could be performed normally, as well as that of the thumb, but flexion
was not quite complete. There was a slight palmar retraction. Such
were the movements that could be produced electrically. Voluntarily,
flexion of the wrist was good, abduction and adduction incomplete;
extension could not be executed to the horizontal position. There was
a tendency to flexion of the ring finger. When the patient tried to
flex the middle and index fingers, these fingers trembled but did not
flex. Weak extension and abduction of the thumb but without opposition
could be voluntarily performed; adduction good; flexion of the first
phalanx, weak; of second phalanx, better. Slight muscular atrophy of
the forearm, which was one centimeter less in circumference than the
left. The hand was subject to a general atrophy; the skin reddish and
moist. The X-ray showed a decalcification of all the bones of the hand
and wrist; trophic disturbance of the small carpal bones although
the trauma had affected only the second interosseous space. No joint
lesions or periosteal thicknesses were found by X-ray. There was a
slight hypesthesia of the palmar surface of the middle finger and of
the index finger. The patient complained of sharp transient pains in
hand and fingers.

In this case, therefore, a wound of the back of the hand produced an
immediate inhibition of muscular action in the forearm, a rapid edema
of the hand and arm, lasting for eight months and followed by reflex
disorders.

There was a considerable diminution in faradic excitability of the
flexor brevis of the thumb, the anterior cubital, the flexor brevis
minimi digiti, and of the dorsal interossei, and slighter evidence of
diminution of galvanic excitability in some of the muscles.

Sollier is said to have been the first to remark trophic bone disorders
in cases of neuropathic contracture.

_Re_ bone changes, Babinski enumerates trophic changes in the tissue of
bones and joints amongst objective signs that permit us to distinguish
the reflex or physiopathic disorders from the hysterical or pithiatic
disorders. Objective signs of this group (indicators of reflex or
physiopathic disorders) are: (_a_) Well-marked and persistent vasomotor
and thermic disorder; (_b_) alterations of muscular tone (either
hypotonus, hypertonus, or a combination of the two); (_c_) increase in
the mechanical excitability of the muscles and sometimes nerves; (_d_)
quantitative changes in the electrical excitability of the muscles, but
without R. D.; (_e_) muscular atrophy and atrophy of skin, bones, and
joints. For cases of this nature, see especially Cases 431 and 432 of
Delherm.


Paralysis: Hysterical? organic?

=Case 430.= (GOUGEROT and CHARPENTIER, May, 1916.)

A man, 22, was wounded September 17, 1914, in the left hand, the bullet
passing from the lower part of the fourth interosseous space out
through the palmar face. The bones were not injured, and it was evident
that only a few nerve filaments could have been injured; but he had
a paralysis extending far beyond this region, which increased little
by little from November, 1914, to August, 1915. Babinski, examining
him in November, 1914, had made the diagnosis of psychic paresis of
the extensors with diminution of electric excitability, with a very
slight slowing of the contraction of the last two interossei and the
hypothenar eminence, connected with lesion of the branches of the ulnar
nerve. The disorder spread to the flexors of the fingers and the thumb
muscles. The fifth finger was flexed at rest; there was no stiffness
of joint or tendon retraction. The extensors and flexors of all the
fingers and the thumb, and the abductor of the thumb showed paresis.
The thumb was able to oppose; the hands were cyanotic. Augmentation
of these phenomena in a period of months, their bizarre distribution,
and the preservation of the opposing power of the thumb suggested
a hystero-organic disease, and Babinski’s notes read, “Partial and
incomplete paralysis of the ulnar nerve, attacking slightly the
hypothenar eminence and the last two interossei; psychic paresis of the
extensors and flexors of the fingers and thumb and of the abductors of
the thumb.” Electrical examination showed, however, that there was not
only electrical disorder of the common extensors of the fingers, the
extensor proprius of the index and of the ring fingers, of the long
and short extensors of the thumb, but also there was a considerable
diminution to faradic and galvanic reaction in extensor ossis metacarpi
pollicis, the radials, the supinator longus, the pronator teres, the
large and small palmar, the common and superficial flexors of the
fingers, the muscles of the thenar eminence, the anterior ulnar, and
the anterior biceps and brachial. In short, there was an irradiation
of seemingly organic phenomena in the domain of the radial, median, and
the non-injured part of the cubital distribution, as well as in the
distribution of the musculo-cutaneous. Apparently, organic paralytic
disorder had spread even to the biceps and had increased over a period
of many months after the wound had healed.

_Re_ what he terms _organo-hysterical association_, Babinski
proposes to distinguish it from hystero-organic association. In
Babinski’s organo-hysterical association, the organic symptoms are
preceded by hysterical symptoms. These cases of organo-hysterical
association,--_e.g._, a case in which a hysterical monoplegia is
followed by a musculospiral crutch paralysis,--are one of the mainstays
of the proof that hysteria and simulation cannot be confounded.
Babinski concedes that he has sometimes said that hysteria was a sort
of semi-simulation; yet a semi-simulation is not a simulation.

As for Babinski’s _hystero-organic association_, we here deal with
cases of organic paralysis or contracture in which the fundamental
disorder is organic, and the psychic disorder is grafted upon it. Both
the fundamentally organic and the fundamentally hysterical associations
are instances, according to Babinski’s phrase, of symptomatic
incompatibilities. In such instances, the hysterical part of the
disorder, whether grafted or original, is dissolved by psychotherapy.
There is a third group of symptomatic incompatibilities, namely, the
_hystero-reflex associations_, in which, _e.g._, a hysterical gait
is combined with vasomotor and thermal disturbances. There may even
be combinations of all three types of disease, namely, the type of
structural disease, of vasomotor disorder, and of hysteria, in what
would then be termed a _hystero-reflex-organic association_.


Wound of toes--Wound of arm: Reflex or physiopathic paralyses,
diagnosis and treatment.

=Cases 431 and 432.= (DELHERM, September, 1916.)

A soldier was wounded in the soft parts of the last two toes and in the
furrow between toes on the left side, September 15, 1914, arriving in
the Central Physiotherapeutic Service of the 17th Army Region, December
27, 1915, left foot in varus, with marked contracture of tibialis
anticus, though passive movements of flexion, extension, adduction and
abduction were well performed. There was a slight atrophy of the leg
(33 cm. left to 34 cm. right). The scar was a little painful, and there
was a slight degree of hypesthesia of foot and lower leg. The foot was
cold and cyanotic; the reflexes were normal. An electric examination in
the region of the external popliteal branch of the sciatic nerve showed
that there was no electrical disorder either faradic or voltaic.

Another case was wounded in the right arm by a shell fragment September
7, 1914, and showed two scars above the epitrochlea and along the
internal border of the triceps. Examination December 30 showed a
normal elbow movement, pronation and supination, with slight flexion
in repose of the palm of the hand and the fingers. Active flexion
movements of the fingers could be performed only imperfectly, and the
finger pad could only be brought within three fingers breadths of the
palm, despite the greatest effort on the part of the patient. Minute
passive movements were entirely possible. The fifth finger could not
be abducted and both abduction and adduction of the third and fourth
finger could not be made on account of the nerve lesion. The thumb was
in a condition of contracture which placed it in abduction in front of
the index finger, and the thumb could not oppose. Passive movements,
on the other hand, were entirely possible. The hand was flexed upon
the forearm through hypertonia of the flexors, which could be easily
overcome with slight but distinct resistance. The hand was in the
position of a radial paralysis. There was a slight degree of muscular
atrophy. Tendon reflexes were normal. Electric examination showed that
stimulation of the ulnar nerve at the elbow was unable to produce
flexion of the last two fingers or any movement in the hypothenar
eminence, of which the muscles were also not excitable. The interossei
could, however, be made to contract. The median and radial nerves were
normal electrically. The above examinations were with the faradic
current.

With the galvanic current the ulnar nerve proved unexcitable at
the elbow, and the muscles of the hypothenar eminence contracted
more slowly. The median and radial nerves and their muscles were
electrically normal.

In short, there was a complete R. D. of the hypothenar and partial R.
D. of the interossei as a result of the lesion of the ulnar nerve.
There was nothing abnormal in the other nerves or muscles of the arm.
The attitude of radial pseudoparalysis is due to the contracture of the
muscles of the thenar eminence.

As to therapy, the general movements of flexion of the fingers, thumb
and hand yielded a marked improvement, but such results cannot be
expected in like cases unless a physician or experienced masseur treats
the case. Babinski and Froment have tried thermotherapy and diathermy
in these cases, finding that the paralysis diminishes and becomes
partial if the limb is warm, although it is important that it should
not become too warm. Sometimes a few treatments with diathermy will
produce movements in a case of long standing paralysis. Babinski and
Froment counsel not only diathermy, but a general motor reëducation.
The idea of the diathermy is that the deeply penetrating heat affects
blood vessels and muscles, bringing about a vasodilatation or even a
direct addition of needed calories. In like manner, galvanism, light
baths, or simple baths in combination, and with diathermy, especially
with the diathermy, act favorably. Casts and apparatus have also proved
without avail, as well as faradic or galvanic reëducation.

The above two cases show how in one instance there may be no electrical
change and in another instance a slight one. In these cases, reflex
hypertonic contracture, hypotonic paralysis, vasomotor disorder,
decalcification of the skeleton (X-ray), mechanical overexcitability
of muscles, unmodified tendon reflexes (except elective exaggeration
of reflex under anesthesia, _e.g._, a persistent unilateral patellar
clonus when all other reflexes have been abolished), and disorders of
electrical excitation are enumerated by Babinski and Froment.

Delherm sums up the electrical disorders as follows: Muscle faradized:

    (_a_) No change.

    (_b_) Subexcitability.

    (_c_) Overexcitability.

    (_d_) Diminished contractility to faradism, associated with
          increased contractility by galvanism (Charpentier).

    (_e_) Anticipated fusion of shocks (Babinski and Froment).

    (_f_) Slow contraction and decontraction on faradism
          (Charpentier).

    (_g_) Rapid exhaustion of rhythmic faradic contraction with
          metronome.

Muscle galvanized:

    (_a_) No change.

    (_b_) Subexcitability.

    (_c_) Overexcitability.

    (_d_) Suddenness of galvanic contraction with subexcitability.

_Re_ decalcification and osteo-articular changes, Babinski points out
that the reflex or physiopathic phenomena run historically back to
John Hunter, Charcot, and Vulpian. Charcot and Vulpian called especial
attention to the peculiar amyotrophy and paralysis which occurred in
joint disease, and upon the lack of parallelism betwixt the intensity
of the joint disease and the severity of the paralysis or atrophy. The
atrophy was without R. D.


Shell-shock: Functional blindness (monosymptomatic).

=Case 433.= (CROUZON, January, 1915.)

A shell burst above the head of a sergeant in a battle near Neuf
château, August 22, 1914. The man was kneeling at the time; felt a
terrible shock, slipped prone, lost consciousness and woke in the
evening blind. Next day he could hardly distinguish light from dark.
Yet the light reflexes were normal; the fundus was normal.

This Crouzon calls the symptomatic triad for functional nerve blindness
of Dieulafoy. There have been similar cases following eclipse of the
sun and nervous shock. The eclipse cases suggest that the bright flash
might have something to do with the sudden blindness (yet blindness has
appeared in cases in which the shell burst behind the patient).

The diagnosis of temporary blindness, with a prognosis of early
recovery, was made. The neurological examination was normal.

For its suggestive effect, glycerophosphate injections and progressive
reëducative measures were adopted. The patient was shown that he could
see, first, the contour of objects, then details and colors, then large
letters and later small letters. In a month the blindness was almost
well. Five months afterwards there was still a certain haze over the
field of vision and a slight difficulty in distinguishing certain
colors.

Jousset states that aside from visual alterations as the result of
cranial trauma, and aside from various transitory amblyopias such as
scintillating scotoma, the main varieties of amblyopia are:

_First_, Congenital amblyopia.

_Second_, Amblyopia due to cerebral intoxication.

_Third_, Retrobulbar neuritis and toxic amblyopia.

_Fourth_, Amblyopia ex anopsia.

_Fifth_, Hysterical amblyopia.

The most frequent amblyopias among the soldiers are exanopsia. Aside
from a few amblyopias caused by prolonged occlusion of the eyelids,
ptosis, or blepharospasm, the most frequent are due to opacities,
ametropia, and strabismus. The hysterical amblyopias are, as a rule,
associated with blepharospasm due to intense photophobia, and are
sometimes associated with constant lacrimation. Vision at a distance
is poor. The patient succeeds in reading but shows an asthenopia of
fatigue. The cornea and the conjunctiva are anesthetic, and sometimes
the eyelids also,--the so-called anesthesia _en lunettes_. The pupils
are large but react properly. The patient complains of many species
of disorder; loss of the sense of the third proportion, micropsia,
megalopsia, diplopia, erythropsia, diplopia in two colors, inverted
image, hemierythropsia, rotatory amblyopia. There is concentrated
limitation of visual fields, exaggerated by fatigue and by intense
light; reduced in dim light or when the patient is provided with smoked
glasses; enlarged upon the instillation of atropin or with convex
glasses. As a rule, with unilateral amblyopia, the functional disorders
start in binocular vision. Practically the most important diagnostic
feature is the anesthesia, since this cannot be readily simulated.
Sometimes corneal anesthesia is found in non-hysterical persons, who
may perhaps be regarded as potential hysterics.


Retrobulbar neuritis (nitrophenol).

=Case 434.= (SOLLIER AND JOUSSET, April, 1917.)

A soldier of the 54th Artillery entered hospital 45, November 4, 1916.
He had had a slight paralysis of the left brachial plexus in 1913,
following a shoulder dislocation, but the only relic of this when the
war began was a deltoid paresis. He had been working from August 13,
1915, at the factory in Saint-Fons, and was as yellow as the majority
of the workers there. He had never shown xanthopsia.

The first symptoms of his left brachial plexus neuritis had begun
six months before, after 9 months’ work in the factory, and showed
themselves in an increase of the deltoid paresis, with pains in the
hand and forearm, and cramps of the hand, interfering with work,
formication in the right hand and in the feet, diminution of visual
peculiarity (objects forgotten and reading difficult). It was only in
November that he got perturbed about these difficulties, which had
begun in May. There was a paralysis of the levators and rotators of
the left shoulder, with a slight atrophy of the deltoid and of the
supra- and infraspinatus muscles. The arm could be extended almost
to the horizontal with difficulty. There was one centimeter atrophy.
The forearm and hand were not atrophic but slightly weak. There was
an anesthesia of the shoulder-joint region, and of the outer surface
of the arm; a hypesthesia of the posterior surface of the forearm and
dorsal surface of the hand and fingers; tendon and periosteal reflexes
normal. Sometimes the hand would contract firmly and could be opened
only by the aid of the other hand. The nerve trunks of the axilla,
upper arm, and forearm, were painful on pressure, especially on the
left side, and the ulnar nerve was thickened and rolled under the
finger. The knee-jerk and Achilles jerk were abolished on the right;
plantar reflex diminished; right posterior tibial nerve painful on
pressure, and its territory was hypesthetic. There were cramps in the
feet.

Gymnastics and electrotherapy and rest reduced these phenomena. The
eye grounds were normal; there was a paresis of accommodation, and an
absolute blindness to green, with retraction of fields to 15 degrees
in the right eye, and 20 on the left. There later developed a slight
edematous neuritis of the nerve, corresponding to the evolution of a
chronic retrobulbar neuritis of toxic origin.

It is the chronic retrobulbar neuritis which is typical of the
so-called nitrophenol neuritis, developing in soldiers employed in
making explosives. The above case is accordingly exceptional in its
association of a severe peripheral neuritis with the optic neuritis.
Typically, after six months to a year in the factory, the cramps
and formication of the legs are felt, and the gradual diminution
of vision with transient blindness, finally leading to inability
to read, sets in. The green blindness, the accommodative paresis,
and diminution of central vision, the concentric contraction of the
visual fields, are the usual story. At first the eye grounds are
normal; there is then an edematous neuritis, and finally a white
atrophy. According to Sollier, the accommodative paresis is like that
in post-diphtheritic paralysis--a disease due to cerebral cortex
intoxication. In fact, the photomotor reflex is normal, and what we
have is an inversion of the Argyll-Robertson sign. These symptoms are
those of retrobulbar neuritis, of nicotino-ethylic origin, and it may
be thought that the melinite was simply acting by creating a soil for
alcoholic intoxication, but none of the patients examined has been
alcoholic, nor has any been permitted to smoke in the factory. The
injurious agent is probably a body in the nitrophenol series, perhaps
dinitrochlorobenzol, but whether this substance is absorbed through
the skin, inhaled, ingested from the hands, or by all three routes,
is doubtful. These workers are often cyanotic while at work because
the nitre products produce vasodilatation. Possibly this dilatation of
vessels has something to do with the neuritis. The workmen will not use
the spectacles and antitoxic masks given them, and even do not use the
rubber gloves constantly. In some factories only, a liter of milk is
given as counterpoison, every day.


Slight wound of occiput: Ophthalmoplegia externa, influencible,
however, by tests and replaced by spasmodic convergence of globes with
myosis; hysterical stigmata and convulsions.

=Case 435.= (WESTPHAL, September, 1915.)

A German volunteer, 20, was slightly wounded in the occiput by
revolver-shot at Ypres. Then followed headaches, vertigo, and
complaints of pains in the eyes such that he could not open them or
see sidewise. May 5, 1915, he showed a picture of an ophthalmoplegia
externa: complete immobility of the two bulbi, lively blepharoclonus,
rapidly passing into blepharospasm, photophobia. The visual field for
white was practically limited to the fixation point. Central scotoma
for all colors. Otherwise normal.

On further examination, the apparently immobile bulbi were found to
pass into convergence upon request to look to the right or left.
_Thereafter_, this position of convergence was assumed if any test
made by a strong light, such as that of a pocket flash, was used.
The pupils contracted to the maximum during this assumption of the
convergent position of the globes, and no further light reaction could
be observed. The convergence gradually passed off when the light was
removed. The appearance of bilateral external ophthalmoplegia had
disappeared.

If the patient was requested to follow a finger moved to one side, the
globe of that side to which the finger was being moved, stood unmoved
in its central position, but the other globe followed the eye and
placed itself in the convergent position. The patient complained of
diplopia. Even after the closure of one eye a double vision appeared
(monocular diplopia). There was achromatopsia. The cornea failed to
react to stimulation.

There was an analgesia of the skin of the whole body, with a
hypesthesia for tactile stimuli on the left side. Smell and taste
absent. The convergent position of the globes with myosis was preserved
in the midst of convulsive seizures, which could be produced by
exciting the patient. When it was attempted to dissolve the eye
troubles by hypnosis, convulsive attacks occurred. The patient was
pronouncedly hysterical.

The case is beyond question hysterical,--the phenomena consisting of
an ophthalmoplegia externa, alternating with spasmodic contracture of
the internal recti, associated with myosis and loss of light reaction.
The influencibility of this situation during the process of tests, to
say nothing of the other stigmata, clinches the diagnosis--an important
one, since the development of an external ophthalmoplegia after
occipital trauma might possibly be regarded as an organic disease due
to hemorrhage in the region of the eye-muscle nuclei.


Sandbag drops on head: Internal strabismus and diplopia. Various
diagnoses. Cure by lenses.

=Case 436.= (HARWOOD, September, 1916.)

A four-pound wet sandbag fell eight feet on the head of a
sergeant-major, 28, lying in a Gallipoli dug-out, November 24, 1915.
The sergeant-major was removed to Lemnos with headache and giddiness,
and a week later developed bilateral internal strabismus with double
vision and head noises. The diagnosis was “brain tumor” or “syphilitic
meningitis of the base.” On the voyage home, the diagnosis was altered
to “multiple neuritis or neurasthenia.”

He was admitted to the King George Hospital, January 1, 1916, unable
to move the eyes outwards; they moved rather poorly up and down. There
was a slight lateral nystagmus. The patient had been unable to read or
stand since the accident. The visual acuity of each eye was less than
6/60, but with an arrangement of lenses he could get 6/5 with either
eye. He had perfect binocular vision and could read ordinary type
comfortably. In a week’s time he was able to stand without support and
walk with a stick. Whenever he took off the glasses, the strabismus and
diplopia immediately returned. Other combinations were tried but failed
to relieve symptoms. The lenses given were +0.375 c. Vert. and L. +0.25
S. +0.25 C. 75 do.


Hemianopsia: organic or functional?

=Case 437.= (STEINER, October, 1915.)

A 19-year old volunteer, 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 the trench nearby but failed to explode. Up
to that time everything had been quiet. The soldier had been looking
out of the loophole, surveying the terrain. He felt a great fear, got
a blow in the neck, fell down unconscious, remained unconscious for
an unknown time, and later walked back with his comrades. About an
hour later, this volunteer,--who was a very intelligent young man,
possessing much 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.


Hysterical pseudoptosis.

=Case 438.= (LAIGNEL-LAVASTINE and BALLET, January, 1916.)

Laignel-Lavastine and Ballet present a case of what they term
hysterical pseudoptosis in a patient who showed no signs of organic
disease of the nervous system, and moreover no special mental disorder.
This soldier, 30 years of age, working in the auxiliary service,
suffered from a troublesome lowering of his left upper eyelid. He went
to the front in February, 1915. Aside from suffering a few mild and
temporary blindnesses (_éblouissements_), he was entirely well up to
the time of being wounded, March 18, 1915, by a bullet in the arm, and
a bullet occasioning a superficial and slight wound 2½ centimeters
above the middle of the left eyebrow. About three years later, a shell
burst near him and made a large contusion about the right eye, without
hurting the globus. He was then evacuated to Châlons-sur-Marne, and
there remained for 48 hours, totally blind, probably on account of
spasmodic closure of his eyelids. He then began to be able to use the
left eye, which remained, however, very photophobic. A fortnight later,
the wounds were healed, but the patient found himself unable to open
his right eye. Three months later he returned to his dépôt, and left
for the front October 24.

He was reëvacuated November 4, as unsuitable for service. He was then
examined by an ophthalmologist at Chartres, who found a very mobile
right pupil and a slightly atrophic right papilla; vision ½; left eye
normal; vision ⅔; total paralysis of right levator palpebrae superioris
without contracture of orbicularis. There was also paresis of the left
upper lid, which ceased when the right eye was closed. The right half
of the face was anesthetic, but there was no corneal anesthesia.

November 15: Right eyebrow lower than left; if the head was moved
backward, the right eyelid followed the movements, and in this position
there was no ptosis.

November 16: Analgesia in the super- and sub-orbicular region. November
17: frontalis and orbicularis functions normal.

At time of examination, patient complained of not being able to open
his right eye, and that he could only partly open the left eye. To
catch a view of his examiner, he had to throw his head back and to the
right. He could not open his eyelids, and in the effort to do so, the
forehead muscles contracted; and whereas the left eyebrow was properly
elevated, the right eyebrow was only partially elevated. Associated
movements could be noted in the musculature of the lower part of the
face. In looking to the right, the eyelids, especially the left, were
elevated slightly. The patient complained of photophobia. From time
to time, he felt completely blind, and at the end of these spells of
blindness, he had a severe headache. His head felt heavy. Sometimes on
looking to the left, he saw objects double, although this diplopia had
grown less marked of late. All the muscles of both eyes appeared to
work normally. Upon pressure on the right globus, especially pressure
directed from above and behind on the internal part, the patient would
raise his left eyelid, but the paresis reappeared the moment the
pressure was released; a fact which the patient himself noted while a
tampon was being placed upon his eye.

It seems there had been a wound at the external angle of the eye, some
nine or ten years before, as a consequence of which the eyelid of this
side could never be parted as well as before. The accident in question
had happened in 1905, and there had been a slight suppuration of a
wound 2½ centimeters from the external angle of the palpable fissure.

The patient then went through a period of reëducation. It seemed that
when he was trying to raise his eyelids, there was a mental inhibition
which could be overcome only by effort. An attempt may be made to
resolve the phenomena into three groups:

First, enophthalmia of the right side (post-traumatic, antebellum, a
predisposing cause).

Secondly, a situation corresponding to so-called hysterical
pseudoptosis of Charcot and Parinaud (eyelid falling without wrinkles,
head thrown back, frontalis contraction on effort to open eyes, eyelid
lowered). The diagnosis of hysteria was supported by the transient
opening of both eyelids when a sudden sharp order was given to move the
eye-_balls_, and further supported by synergic automatic lid-movements
when the patient voluntarily raised his eyes. He could not raise his
eyelids to order.

Thirdly, functional ocular palpable synergy (left eye opening upon
compressing the right eye).


Shell-shock Rombergism.

=Case 439.= (BECK, June, 1915.)

A soldier, 24, had sundry signs of traumatic neurosis. A curious and
unexplained feature is the fact that in the course of testing for
Rombergism he would fall forward like a log if his head were held in
the vertical position, but if it were turned to the right he fell to
the right; if it were turned to the left, he fell backward. Tests
showed that he had no disease of the vestibular apparatus and no sign
either of cerebral or of cerebellar disease.

The question is raised whether shell-shock can produce a differential
Rombergism such as hitherto would have been explained on the basis of
some organic vestibular disease.

_Re_ Rombergism, see especially Bourgeois and Sourdille’s (edited
by Dundas Grant) remarks on disturbances of balance which, if of
labyrinthine origin, obey Romberg’s law, namely, are greatly increased
with the eyes closed. Upon test, however, normal equilibrium,
tottering, or a tendency to fall will be usually found. The tendency to
fall is, as a rule, toward the side of the affected labyrinth, yet it
varies according to the position of the head; that is to say, actually
upon the position of the labyrinth with relation to the body. If there
is a lesion of the right labyrinth, for example, and the head is turned
to the right, falling is to the right; but if the head is turned 90
degrees toward the right, the patient tends to fall backward because in
fact the injured right labyrinth has now become posterior in position.
But if the head with the injured right labyrinth is displaced 90
degrees to the left, the tendency would be to fall forwards.

According to Beck, there was in his case of Shell-shock Rombergism no
ear disease or any evidence of cerebellar or cerebral disease.

Walking with the eyes open yields in marked instances a sidewise
bending or even the classical staggering called the duck’s walk and
drunken gait upon a broad base. The most delicate test, according to
Bourgeois and Sourdille, is the Babinski-Weil test of walking with the
eyes shut. A man with labyrinthine disease deviates from the straight
path (he is made to walk forwards and backwards ten times in a clear
space); bends pretty constantly to one side when walking forward,
and pretty constantly to the other side when walking backwards.
Spontaneous and Babinski’s induced nystagmus (rotation; caloric) and
Babinski’s voltaic vertigo test are the other tests commonly employed
in equilibrium investigation.


Otology and neuropsychiatry should go hand in hand.

=Case 440.= (ROUSSY and BOISSEAU, May, 1917.)

A soldier in the engineers, 29, entered the neuropsychiatric center
at Scey-sur-Saône, August 23, 1916. His diagnosis was: organic shock
syndrome with right-side deafness and tremors. He carried a ticket
showing an otological examination: tympanum normal; Rombergism absent;
walks with eyes closed swerving to right; tends to fall, eyes closed,
on standing on one foot; vertigo produced by rotation in either
direction; no nystagmus either spontaneous or by test; deafness
especially on the right side; equilibrium function insufficient.

The patient had undergone shock in April, 1915, being buried and then
losing consciousness for twenty-four hours. The tremors appeared next
day, and also deafness but without speech disorder. Nine comrades
are said to have been killed beside him. The hospital ticket, April
13, said: deafness and multiple contusions from shell explosion. The
patient was evacuated to Clarmont-Ferrand and went back to service with
the same tremor and auditory disorder. He was shortly sent back to the
interior for six months and returned improved to the front August,
1915. But he heard the cannon in the distance, and, under the influence
of emotion and the fatigue of the journey, the tremors and deafness
reappeared.

The tremor was generalized, involving both arms and legs and a slight
lateral movement of negation of the head every ten or twelve seconds.
Occasionally tonic contracture of the face, lips, cheeks, forehead;
tremors of tongue; winking. The tremors were somewhat suggestive of
toxic tremors.

The deafness was evidently exaggerated. Voltaic vertigo tested normal.
Reflexes normal.

The diagnosis psychoneurosis was made and the patient was rigorously
isolated, given a long psychotherapeutic talk concerning the nonreality
of his deafness and his vertigo and the possibility of cure by means
of a very disagreeable electrical treatment. He made improvement upon
psycho-electrical treatment and the next day both tremors and deafness
had greatly diminished. September 4, the patient was considered
completely well. There was a slight diminution of hearing in the right
ear, the whispered voice was heard at 50 centimeters on the right side,
the watch at 25 centimeters on the right and 60 on the left.

October 5 the patient was sent back to his corps. On the evening of
his departure, angry at not having received leave, he boasted to his
comrades of having passed but three days at the front since his injury.

It is remarkable, according to Roussy and Boisseau that this patient
had passed sixteen months without ever having been taken for a
neuropath or treated as one. The otologists gave the diagnosis
of labyrinthine shock, but did not attend to the tremors. The
pseudo-symptoms disappeared in six days at the neurological center and
the cure had lasted six weeks at the time of report.

_Re_ otology in these cases, see Bourgeois and Sourdille’s book
mentioned under Case No. 439, particularly Chapter III, upon the
functional examination of hearing. In the present instance, it will be
noted that voltaic vertigo tested out normal. According to Bourgeois
and Sourdille, the Babinski electrical test is the most convenient
one to begin with, to learn in a few moments whether the vestibular
system is working normally or not. These authors found amongst twelve
patients, three normal reactions and one instance of hypo-excitability
amongst four subjects who, by other tests, failed to show vestibular
disturbance. Inexcitability as to voltaic vertigo was found in
one man with a destroyed labyrinth. There were four instances of
hyperexcitability in Babinski’s cases with marked equilibrium disorder.
A case of Ménière’s disease yielded the same results. According to
the intensity of the current, the following phenomena (in addition to
the pricking sensation) are noted; (_a_) salty taste; (_b_) sidewise
swaying with slight vertigo; (_c_) nystagmus with more pronounced
vertigo; (_d_) sensations of sound. In short, nerve branches that go
through the petrous bone, namely, the chorda tympani, the vestibular
nerve, and the cochlear nerve, have been successively stimulated.
Babinski’s test was published before the Barany work on induced
nystagmus, but Barany’s rotation test for the physiological excitation
of the semi-circular canals, and his caloric test for the investigation
of the ears and canals separately are to be utilized in addition to
the Babinski voltaic test. Babinski’s law of voltaic vertigo is that a
normal subject inclines to the side of the positive pole; a pathologic
subject falls to the side to which he tends to incline spontaneously.
If the labyrinth has been destroyed, there has been no reaction.

_Re_ Case 440, Roussy and Boisseau in their capacity as
neuropsychiatrists, point out the inadequacy of an otological
examination taken by itself. They insist that neuropsychiatrists
should be called in. It is probably equally true that neuropsychiatric
work upon deaf cases is often inadequate on account of the lack of
otological examinations. According to Bourgeois and Sourdille, the
expert otologist’s problems are as follows: (_a_) Deafmutism; here
Gault’s cochleopalpebral reflex is of value. The hearing of a sudden
noise causes contraction of the orbicularis palpebrarum on the side
upon which the noise is suddenly and unexpectedly made. Eyelash tips
are particularly watched.

(_b_) Complete bilateral deafness. This is practically never organic;
complete bilateral deafness is a phenomenon either of traumatic
hysteria or of simulation. Sundry methods of surprising the patient
into hearing have been adopted. The practice of teaching lip-reading to
simulators and hysterics has led to some difficulties in diagnosis, but
tests have been produced by Gosset (of one sound with the lips set to
form another, and the like) which are of service.

(_c_) Extreme bilateral dulness of hearing.

(_d_) Total unilateral deafness. For the minutiae of tests for these
types of hearing disorder and their simulation and exaggeration, see
the War Manual of Bourgeois and Sourdille.


Jacksonian syndrome: Hysterical.

=Case 441.= (JEANSELME and HUET, July, 1915.)

A Lieutenant of Infantry, 32, was struck by a bullet September 6,
1914, in the upper part of the left temporal fossa 4 cm. above the
external auditory meatus. He did not lose consciousness, but had the
sensation as if his head had been shot off, and about three minutes
later he turned about, fell down, and lost consciousness. However, he
regained consciousness a few minutes later and walked with support
for about an hour. At the ambulance, he lost consciousness again, for
half an hour. He was then carried to Amalie-les-Bains. The trip lasted
108 hours. The left side of the face was now swollen so that he could
not open the eye nor could he chew from swollen mucosa folded between
the jaws. The bullet was removed Sept. 12, from just below the scalp
outside the bone, the point being slightly bent back. The bone had
been depressed slightly for an area the size of a franc piece, and
pressure at this point yielded a feeling of pain and discomfort. There
was no suppuration. After a week, the man got up. He returned to his
dépôt October 3 or 4 and was about to rejoin his corps when he had a
sensation of pressure in the head and fell. When he came to himself he
found that there was a frothy saliva at the left side of the mouth and
that the whole left side of the body felt weak. The tongue had not been
bitten nor had urine been passed, and twenty minutes later he felt as
well as ever. He returned to the front in the Argonne, having from time
to time similar crises,--at least once a week. Ordered to take a trench
the night of January 17, he failed the first time, about midnight, but
succeeded at four in the morning,--just afterward falling exhausted in
another crisis, with unconsciousness. The stretcher bearers took him
back and he was evacuated to Perpignan. He had two convulsions.

While with his family the crises grew in number to three or four a
week, and sometimes twice a day. Upon request, he was sent to hospital
in the Pantheon May 5.

There was always a sensory aura, consisting in a violent shock felt in
the left side of the cranium like a blow of a club. There immediately
followed a crawling sensation in the fingers and hand of the left
side, running up the arm, with loss of consciousness coming on before
the crawling reached the elbow. The seizure would last two or three
minutes. There was no initial cry. The face grew pale. There was apnea,
and frothy fluid running out of the left side of the mouth. There was
no jerking of face or limbs; at the end of the seizure there were no
deep inspirations. The extremities of the left side were rather flaccid
during the attack.

A hemianesthesia was found affecting both skin and mucosae of the left
side, and a slight retraction of the visual field on the left side
was found. There were no other sensory disorders; the knee-jerks were
lively on both sides but not actually exaggerated. Plantar stimulation
was not perceived on the left side. The toes, except the great toe,
were slightly extended. The fascia lata reflex failed to demonstrate
itself. On the right side the great toe went into flexion on forcibly
stimulating the sole. Sometimes the abdominal reflex on the left side
was weak or even absent. The patient, who had never been nervous, had
now become so since his attacks. He had had nocturia up to 12. There
was no evidence of neurosis or psychosis in the family. Bromides
diminished the crises a little in number. Static electricity was given
from January 8,--no attacks for 8 to 10 days.

According to Jeanselme and Huet, this is a case of Jacksonian syndrome
of an hysterical nature, about which it may be noted that the bullet
struck the left side of the skull and the hemianesthesia and muscular
resolution appeared on the same side as the injury.


Leg tic: Phobia against crabs.

=Case 442.= (DUPRAT, October, 1917.)

A man, shell-shocked in 1916 (with loss of consciousness,
disorientation and confusion followed by nightmares, memory
disorder, attention disorder, irritability, mental instability and
over-emotionalism) later still showed a choreiform tic. He had a
knife-grinding movement of the left leg which made standing and
walking difficult. There were no signs in the reflexes or reactions of
organic disease. The man himself said that he felt a sensation like
little electric shocks when his foot touched the ground, a sensation
like pinching. He also had certain hysteriform crises. He was able to
remember nightmares in which he felt as if he had fallen into a hole
where there were crabs. In point of fact, he had a true phobia against
crabs, crayfish, lobsters and the like; if he saw one, he always felt
as if he were going to have a new crisis. The defense movement of the
leg and foot was against a supposed pinch of the crab. At rest, there
was no trace of the choreiform movement. The tic was especially marked
when the man was suddenly asked to get up and walk. In a few days,
when he had become more clearly conscious of his phobia and had slept
better, the tic grew appreciably less.


Convulsions reminiscent of fright.

=Case 443.= (DUPRAT, October, 1917.)

A soldier, 28, was blown up February 8, 1915, by a shell burst. He
sustained no contusions but became completely mute. On July 3, he began
to speak in a low voice. The _torpillage_ treatment was unsuccessful
because the man felt a morbid apprehension that the vibration of a loud
voice or even of a rapid walk would resound in his brain. He had a sort
of noise phobia, probably maintained by nightmares which frequently
woke him up with a jerk though he could not remember their content.
On the way back to his dépôt this man got off the train at the first
station and went to a hospital complaining that the vibration of the
train was going to be transmitted to his brain. Hysteriform crises
developed in a few days.

According to Duprat these crises are nothing but a psychomotor
development of the initial complex. The clonic and tonic convulsions
are reminders of his states of extreme fright, a phenomenon of revival
of the ideo-affective process, aggravated however by the oniric or
post-oniric images.

_Re_ diagnosis of hysterical fits, the absence of facial cyanosis,
sub-conjunctival hemorrhages, petechiae of skin, and the Babinski
reflex are suggestive for hysteria. Babinski points out that the
initial cry, the fall, the loss of consciousness, the tongue-biting,
the bloody frothing at the mouth, the urinary incontinence, and the
post-convulsive prostration can all be consciously or unconsciously
imitated. Hysterical convulsive movements are apt to be of wide range,
gesticulatory, and opisthotonic.

Babinski announces to the supposed hysteric that he is going to
reproduce the attack, as he is perfectly able to do by electricity.
A mild current or mere electrode application suggests a fit in a
hysteric, often very quickly. Babinski now announces that he can arrest
the fit; carries out some selected procedure, and stops the fit. During
the hysterical fit, the patient of course hears what is being said and
during this time wrong suggestions must not be offered.


Fugue in a motor cyclist, with prodromal fatigue and subsequent
delusions--recovery in six weeks.

=Case 444.= (MALLET, July, 1917.)

A motor-cyclist, 36, with the colors from the outbreak of the war,
about April, 1916, grew very weary, suffering from headache and
seizures without loss of consciousness. Finally there was a voice:
“Sleep, you must sleep.” Then other voices; then ideas of thought
transference with people around him.

Observed in the psychiatric center, May 12, 1916, he had the same ideas
of thought transference, and he made as if to talk with the attendants
by responsive-looking gestures. Sometimes, he said, fluid struck his
forehead, calling on his thought. Whereupon he listened. The man made
no complaints about his plight, was not astonished in any wise at what
was happening, nor did he seek to explain it. There was nothing in
his history to suggest psychopathy except perhaps that his father was
unknown.

The diagnosis of a chronic hallucinatory psychosis was made, but the
outcome promptly overset the diagnosis. The man talked with ward-mates,
and particularly with another patient who also talked about thought
transference. This shook the man in his convictions, and he decided
that it was but imagination and delirium.

He now told his story: How it seemed that he had in his thoughts the
phrase, “Sleep, you must sleep;” how he had gotten up, saying, “No;”
had noticed the others paying no attention to him; had gone back to his
work and from that moment had begun to go into delirium. During this
delirium or delusional state, his whole life from birth up, came back
to him, as if some one were telling him. The headaches, which he at
first felt due to Hertzian waves, suddenly ceased.

Shortly, however, a new phase had set in, in which he felt himself
surrounded by spies and that others had control of his thoughts and
were reading them. In fact, he grew a little proud of the fact that
people reading newspapers all around him were actually reading his
own thoughts. The letters he wrote were being dictated. May 9, he
spent a night with a succession of nightmares, and woke up with the
firm purpose of going back to Paris by motor cycle to find the spies.
He described his fugue and the thousand ideas he had on the way, his
arrest, his imprisonment in a cell of Hertzian waves with a smell of
sulphur and poisoned bread--a necessary fate on account of the spies.

On arrival at hospital, he had not known what was going forward.
The nurses were giving him milk to destroy the taste of sulphur;
the delirium then grew less and less. The room-mates were neutrals,
war-weary; he seemed to be reading the newspapers before his mates, and
they seemed to be talking of thought transference. May 20, the ward was
changed. The new ward-mates did not believe in thought transference and
laughed, causing the man to doubt.

June 2, the cure was in full process, and the ward was changed again;
but in the new ward was a patient who had the same ideas of thought
transference as the patient. At this time, the man’s autocritique
saw through the delusion. He talked with his telepathic comrade and
pretended to engage in a fake conversation about it. The delusions
shortly disappeared, having lasted about six weeks.


Ordinary gunner’s life; a few days’ feeling of moral and physical
discomfort: Obsession leading to fugue.

=Case 445.= (MALLET, July, 1917.)

An artilleryman, 32, gave himself up a few kilometers back of the
lines, three days after deserting his post. The man was a very good
gunner and had never been punished once. Moreover, the battery was not
under any special bombardment, and he had been in the same place a
number of weeks.

He explained that he had gotten tired during the last few days.
Everything was well at home and in the regiment, but he felt sad, his
head felt bad, and he couldn’t sleep. Something drew him to leave,
but then “_sang froid_ came back to me, and I gave myself up.” He had
lived the three days without eating and without sleeping. He was very
emotional over what he had done, but he began to work and asked that he
be sent back.

His mother had been very nervous. There was a marked facial asymmetry
and faulty arrangement of teeth. The man was not alcoholic.

According to Mallet, in these cases of fugue, and in other cases of
absolute delirium of apparently sudden onset, there is a feeling of
moral and physical discomfort for some days before the outbreak. The
outbreak itself is sudden on the occasion of some idea, either an
obsession or a hallucination. Of all the prodromal signs, headache is
the most striking. According to Mallet, such fugues are the expression
of a mental imbalance allied to the onirism of Régis.


Aprosexia and bird-like movements.

=Case 446.= (CHAVIGNY, October, 1915.)

A soldier of the dragoons, 25, entered Chavigny’s service May 30, 1915.
He acted like a mechanical figure, requiring guidance. The face was
without expression except for the mobile eyes, and sudden bird-like
movements of the head, continually attracted to new noises and objects.
An interlocutor was glanced at but not responded to. If an intense
electrical shock was passed through his abdomen, for example, the man
would look for a moment in that direction, but only the most fugitive
defence reaction would be made, and the stimulus could be repeated with
the same result, a moment later.

After three days, this aprosexia began to clear, and in four or five
days, answers to questions and ordinary associations set in. Memory
reappeared. It seems that he had been in concealment in the loft of a
barn, when he saw his commanding officer carried by, having lost an
arm and a leg. He lost consciousness and fell three meters, through
the trapdoor of the loft. There was thus a combination of trauma
and emotional shock. No external lesion was produced in the fall.
His memory showed a very sharply defined gap for the period of his
aprosexia with the bird-like movements, of eight days, and his memory
was perfectly good up to the time of the fall. This is one of five
cases observed by Chavigny, who remarks that there is something in
the attitude of the young child which recalls the aprosexia of these
patients. (Perhaps the phrase of James, “buzzing, blooming confusion”
might be used.) One must go back to a period in the child’s development
when he is not yet able to smile or keep his glance fixed on a shining
object. On the whole, the resemblance is closer to the attitude of
certain caged birds.

_Re_ aprosexia and bird-like movements, see discussion under Case 353.
See also Case 334.


Shell-shock; unconsciousness (45 days): Mutism (monosymptomatic).

=Case 447.= (LIÉBAULT, 1916.)

A soldier, 32, had a large caliber shell burst one meter from him
September 26, 1915, lost consciousness and remained comatose 45 days.
He then got progressively better but did not recover speech. He was
neither blind nor deaf. He was examined at the neurological center
at Nantes and there Mirallié called him a case of hysterical mutism,
finding no paralytic disorder of any sort and finding the patient able
to write his story, to read and to understand what he read, but without
much power of retention. He was placed in the phonetic reëducation
service March 30, but made no progress. In the effort to speak the
patient made strong generalized contractions, including contractions
of his face and winking of his eyes, contractions of the jaw, and
movements of the neck muscles. In fact, he seemed to be agitated by
a sort of cervico-facial tic, and sometimes, although not always, he
succeeded in getting out a loud voice sound, in which one could imagine
the syllable that he was trying to utter.

In this case the mutism was evidently secondary to motor disorder.
It is an example of functional dyskinesia (Benon). As long as this
functional dyskinesia remains, the patient will not speak. The
respiratory muscles are disordered, since the respiratory capacity does
not go over 3 liters. This approaches the normal, however, and if the
subject cannot speak it is because his diaphragm is subject to jerky or
cramplike movements and because the lips and tongue do not execute the
proper movements either for sounds, syllables or words. Such a patient
cannot protrude the tongue or even bring it beyond the teeth.


Shell-explosion: Recurrent amnesia.

=Case 448.= (MAIRET AND PIÉRON, April, 1917.)

A shock case of Mairet and Piéron had a disorder of memory.
Association paths were open one day and closed the next. Subjected to
shell-shock, September 18, 1915, he was found wandering in the woods
a few days later, having completely lost his memory, even for his
name. In November he recovered his surname but not his given name. On
stimulation he was gotten to remember his city, his father, the street,
and the like. Shortly he could get back his memories more quickly;
after a week it took only 35 seconds to remember that he was born at
Paris. However, his recollection of the Trocadero and of the Eiffel
Tower, which had come back to him in November, 1915, was lost again
in April, 1916, to return once more in August. December, 1915, he
could not write to dictation, but copied writing as he would a design.
He suddenly felt himself able to write in the Morse code (he was a
telegrapher); then ordinary writing returned. February, 1916, however,
he had forgotten what the Morse code was. In April, he was taught
numbers. One day he would know left from right, but had forgotten it by
evening.


Shell-explosion: Comrade killed: Amnesia.

=Case 449.= (GAUPP, April, 1915.)

F. K., a 23-year old soldier, 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. On
the 26th a number of shells exploded near him. The troop was excited
and took refuge in a cellar. K.’s best friend was torn to pieces by a
shell. When his body was removed, K. felt sick and lost consciousness.
He arrived at the clinic in Tübingen in a stuporous condition, by
hospital train, on 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 little 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 shell hissing with an
expression of intense anxiety, getting accustomed to 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 internal restlessness and tension.

Amnesia for the period of August 26 to September 1 remained; all that
K. could add to the story of those days 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 the middle of September he
was well and discharged for garrison duty.


Shell-explosion: Recurrent amnesia.

=Case 450.= (MAIRET AND PIÉRON, July, 1915.)

A man, 33, had suffered shell-shock early in December, 1914. His
intervening history is not reported, but he showed on admission to the
service of Mairet and Piéron, May 5, 1915, a remarkable amnesia. There
was a complete cutaneous anesthesia, anosmia, and ageusia, and he was
mute. He lived only in the specious present. His previous life was
completely abolished for him. He could dress himself, eat, use a fork
and spoon, and a glass. He understood ordinary words; such words as
man, woman, day and night, however had no meaning. He was observed for
15 months and presented four phases.

In phase one, there was a measure of success in reëducation, such that
he grew able to recognize a few persons, to find his bed, and name
objects. He was got to copy writing, to learn the alphabet, and to say
a few words. He could not write from dictation, however. Less than two
seconds after looking at an _A_, he had forgotten how it looked and
could not trace it. This first phase lasted about two months.

The second phase began with fatigue, headaches, and the rather quick
effacement of all he had relearned. If an errand was given him to do,
he would run to do it before he should forget it; but if the trip
required more than 4 or 5 seconds, he had to stop, not knowing what to
do with the thing in his hands. He was still able to recognize 4 or
5 persons, but could add no more to his repertoire; and when one of
them had been absent for a fortnight, he did not recognize him on his
return. He could not remember the time for his meals.

The third phase was ushered in by improvement after vomiting; his
speech came back in a feeble voice, November 16, 11 months after the
shock. Reëducation could now be undertaken again. He easily relearned
a number of things, feeling the greatest astonishment at his new
acquirements as to the sun and the moon, the trees and the flowers, and
the like. He expressed a curiosity to see his own home, but when he
went thither, he could recognize nothing. He wanted to get back home,
namely to the hospital where he had lived all his life; where, in fact,
he had been born from the psychic point of view.

At this time began the fourth phase, April, 1916--a phase of decline
once more, in which a large portion of his acquisitions were again lost
and he fell back to his condition in the second phase.

See discussion under Case 353 and under Case 367. _Re_ confusional
mental states, Roussy and Lhermitte, after distinguishing stuporous
confusion from simple confusion, go on to differentiate what they call
obtusion (see also discussion under Case 353). These authors say that
Régis, in common with most psychiatrists, fails to distinguish the slow
thinking and amnesia of true mental confusion from the temporal and
the spatial disorientation that characterize the so-called obtusion.
Of course, in all attacks of confusion, both attention and memory are
affected, but there are special types in which attention defects and
memory defects stand out in relief. The first of these types is the
aprosexic type with birdlike movements, described by Chavigny (see for
an example, Case 446). This aprosexia may be combined with mutism,
deafness, or convulsions. The form of confusional disease in which
amnesia is the out-standing feature is due to toxic or infectious
disease, or is a Korsakow phenomenon, _i.e._, in the psychiatry of
peace times; but the war has brought out amnestic confusion in other
states than the toxic, infectious, and alcoholic states (Régis,
Chavigny, Dumas, Roussy and Lhermitte). The amnesia may be incomplete,
a sort of dysmnesia, or twilight memory, but as a rule, the amnesia
is lacunar. The toxic and infectious amnestic confusions have a loss
of memory for events following the onset, but these war cases of
amnestic confusion have the loss of memory running back far into the
patient’s past, slipping from the mind his name, his parentage, age,
and vocation. Instead of being like the toxic confusional amnesia, an
anterograde amnesia of fixation, the Shell-shock amnesia is apt to be
antero-retrograde. These antero-retrograde amnesias, whether due to
emotion or to strong physical shock, may sometimes leave in sharp
relief the recollection of the shock or event itself which initiated
the amnesia. Meanwhile the patient does not forget automatic actions
of dressing, reading, writing, and the like. The amnesia may be very
selective, imitating aphasia, word blindness, letter blindness,
agraphia, and the like. All this is part of the hallucinatory form of
mental confusion which Régis describes as oniric delirium (see for
oniric delirium, discussion under Case 333).

Lépine distinguishes amongst the confusions, five forms as follows:
Simple confusion, hallucinatory confusion, acute delirium, stuporous
confusion (under which Lépine also considers the battle hypnosis of
Milian, see Case 365, and Roussy’s narcolepsy), and amnestic confusion.
All these phenomena from the clinical point of view are connected
with an acute and fleeting insufficiency of the most delicate or, as
it were, psychic portions of the cerebral cortex, the delirium, so to
speak, being activity of the unconscious, whereas a confusion is due to
a clouding of the centre O of Grasset’s polygon.


Soldier’s heart, both neurotic and organic.

=Case 451.= (MACCURDY, July, 1917.)

A territorial, 19, who had enlisted in January 1914, reached France
in September, 1916. He was of neurotic make-up (night terrors, fear
of dark, giddiness in high places, fear of tunnels, enuresis until 10
years, worry about seminal emissions), and had always had a tendency
to short wind. Enlisting at 16, he found it hard carrying his pack
at first but soon grew stronger. The trench life was distasteful.
He began to wish that he might be killed, or at all events removed
from the trenches. Pains developed under the heart, with shortness of
breath, palpitation, dizziness, and faint feelings. The man connected
these heart symptoms with what he called his weakness of gall bladder
(namely, enuresis). He was several times sent off duty for heart
treatment. After three months in and out of hospital, he got trench
foot, was sent to England, and transferred to a special heart hospital.
Here the pulse test was positive, in that the rate did not diminish as
it normally does after two minutes’ rest. After graduated exercises for
several months, the pulse test had become negative and the heart had
gradually improved from the organic standpoint. The patient, however,
insisted that his heart trouble was as bad as ever, and was probably
consciously hoping that his symptoms might persist.

_Re_ soldier’s heart, Abrahams classifies cases that come to the
military surgeon for heart symptoms as (_a_) functional fatigue cases;
(_b_) nicotine and drug cases; (_c_) organic heart disease and Graves’
disease; (_d_) the true soldier’s heart, occurring in men with a
neurasthenic soil that lose control of the vasomotors and inhibitors of
the heart.


Soldiers heart, neurotic.

=Case 452.= (MACCURDY, July, 1917.)

An Australian gunner, 35, of a neurotic make-up (night terrors; horror
of blood; fear of thunderstorms, high places, tunnels, horses; shy with
both sexes), benefited by military training physically, but remained as
neurotic as ever. On the way to his first service in Egypt, he feared
shipwreck, and in Egypt was troubled by the weather and occasional
palpitations and sinking feelings. He was transferred to the French
front, May, 1916. He was terrified and depressed under shell fire, and
horrified by blood. Peculiar sinking sensations or feelings that the
soul was leaving the body came to him as he was going off to sleep;
from which he woke at times with sudden starts. Later he had nightmares
of things, mainly shells, falling on him. He worried, wanted death, and
thought of suicide. In May, 1917, he was blown off his feet by a shell.
Thereafter he began to feel that shells were being especially aimed at
him, and four days later got a pain in the side, and began to tremble
and breathe with difficulty, as if his throat were swelled up and he
were going to choke. He ascribed this to gas. The bombardier finally
sent him back to a hospital, where he grew weaker and screamed aloud
on being awakened by his dreams. After six weeks in a special heart
hospital, all the symptoms cleared up except the choking feelings and
fear of instant death. Organically the man appeared normal. An initial
pulse of 96 ran up to 168 after exercise, and down to 84 after two
minutes’ rest.

_Re_ soldier’s heart, Abrahams speaks of sundry hypotheses that he
regards as erroneous. Soldier’s heart has been thought to be (_a_)
athlete’s heart; others regard it as (_b_) a toxemic condition,
possibly of bacterial origin; (_c_) hyperthyroidism (a larval form
of Graves’ disease has been incriminated); (_d_) excessive cigarette
smoking; and (_e_) deficiency of buffer salts in the blood, have been
proposed by other authors.

Gallavardin has especially studied the tachycardial cases revealed by
the war, cases in which auscultation is frequently unable to detect
aught. These tachycardiacs are often hypertensive. Sedentary service
should be found for them.

_Re_ pulse 168 after exercise, Gallavardin found 8 per cent of 500
non-organic and non-tuberculous cases to run up from 150 to 175 (125
to 150 in 27 per cent; 100 to 125 in 37 per cent; 75 to 100 in 26 per
cent; 50 to 75 in 2 per cent).

_Re_ cardiac neuroses, Brasch points out that cardiac neuroses in
the male in war time have found a strange new association with
hyperesthesia of the skin. The patients showed dermatographia and
hyperreflexia. The hyperesthetic zones of Head and Mackenzie were found
by Brasch in all cases of organic cardiac disease, but also in two
cases of cardiac neurosis in hysterics.

Moore calls attention to somewhat similar phenomena in the somatic
group of nervous and depressed cases found in the war. These patients
are fatigued, exhausted, sleepless, tremulous, vascular, and cardiac
cases, with dermatographia, areas of paresthesia, and pains in the
neighborhood of wound scars.


War Strain; Shell-shock: Hysteria (question of malingering).

=Case 453.= (MYERS, March, 1916.)

A sergeant, 32, with 11 years’ service and eight months’ service in
France, was admitted to a base hospital for inquiry as to possible
malingering. It seems that he had taught in an army school for seven
years before the war. He found heavy marches in France too much for him
and fainted in the retreat from Mons and during the fighting on the
Aisne, where he had reported sick for dysentery. The field ambulance
where he was treated was near the shell fire, and a shell knocked him
into a ditch. The ambulance had to move to a cave. Thereafter the
patient suffered from tremor when spoken to or when watched. After
discharge, he was employed as a dispatch rider on a motor cycle, but
after three months lost his nerve for this work and took charge of
fatigue parties. He found the work too much for him. He had been a
total abstainer. Finally the malingering charge was brought up.

The patient was nervous, delicate-looking, with widely dilated pupils,
prominent eyeballs, tremor of right arm, and pulse of 102. The tremor
was markedly lessened when he was alone, and was somewhat under
control. He felt that his memory was defective, and tests demonstrated
the defect.

In hospital patient slept better, the pupils grew smaller, the pulse
rate diminished. There was a reduction in sensibility to pain over the
right side of the head and body and over the right limbs. A prick of
the right arm or leg was described as a finger touch. There was also
almost complete hemi-anosmia and complete hemi-ageusia on the right
side. Visual acuity was diminished on the right, and there was general
limitation of right field; left-sided vision and field normal.

After a month in hospital at home and two months’ leave, the patient
was discharged no longer physically fit for service. He is now weak
physically and mentally, subject to severe headaches, and tremulous,
especially in the right arm, when tired.

_Re_ malingering, Sicard denies the existence of unconscious
malingerers (presumably regarding this phrase as a figure of speech
in relation to hysteria), and divides malingering into a creative and
an acquired form. The _simulateur de création_ assumes attitudes and
symptoms to attract attention or pity; the _simulateurs de fixation_
having been sick in the beginning, perpetuate their disease, in brief,
crystallize their neuroses. The _fixateur_ may be very realistic in
all this, seeing that he has known from his own experience what a real
disease is. The formula runs: The _simulateur de création_ improvises;
the _simulateur de fixation_ repeats.

According to Mott, malingering in the form of an assumed Shell-shock is
not uncommon amongst soldiers, and is rather hard to distinguish from a
neurosis developing on the basis of an _idée fixe_.

Ballet’s definition of simulation is “a subjective or objective
disorder which the patient invents with the idea of voluntarily and
consciously misleading the observer.” Closely related to simulation
is exaggeration or prolongation, conscious or intentional, of a real
disorder. Babinski states that cases of genuine simulation are very
rare, and that the subject under suspicion should be given the benefit
of the doubt. Especially the word _simulation_, or similar words,
should not be uttered in the presence of the patient. Practically
speaking, psychotherapy applied as in cases of hysteria may often cure
the simulator and the exaggerator.


The officer who could not kick.

=Case 454.= (MILLS, January, 1917.)

An officer had had a bullet in the right calf, of which nothing was
evident months later but small scars of entrance and exit. Nevertheless
he complained of pain, especially after walking, and of inability to
dorsiflex the foot beyond a certain point. No wasting could be found
and no impairment of sensation. The muscles were faradically normal.
Mills thought the symptoms were exaggerated and so remarked to the
officer.

Under anesthesia, however, the dorsiflexion also proved to be
impossible, and after exerting considerable force, Dr. Dunhill was
able to rupture a massive fibrous band of adhesions that had prevented
extension. The officer made a good recovery.

Dr. Mills confessed his error to the officer who had naturally resented
the suggestion of malingering. The officer forgave him.

_Re_ malingering, Moore states that no diagnosis of malingering should
be made without the most careful examination and consideration of the
individual as such, on account of the fact that the erroneous diagnosis
dejects the patient and postpones recovery. It is particularly unwise
to term the trouble “imaginary,” or to talk about “suggestion” or use
similar terms in the presence of the patient.

Craig has found very few cases of actual malingering and states that
tremors and paroxysms are often mistaken therefor. Bispham remarks that
few malingerers are found among the patients of a doctor who is known
to be a thorough examiner.

_Re_ orthopedic cases like Case 454, Gleboff remarks upon the
simulation of joint affections and upon methods of surprising the
malingerers into sudden movements made in obedience to request in the
course of medical examination.


Doubtful accounts by patient concerning arm palsy: Incorrect diagnosis
of simulation.

=Case 455.= (VOSS, November, 1916.)

A volunteer, 18, just before the war had a fall in which apparently he
injured his skull. In December, 1914, he hurt his left forearm. About
this injury he sometimes said he fell in a storming attack in a trench
and broke his arm, and again he said his arm had been smashed by stones
from a falling house. From that time forward there was paralysis of the
left forearm with flexor contracture. May, 1915, slight hypesthesia
could be demonstrated on the ulnar side of the arm, suggesting ulnaris
injury. There were, however, no considerable electrical changes.

Six months later the man was sent up with a suspicion of simulation.
In the meantime the contracture had resolved and there was a typical
hysterical paralysis with all signs of neurosis. Six months later he
was well enough to be examined for military service.

Here was a case in which the incorrect data offered by the patient
himself as to the origin of his paralysis gave rise to the suspicion
of simulation, whereas, as a matter of fact, the man was clearly
hysterical.

_Re_ incorrect data supplied by the patient to his own disadvantage,
Lumsden remarks on the great difficulty of diagnosis in cases where
hysteria and malingering have been combined, and Morselli states that,
if the doctor has really made up his mind that the man is shamming, he
should send him back to the fighting line at once.


Forearm wound: Hysterical edema?

=Case 456.= (LEBAR, July, 1915.)

A corporal, 26, formerly a farmer, was struck in the forearm by a
shell fragment on the mid-portion of the radial border. The wound was
slight (the fragment entering and emerging hardly 2 cm. apart) but
bled profusely, according to the patient, who was evacuated next day
but one to a hospital in the interior. By this time the right hand was
swollen, nor could any movement of hand or fingers be made. Massage,
mechanotherapy, passive movements did no good.

The man entered the neurological center of the Eighth Region, July
7, 1915, when there were already a few skin changes with dorsal
thinning and palmar thickening. There was cutaneous anesthesia not
only of hand and fingers but of the forearm to the elbow, and this
anesthesia included heat and cold. Position sense was preserved. There
was no evidence of atrophy except for the skin changes. An electrical
examination showed normal conditions.

July 13, a sealed bandage was put on, but at the end of five days
the hand looked as before. July 19, a new treatment was announced to
the patient. With a hot needle a number of pricks were made on the
dorsal surface of the hand and a few c.c. of fluid were withdrawn
(containing a slight amount of albumin and a few lymphocytes),
whereupon a dry bandage was put on. The next day a few finger and
thumb flexion movements could be made and sensation had returned.
Sensation completely returned July 21. The flexion movements were still
incomplete, by reason of the edema and dryness of the skin. However,
July 22, flexion was better and the swelling had gone down sixty per
cent. Jacquet’s biokinetic treatment (active gymnastics of the hand
and fingers) was given for four hours. July 25, the edema had greatly
diminished and normal motion had returned.

Examination excluded renal disease. There was no sign indicating
phlegmon. Quincke’s disease had other features. Fraudulent application
of a bandage might be considered, but the course of the disease under
sealed conditions seems to exclude this hypothesis also. May it,
therefore, not be a case of hysterical edema?

_Re_ hysterical edema, see remarks under Case 407. In the case above,
of Lebar, Babinski calls attention to the fact that the edema and the
contracture diminished though they did not entirely disappear after
the scarifications. This physical treatment did not act, according to
Babinski, wholly as a matter of suggestion, and he fears that some
cases of so-called hysterical edema are really cases of physiopathic
vasomotor disorder; in fact, three of the cases published (and amongst
them, the present case of Lebar), were cases of edema associated with
contracture and developing in an injured limb. To prove a case of
anything to be hysterical is, of course, according to the Babinski
school, to submit it to a therapeutic test and cure it by suggestion.


Shell splinters in head: Suspicion of (_a_) simulation, (_b_) hysteria.
Case actually surgical.

=Case 457.= (VOSS, November, 1916.)

A man, injured by shell fragments in the head and sustaining fracture
of both arms and a thigh, got well of his wounds, but fell into a
nervous state with headache and dizziness. He was given prolonged
observation psychiatrically and then sent back to the front as fit for
service, but was shortly returned to hospital and sent to Cologne under
the suspicion of simulation.

The picture was of unilateral increase of tendon reflexes, accelerated
pulse, disorder in the intake of ideas, difficulty in finding words and
delayed associations. His gait suggested a psychogenic disorder. X-ray
showed two shell fragments in the vault of the skull.

According to Voss, it is a sad fact that victims of skull injuries
are frequently charged with simulation or exaggeration. In the above
instance, moreover, this charge was undoubtedly inaccurate.

_Re_ simulation, see remarks under Case 453. _Re_ neurological cases,
the Neurological Society of Paris sent to the War Ministry a special
note pointing out how tardy was the reference of sundry neurological
cases to the special neurological service. They pointed out how
important it was to send to these special services all cases of bullet
and shrapnel lesions.

_Re_ the malingering question, there is a wide divergence of opinion,
even amongst experienced workers in the same city. The late Professor
Dejerine said he had not seen a single case of malingering. In fact,
he thought that malingering amongst soldiers and amongst injured
industrial workers had been much exaggerated. Marie, however, working
in the examination of many surgical cases, found malingering relatively
common. Amongst forty of his cases, he regarded at least nine as
malingerers or exaggerators.


“Sciatica,” torticollis, stiff arm: The desire to avoid active service
plus functional disease.

=Case 458.= (COLLIE, January, 1916.)

A man enlisted September, 1914, went to France after six months’
training, immediately put himself on sick list, and was admitted to
a base hospital: Diagnosis, sciatica. Later, he ceased complaining
of sciatica and developed spastic torticollis. He was sent back to
England, was treated with radiant heat and so on, and was eventually
sent to the Royal Bath Hospital at Harrowgate.

He recovered from torticollis after six weeks’ treatment; but then
developed a spasmodic contracture of the right shoulder and forearm.
He was massaged for this and also given high frequency treatment. Then
came two transfers (massage).

Early in December, 1915, he came under Collie’s observation. He then
showed right wrist bent at right angles to the forearm; hand tightly
clenched, so firmly that it seemed as if the wrist were ankylosed.
The case was obviously a functional one. The man refused to enter
hospital at Collie’s suggestion. He was sent to the Maida Vale
Hospital. Previously he tried to persuade the medical officer that
further hospital treatment was unnecessary, stating that he was now
able to straighten his arm and that he was applying a splint to keep it
straight. He progressed slowly in the institution. Told, if he would
recover within fourteen days, he would be classified “for home service
only”--before the fourteen days were up, he had suspended his weight on
a trapeze and pulled himself up to his chin on it; had also lifted a
28-lb. weight with his paralyzed hand. In short, he wholly recovered.
He is now doing duty with his unit.

Collie says this is not deliberate malingering but a mixture of
functional disease and an obvious desire to avoid active service. When
he appeared before the board for a final decision, there was a tendency
to assume the old paralyzed position until he was sharply called to
order, when his arm assumed normal position.

_Conclusion_: The direct personal treatment of his mental condition and
an appeal to his lower instincts were immediately curative and of much
more value than the radiant heat or high frequency treatment.

_Re_ Collie’s case, Russel finds surprisingly large numbers of
malingerers; he found many at the time of the battles at Loos. It was
particularly easy in cases of epilepsy to demonstrate a close relation
between hysteria and malingering. In the psychogenesis of these
conditions, Russel emphasizes the initial element of deception, which
soon enormously increases either through the patient’s convictions of
his ability to deceive or through a process of autosuggestion. Cases of
semi-malingering are not uncommon. In England, Russel found more cases
of a clearly psychogenic nature; yet in these, also, there was always
primarily an element of deception.


Yes-No test of value _re_ anesthesia.

=Case 459.= (MILLS, January, 1917.)

The “Yes-No” test proved of special value in the case of an Australian
private. Shortly after landing at Gallipoli this man had a bullet graze
his ankle and fell some thirty feet over the bow of a ridge. He was
picked up unable to move his legs and insensitive therein.

The paraplegia and anesthesia lasted three months. “Fracture
dislocation of the dorsal spine” was the diagnosis made, and
laminectomy was even contemplated. The sphincter reflex was normal and
there was no atrophy, no rigidity and no reflex disorder. Asked to say
“no” when he could not feel a pin-prick and “yes” when he did feel it,
he replied “no” to each prick to the anesthetic area and changed his
reply to “yes” when the sensitive parts of the body were examined. At
another time the answers were found not to correspond with those given
before.

The soldier was assured that he would get well and that as soon as he
could walk he would be boarded and returned to Australia.

After a number of weeks he became able to walk.


Arabian fever.

=Case 460.= (ROUSSY, April, 1915.)

An Arab fell on his knee, one day in the trenches. A contracture of the
left arm, with great pain, and a temperature of 38 to 40 degrees, with
hemoptysis, developed. This man had been considered tuberculous. One
day, however, the thermometer went up to 41 degrees. It was discovered
that he took artificial means to push the mercury up, and that the
spitting of blood was voluntary. All these phenomena disappeared after
he was put in the guardhouse for 24 hours.


Shrapnel scratch of head: Hysterical amaurosis “?” On isolation in a
dark room, the patient began to see light!

=Case 461.= (BRIAND and KALT, February, 1917.)

A man may seek to exaggerate an anomaly of his eye which had existed
before the war, in order to live comfortably far from the front.

A soldier sustained a slight scratch from a shrapnel bullet in front
of the left ear, which scarred over in a few days. The soldier said,
however, that the bullet had gone through his skull and a few hours
after his wound said he could not see. Sent to the hospital he
continued to say he was blind and finally brought up in an asylum for
the blind near Lyons where he was taught to cane chairs and to write in
Braille. This happened in July, 1915.

In October he was sent to the Hospital at Quinze-Vingt where a
diagnosis of hysterical amaurosis was made with a large interrogation
point. He was then sent to Brequet where there was a section reserved
for disciplinary cases and very nervous cases not wanting to get well,
a service under the charge of Roubinowitch.

The soldier escaped with a comrade and eventually reached Val-de-Grâce
where the diagnosis of hysterical amaurosis was again made.
Examinations several times showed that there was nothing abnormal
about the eyes except that the eyelids presented habitual fibrillary
movements (antebellum).

The eyelids passively opened, would remain open for a few minutes and
then close. There was no winking of the eye to a light, yet the pupil
preserved its reflex power.

Vision was abolished, however, the soldier said. He was without any
other motor or sensory disorder. Much sympathy was given to the poor
blind soldier. People were much astonished when the chief of the
ophthalmological service had the man isolated in a dark room. Three
weeks later the man had begun to see the light a little. A week later
the eyes remained open without the necessity of having the lids raised
by the fingers, and vision returned.

_Re_ amaurosis, Parsons explains the blindness which may remain after
consciousness returns following Shell-shock, as a condition in which
the lower visual paths are carrying on their functions normally. For
example, the pupillary reactions are preserved. The condition is not
unlike that found in amaurosis of uremia, and Parsons has found it
in children with posterior basic meningitis. For Parsons, therefore,
the block occurs in the higher centers above the thalamus, possibly
in the synapses of the optic radiation fibers. Ormond states that the
true cases of concussion blindness invariably pass through phases of
great discomfort; whereas the malingerers are without such discomfort.
Medical suggestion, also, has a powerful effect here, and may actually
retard recovery.


A newspaper cure.

=Case 462.= (SICARD, October, 1915.)

Sicard read in a French newspaper a story to the effect that, at two
o’clock in the afternoon, a soldier had fallen on the sidewalk between
Nos. 40 and 42 Boulevard de Liberté, in a nervous crisis. The people
ran and picked him up. When he came to, he was very joyful, perceiving
that the shock had given him back his speech, which he had lost the
August previous. This soldier, the newspaper continued, became deafmute
through the explosion of a bomb in a fight in Upper Alsace. “The brave
soldier is most happy over the unexpected result.” The newspaper went
on, “We congratulate him sincerely, as well as the people who assisted
him.” He was the more contented that he had gotten well because, the
soldier said, he would now be able to go back among his comrades to
fight with the Boches!

Now, in point of fact, Sicard had dealt with this soldier the morning
of the day in question. He had been simulating mutism for ten months,
and finally told Sicard that he would like to leave that afternoon
as he felt cure coming. Sometime after, he wrote a letter of profuse
thanks for the benefits received, and said he did not deserve to avoid
court-martial. He also said that he was going to do everything he could
to justify himself. Incidentally, he kept his word and an officer in
his regiment later gave him an enthusiastic recommendation.

_Re_ malingering, see discussion concerning _simulateurs de création_
and _simulateurs de fixation_ under Case 453.


Deafmutism: Explained by patient as malingering.

=Case 463.= (MYERS, September, 1916.)

A pure malingerer, of set purpose, initiates a quasipathological
condition which he will discard when he has gained his end or when he
is assured that he is unobserved. Malingering in the field of speech
is rare. A private, 26, one year in service, three months in France,
entered a base hospital, deafmute for nine weeks. He wrote: “I should
be very happy if you can do anything for me. I cannot give a very clear
account of what happened, as it is sometime since. I remember retiring
from Hill ---- with some more to some trenches, and in the open we
were shelled and I lost touch with our chaps or else they were killed.
I remember a great concussion and finding myself on the ground, and a
soldier dragged me up and we ran for the trench. I was very thirsty and
I ran down the trench to get some water. I met one of our chaps and
tried to ask him for some, and I could not make him understand. He only
smiled at me. The man who picked me up took me to an officer who was
sitting on the edge of the trench and tried to make me understand, and
then he sent me with this man to a dressing station, and from there I
have been to different places, the names of which I do not know, except
the last place, No. -- Convalescent Camp. I have been there about two
months----”

He seemed anxious to get well. He could not understand what was said.
Induced anesthesia caused no phase of excitement, and the patient
failed to regain his speech. He was evacuated to England. Three months
later the patient thence wrote the following confidential letter from a
Convalescent Home. “Sir,--I regret very much to inform you that I was
imposing upon you.----I may state that I was physically unfit for the
Front.----During the whole time of training my pay was chiefly spent in
tonics and drugs, but I kept going as I was determined to see what it
was like at the Front.----I have written this----that your ‘notes’ on
cases will not suffer any detrimental effect through my imposture.----I
have not got my discharge yet, but shall stick out for it. I ‘speak’
but do not ‘hear’ very well.--” He was in two hospitals for functional
nervous disorders in England, but in neither institution was he
regarded as a malingerer.

_Re_ hysteria explained by the patient as malingering, Chavigny
discusses what he calls _sursimulation_. The physician must not fall
into a permanent state of suspicion, and especially must not reveal
his suspicions to the accused or to the bystanders. Chavigny quotes a
French soldier whose letter to his wife was intercepted, stating that
he was going to feign deafmutism to secure his discharge. Before he had
succeeded in doing so, however, he suffered Shell-shock, and got a true
hysterical deafmutism, which showed no signs of malingering whatever.


Deafmutism: Appearance of malingering.

=Case 464.= (MYERS, September, 1916.)

A stretcher bearer was seen by Lt.-Col. Myers two days after admission
to a base hospital. Stolid looking and mute, he had nevertheless talked
in his sleep, had written a few words about “shells coming over,”
and understood what was said to him. Lt.-Col. Myers’ notes run, “He
puts out his tongue and closes his eyes and holds out one hand when
I ask him to do so, but gets stupid (as if sulky) when I ask for the
other hand. He _will_ not hear any more. Next day quite deaf, and the
following day light anesthesia with ether caused a return of hearing
and of speech, with repetition of syllables to request on the way to
deeper anesthesia. On awaking he cried as he was induced to resume his
speech, and complained of pains in the head.

“Two days later, he seemed normal and said that he could have spoken
on the second day, but that his eyes and ears had begun to swim, that
he had felt dizzy, and was afraid to talk. He did not want to be sent
back to the trenches. There had been severe shelling. He had lost
consciousness until he awoke in a hospital at Y--. He recalled, little
by little, how he had been taken back by a corporal to a cellar. He
said he wanted to go back, but wanted a rest first. He went back to his
unit and was reported as having done well for four months.”

There was a certain suggestion of malingering about the admission of
the lad that he could have spoken before he was induced to do so.
According to Lt.-Col. Myers, a number of patients upon recovery of
speech are apt falsely to believe that they have been malingering.
Functional disorders may simulate malingering.

Lannois and Chavanne warn against the suggestions given to malingerers
and to hysterics by the statements on the tickets of admission borne by
the patients for transfer, _e.g._ “incurable deafness.” These authors
found 11 per cent malingerers amongst 262 cases of labyrinthine shock.


Simulation of deafmutism.

=Case 465.= (GRADENIGO, March, 1917.)

A soldier in the mountain artillery acted like a deafmute. He was
unable to read or write. It was reported that he had been wounded, but
no evidence of wound could be found. The man had a low forehead and a
furtive glance, his whole impression being that of a criminal.

The only evidence of disease found was inflammation with perforation of
the tympanic membrane of the left ear. Deep in the left auditory meatus
was found _a grain of crushed oats_! The man’s speech difficulty was of
a stuttering nature, but he stuttered in a different way at every test.
He was unwilling to be narcotized. Finally by a process of scolding and
cajoling, the man was made to confess that he could both hear and speak
well. The peculiar stuttering early led to the diagnosis of simulation,
but the fact that the tympanic membrane was not anesthetic, and that
there was no anesthetic zone in the body strengthened the suspicion--to
say nothing of the refusal of narcosis and the general behavior of the
somewhat criminal-looking soldier.


A lame rascal.

=Case 466.= (GILLES, April, 1917.)

An infantryman, 28, had an equinovarus, for which he was evacuated,
hospitalized, given treatment, sent home for convalescence, and
declared unfit for service. He was, however, sent back to the front,
and on arrival, went lame; whereupon the regimental surgeon sent him
to a nerve center. The equinovarus was there but it was nothing but a
simple contracture without pain, atrophy, sensory, reflex, electrical,
or X-ray disorders.

The abductor muscles were stimulated by electricity and the foot
straightened. He was kept under observation for a time, was lame no
longer, and was sent back to his regiment.

However, sometime later he was evacuated again to the same neurological
center, stating that he did not know why. There was no longer any varus
or anything abnormal. The rascal had enjoyed the game of going lame and
had prevailed upon his officers to evacuate him. He then saw that he
was found out and pretended that he had been forcibly evacuated.


Mother love and jaundice.

=Case 467.= (BRIAND and HAURY, January, 1916.)

A soldier, 19½, entered the central psychiatric service at
Val-de-Grâce, having been evacuated from a hospital in Paris, _suspect_
of having brought about a picric acid jaundice. He had been undergoing
treatment in this hospital, when the physician who had isolated him
found that he was getting picric acid in packages secreted in his képi.

It seems that the soldier lived with his mother, and enlisted when he
was not yet 18. He proved to be as good a soldier as he was workman,
and came through the campaign without wound or disease. Accordingly, in
December, 1915, he got a six-day leave. His mother, who loved him well,
and of whom he was the sole support, had much regretted his enlisting.
She was sick with some stomach disease and, after he enlisted, she told
everybody that she was going to die and that it was his fault. So,
when he came on leave the next day, she asked him to take a powder so
he might stay a fortnight. She did not tell him the name of the drug;
only told him how to take it in a small paper, swallowing it with a
little water. She said he would become yellow and that he would get a
supplementary leave. Three days after his return to the front, the boy
took three of the ten powders; took the same number three or four days
later; and the others five or six days later. He soon had jaundice with
colic and diarrhea, and apparently was exempted from service for a few
days. He had returned to the front hardly a month when his mother died
and the boy got another six-day leave for the funeral. He took ten
fresh doses of picric acid while at Paris, and was put into hospital by
a physician without suspicion. His relatives thought he was suffering
from a recurrent jaundice. When the story was told, the boy confessed
to the family, and said that he had taken the drug in the first place
only to please his mother. It is harder to explain the second trial,
since he talked about the compassion and sense of obedience he felt to
his dead mother. It is probable that he simply wanted a prolonged leave
at Paris.

_Re_ malingering, Blum speaks of fictitious jaundice as having received
the name of _La Carotte_ (the carrot) from the soldiers. Blum gives a
partial list of instances of simulation as follows:

SIMULATION

(BLUM, DECEMBER, 1916)

_False angina_, from irritating solution.

_Gastric disorder._ Oil and tobacco (with tachycardia or jaundice) (use
ipecac).

_Diarrhea._ (Isolate.)

Diarrheal stools imitated by a mixture of urine and water.

Dysenteric stools imitated by the addition of fat pork and bits of raw
meat.

_Appendicitis._ Complaint of pain at the well-known McBurney point.

_Tape worm._ Carriers supply others.

_Jaundice._ (Smoke mixture of antipyrin and tobacco; drink tobacco
juice. Ingest picric acid.)

_Hemoptysis._ Irritation of throat surfaces with a needle.

_Albuminuria._ Eat kitchen salt to excess in a bowl of milk. Edema and
albumin disappear on surveillance. Albumin injected into bladder.

_Diabetes._ Phloridzin, or oxalate of ammonia. Glucose added to urine.

_Incontinence._ (Difficult to prove fraudulent. True incontinence in
middle of night. Simulated, just before waking.)

_Skin diseases_:

    _Erythema._ Herbs.

    _Eruptions._ Mercury, arsenic, iodine, bromide.

    _Herpes._ Euphorbiacae.

    _Eczema._ Rubbing with slightly warmed thapsia. Rubbing
    excoriated skin with acids, Croton oil, bark of garou, sulphur,
    oil of cade, mercurial pomade.

_Impetigo._ With cantharides plaster and _pomade stibiée_.

_Intertrigo._ (In the infantry.)

_Hyperidrosis of feet._ Prolonged hot baths. Hot foot baths with
excoriation, followed by scratching and covering with linen soaked in
urine.

_Edema of legs._ Constriction.

(In Lombardy, cases due to introduction of equisetum arvense, an
astringent herb, by fingers and toes, followed by energetic rubbing.)

_Recurrent wounds._ (Cover with wax sealed bandages.)

_Abscesses._ Introduction of septic material. A thread soiled with
tartar from teeth is drawn through the skin. Characteristic odor of
resulting abscess.

_Phlegmons._ Subcutaneous introduction of turpentine or petrol.

_Paraffine tumors._ (Apply heat.)

_Sprain._ A stopper is put under the heel; or compress the leg with
bandages to stop circulation and knock below repeatedly and forcibly.
Edema and ecchymosis follow.

_Conjunctivitis._ Ipecac, pepper, septic or fecal materials. Pupillary
dilatation has been produced by introduction of a belladonna grain
under the eyelid daily.

_Ears._ Running at the ears produced by placing urine or chemical
product in the ear.

_Emaciation and pallor._ Ingestion of a large amount of vinegar. Abuse
of strong tobacco.

_Muscular weakness._ Arsenious acid in eggs. Voluntary lead and
mercurial intoxications.

_Epilepsy._ Absence of pupillary reflex to light and pupillary
dilatation, insensibility of nasal mucosa and modifications of pulse
persistent after the attack is over cannot be imitated.

_Fever._ Striking elbows against walls to elevate the mercury in the
thermometer. Take temperature by rectum.

_Bites._ One simulator had a fork with twisted teeth to produce the
effect.

_Intra-abdominal projectiles._ Bullet swallowed.


Swelling of hand and forearm, seven months.

=Case 468.= (LÉRI and ROGER, September, 1915.)

A soldier was wounded September 22, 1914, at Charleroi by a bullet in
the forearm. He came under observation May 14, 1915, with a huge edema
of forearm and hand, suddenly stopping at the elbow, an elastic edema,
especially marked in the palm, which was restored to its smooth contour
very quickly after being compressed by the fingers, and very like an
elephantiasis. The hand was in a position of moderate extension on the
forearm, with fist clenched. There was a linear ecchymotic line at the
upper edge of the zone of edema, especially on the antero-internal face.

According to the soldier’s own story, the swelling had begun a
fortnight after the injury. He said that a very tight moist dressing
had been applied during the first few days.

The patient was cared for by massage, and then by local baths. He was
anesthetized in December and several drains were inserted; no result.
In January he was chloroformed again and two long incisions were made
along the internal border of the supinator longus and along the ulnar
border of the forearm. He was better for two weeks after this second
operation, but then grew worse.

The diagnosis of syringomyelia was now made, based upon the appearance
of the arm and upon some ill-defined hypesthesia. This diagnosis was
not entertained by Léri and Roger who, when they obtained the patient,
put him into a plaster cast up to the shoulder. The edema went down
rapidly to normal. In short, it was here a question of a simulator, who
was even willing to undergo surgical operations with general anesthesia.

_Re_ evading service, Gleboff’s classification is as follows: 1. False
assertion of disease of (_a_) internal organs, (_b_) vision, (_c_)
hearing, (_d_) joints. 2. Simulation of temporary disease of organs. 3.
Mutilation of limbs.

_Re_ swelling of hand and forearm, see remarks on hysterical edema
under Cases 407 and 456.


A German shell-shy.

=Case 469.= (GAUPP, April, 1915.)

Gaupp’s simulator had not been under shell fire. He said to his captain
that he wanted to see his badly wounded brother (he had in fact no
brother), and got a furlough on this ground. He then fled as far as
possible from the front, into the interior, roved about for some days,
falsely asserting that he was under dentist’s treatment.

He was brought to Tübingen on the ground of mental derangement,
on a hospital train, and was delivered to the clinic as a case of
Shell-shock. This man’s state of excitement soon ended. As Gaupp could
not make out his case clinically, he applied to the regiment and
received in return court-martial papers. The man confessed that he
had made false statements and fled because he was afraid of shells.
Reproached with simulation, he preserved a shameful silence.


A fair exchange no robbery: France gets a simulator in an exchange with
Germany of prisoners “unfit for service.”

=Case 470.= (MARIE, April, 1915.)

A French soldier arrived in France from Germany in a reciprocal
exchange of prisoners supposed to be incapable of bearing arms. The
man showed a paraplegia with clonic movements of exaggerated degree.
He was rapidly “cured” after being placed in a military hospital, and
disciplined. He proved to be a vulgar simulator.

It was clear that the German physicians had made a gross error in
diagnosis; but what, asks Marie, should be done with such a man, since
he evidently should not be given a convalescent leave or a retirement?
Should he be sent back to his dépôt?

If a year’s treatment yields no results, Grasset suggests discharge
with suitable gratuity.


SIMULATION: Question of Quincke’s disease.

=Case 471.= (LEWITUS, May, 1915.)

An infantryman was brought to the eye department of the Wieden Hospital
early in May, 1915, with a diagnosis (from the internists) of Quincke’s
disease.

Under the conjunctiva of each globus oculi were countless small air
vesicles. There was not the slightest emphysema of the eyelids or of
the skin about the eyes. The skin in the neighborhood of the zygoma
was thick, red and swollen; but no air could be demonstrated in the
subcutaneous tissues on palpation. Next day the skin swelling and
the conjunctival emphysema had disappeared. No communication of the
orbits with the air spaces of the skull could be demonstrated nor was
it possible to push air into the conjunctiva by nose-blowing. The
fundi were both normal and vision was normal. Special rhinological
examination showed the nose to be normal. It was the skin swelling of
the orbital region that had given rise to the diagnosis of Quincke’s
disease. The man had been then referred to the internists who could,
however, find no evidence of disease whatever.

During the three months’ stay of the patient in the eye department,
once more swelling of the left orbital region and air under the
conjunctiva of the left globus oculi suddenly appeared one day, but
disappeared over night. At this time small subconjunctival ecchymoses
were found.

This case must be regarded as one of simulation but produced in a
manner unknown.


Bruises of head and back, not severe: “A case of pensionitis, a
self-made neurasthenic for medicolegal purposes.”

=Case 472.= (COLLIE, May, 1915.)

Sir John Collie remarks that sometimes one has to recommend a pension
knowing that what amounts to a fraud is being perpetrated. A seaman,
25, got newspaper notoriety after receiving some not very serious
bruises of head and back. Two months later, when seen by Sir John
Collie, he was a victim of bent back. He was finally able to remove
his clothes and put them on with some alacrity, although at first he
declared he could not. Woebegone during examination, he was noted to
laugh and gossip with strangers outside. A physician had diagnosticated
it as an obscure spinal lesion, but as he was fit to work, he was sent
back.

Forty-one days later he put himself on the sick-list again. Pluck and
nerve were gone beyond recall, according to his physician. In hospital
his appetite was good, he slept well, and he had no troubles except an
hysterical loss of sensation. There followed 33 days in hospital, three
weeks in a convalescent home, and return to work for a month. Unable to
stoop or kneel for pain, he was thought organic.

Sir John found him without desire to get well, hysterical, and
suffering “from pensionitis, a self-made neurasthenic for medico-legal
purposes.” He was placed for four months in a nerve hospital. On
leaving this hospital he was still in the bent-back position, and went
into a pantomime display when asked to touch his toes. Four weeks in
the convalescent home found the following: The attending physician
now suggested locomotor ataxia as the correct diagnosis! Sir John
Collie was asked to report finally as to the fitness for work. Well
assured that the patient was really a malingerer, Sir John nevertheless
certified him as permanently unfit for further service as a case of
traumatic neurasthenia, venturing to predict that after receiving the
pension, he would be at work within six months. He received the pension
(25 s. a week for life), and Sir John Collie’s ability at prediction
was justified by his return to work, at the end of exactly six months.

_Re_ malingerers, Glueck remarks that a malingerer, besides being a
malingerer, is a worthless sort of person in any event, and calls
attention to the fact that special stresses may reduce men to lower
cultural levels, to which lying and deceit may be more appropriate.
Glueck remarks that the lay mind does not readily appreciate that
a man with mental disease may at the same time be a malingerer of
additional mental symptoms. It may be added that the professional mind
is sometimes equally slow to appreciate the fact.

                               CHART 14

                              SHELL-SHOCK

      GROUP I. EXHAUSTION

                 (ALCOHOLISM PERTURBS TREATMENT)

     GROUP II. HEREDITY

                 (CERTAIN POOR RECRUITS)

    GROUP III. MARTIAL MISFITS

                 (WRONG ATTITUDE OF MIND)

                                             After Farquhar Buzzard

                               CHART 15

                     NEUROSES AND PSYCHOSES OF WAR

    1. NEUROSES

         MOTOR
         SENSORY

    2. NEUROSES

         SPECIAL SENSORY
         SPEECH

    3. NEURASTHENIA

         HEMICHOREA
         EXOPHTHALMIC GOITRE
         TRENCH SPINE

    4. PSYCHOSES

         MINOR
           GUN-SHY, INSOMNIA, DREAMS, PHOBIAS, PSYCHASTHENIA,
           HYPOCHONDRIA
         STUPOR, ANERGIA, ACUTE DEMENTIA
         PSYCHOSES (Civilian Forms)

                                               After A. W. Campbell




D. TREATMENT AND RESULTS OF SHELL-SHOCK.

    “E però leva su, vinci l’ambascia
      con l’animo che vince ogni battaglia
      se col suo grave corpo non s’accascia.

    “Più lunga scala convien che si saglia:
      non basta da costoro esser partito
      se tu m’intendi, or fa sì che ti vaglia.”

    “And therefore rise! conquer thy panting
      with the soul, that conquers every battle,
      if with its heavy body it sinks not down.

    “A longer ladder must be climbed:
      to have quitted these is not enough;
      if thou understandest me, now act so that it may profit thee.”

                                         Inferno, Canto XXIV, 52-57.


In previous sections we have already become acquainted with many
therapeutic successes and failures: indeed it was almost necessary to
detail treatment in certain cases to show the nature of the disease in
hand or the correctness of a given diagnosis. In the present Section we
approach the question more systematically.

After presenting a few examples of various spontaneous and non-medical
recoveries, we bring into contrast the types of medical recovery that
may be termed rapid (or miracle) cures and those that fall under the
general head of reëducation. Admixed are cases of failure as well as of
success: if it be remarked that the case method puts forward the best
foot, it is probable that the same is true of almost any therapeutics
as reported in early articles. As we go to press, trench reports
indicate that at least one part of the profession is far more hopeful
of successful psychotherapy even in the physiopathic group of disorders
than their expounder, Babinski, could concede. The true statistical
evaluation of the results must come years later.

Some neuropsychiatrists have been fond of saying that there is nothing
new in Shell-shock, that specialists have long been familiar with the
psychoneuroses, etc. Yet in the past, specialists have not learned
overmuch about the true inwardness of the psychoneuroses. Even a casual
inspection of the various therapeutic efforts here described shows how
much novelty of observation and ingenuity of plan must eternally be
shown in these ever-so-simple psychoneuroses!


Shell-shock: Deafmutism. Spontaneous cure.

=Case 473.= (MOTT, January, 1916.)

A British soldier, 25, a coal miner, had had a bicycle accident five
years before, after which he was unconscious for 2½ hours, and gave up
work for five weeks, with headaches, fainting-fits, and nervousness
ever after and with a tendency to imagine he could see things when
there was nothing to be seen.

September 19, 1915, he was under shell fire in trench and dugout. A
sergeant and three men working with him were killed by an explosion,
and he remembers his cap being lifted off his head. He came to in 46
Rest Camp, some time later, unable to see clearly, or to hear or speak,
and with headache and insomnia. He brought a paper from a hospital in
France, saying, “Doctor, I had an awful dream last night again; I was
dreaming that I was in the trenches; I could see the men falling and
the great big shells exploding. I could see the light from the bursting
of the shells very plain. They fairly lighted all the place up. I woke
up very anxious I can tell you. I wish I could give over dreaming, and
I keep having pains in my head right across my eyes.”

October 15, while sitting by himself outdoors, he felt a slight
crackling in his head, noticed that he could hear sounds faintly, and
in a few minutes he could hear fairly well.

October 17, he was heard making inarticulate noises in his sleep. The
corporal next him told him about the noises in his half drowsy state;
he tried to speak and said, “Mother.” He then felt queer all over, with
pain in his head, and afterward became able to talk very well with
slight hesitation.

_Re_ spontaneous cures, Elliot Smith and Pear cite the cure of two
mutes on hearing that Roumania had entered the war, and the cure of
another by seeing Charlie Chaplin’s antics. Some workers (for example,
Aimé), treat the functional mutes by simply leaving them to themselves,
and maintain that they secure numerous spontaneous recoveries,
regarding these as superior to cures by isolation, psychotherapeutic
treatment, and the like.

                               CHART 16

                       METHODS OF PSYCHOTHERAPY

    HYPNOSIS
      VERBAL SUGGESTION
      FIXATION
      FASCINATION
      VARIOUS

    SUGGESTION (WAKING)
      VERBAL
      DRUG
      APPARATUS

    AUTOSUGGESTION

    DISTRACTION

    TERRORISM

    INFLICTION OF PAIN

    PERSUASION

    WILL TRAINING

    OCCUPATION THERAPY

    ISOLATION

    PSYCHOANALYSIS

_Re_ mutism spontaneously or non-medically cured, see also cases 476,
480, 481, 482. For various medical methods of treatment, see, _e.g._,
cases 516, 518, 520, 526, 544, 579.

Mott had a case which had been mute more than six months, unable to
whistle, phonate in coughing, or blow out a candle, though heard to
shout in his sleep: This patient recovered his speech when pitched out
of a punt on New Year’s Eve. The condition was in one sense physical
enough, as the X-ray showed that the man’s diaphragm hardly moved
even with the greatest effort. Mott regarded the inhibition of the
breathing movements, especially the phonation, as caused by fear. Mott
speaks of a case that recovered on being told by a comrade that he had
talked in his sleep. The man was so astonished by this statement that
he said, “I don’t believe it.” Other instances of cure under quasi
natural conditions are related by Mott: In the presence of a functional
mute, Mott speaks loudly to the patient’s sister so that the patient
may hear: “This man must be kept on a No. 1 diet, and when he can
ask loud enough for you to hear, he can have a bottle of stout and a
mutton-chop.” Several mutes are reported to have gotten well the next
day under this treatment.

These effects shade imperceptibly over into the manifestly suggestive,
and probably no sharp line can be drawn between the effects of medical
suggestion, non-medical heterosuggestion, and even autosuggestion.
Adrian and Yealland rather decry the Micawber line of waiting for
something to turn up. Zeehandelaar, a Dutch professor, studied Berlin
methods (Lewandowsky), and found numerous cases (both of mutism and of
deafness, paralyses, contractures, and tremors) lying about without
special treatment. According to this observer, the expectant treatment
was sometimes successful, and sometimes not; if unsuccessful, the
soldier was sent home, and re-examined a year later; whereupon he might
be found to have profited by this long waiting and to have gotten well
enough to return to army duty.


A decorated officer, evacuated for Shell-shock on the third day of the
Aisne, after four days returns to the front. Evacuated a second time,
after weeks returns to the front without relapse.

=Case 474.= (GILLES, 1916.)

A young officer, with many decorations for brilliant Colonial service,
was in the battle of the Marne, under six consecutive days’ shell fire,
smoked phlegmatically a cigarette no matter whether walls were crashing
or horses disemboweled beside him, and was uniformly able to stimulate
his men to the heavy work by humor or heroic phrases.

A week later, on the third day of the Aisne, he had to be evacuated.
He was another man--wild-eyed, shivering, jumping at the least noise,
unable to eat or sleep, given to battle dreams. He had to be carried
away from the battle zone and put in a bed in a town in the rear and
given chloral. The nightmares continued. On being awakened he would
ask where he was. He was kept in bed, given strychnine cacodylate,
and dieted. He went back to the front in four days. Two days later he
had to be evacuated a second time. After some weeks more in the rear,
however, he went back to the front, and thereafter had not relapsed
(April, 1916.)

_Re_ relapses, Wiltshire thinks their causes and frequency prove the
psychogenic nature of Shell-shock. Ballard states that a severe case
lasting six months does not recover in the army. Many that are said to
recover in hospital break down at dépôts, often with symptoms quite
unlike those which they originally presented, and it will be remembered
that Ballard has an epileptic theory of the nature of Shell-shock.
See Cases 82, 83, and 84 in Section A, III, Epileptoses. But another
portion of Ballard’s contentions relates to a causation through fear
suppressions released by perturbing events. According to Ballard, if
the man endeavors to re-suppress the released fear, the fits occur.
Ballet and DeFursac note the frequency of relapses--fewer after
treatment at the front.


Vicissitudes in fifteen months of a Shell-shock case with mutism and
amnesia. Attacks of mania. Hyperthyroidism?

=Case 475.= (PURSER, October, 1917.)

An Englishman, 21, in a rifle regiment, arrived in May, 1915, at
the Dublin University V. A. D. Hospital, being dumb, impaired as to
vision and hearing, having dilated pupils, tremors, restlessness and
weakness, and giving the impression of visual hallucinations. Although
suspicious, he was treated kindly for a few days, recovered his
hearing, and wrote the few things that he remembered about home and the
war, now and then tremulously and perspiringly writing down, “Asylum;
do not lock up; I am not mad.”

With the idea of hypnosis, his bed was surrounded by screens, whereupon
he grew so perturbed that the attempted hypnosis could not be executed.
He learned the letters PP, TT, SSS, A-OOO, and finally AA-SS, AA-TT,
T-OO, and after many weeks SS-SST-R and B-TT-R. His father visited him
and probably was recognized.

At the end of September another dumb Shell-shock case recovered speech
upon being given ether. Maj. Purser asked the sister to arrange for a
like treatment for the first case, explaining that an examination of
his throat might be painful. The cure of the second case by anesthesia
got into the papers and before he was treated the account was possibly
seen by the hitherto gentle rifleman. At any rate, he was seized with
a sort of spasm, became furious and could only see Germans coming and
carrying off his machine gun. He shouted for help. A half grain of
morphine was given him and when it began to take effect the fighting
spirit gave way to despair. He trembled over the loss of the gun, and
remained in this state of despair for three days, remembering his
regiment number and the like, but amnestic for his life during the past
few months. He could not read now because print was indistinct. Words,
when he had spelled them out, conveyed no meaning. He had a functional
alexia. When he saw a picture of a bunch of flowers in a notebook
of his, he had another spell of excitement and regained his power of
speech, remembering about his experiences only that he had been locked
up. He had now completely forgotten his father, who came to call.

By the end of October he was stronger, but his horizon was still
limited to the hospital surroundings and a little newspaper reading.
Headaches and impaired vision persisted. Sight temporarily left him
early in November, and there was a suggestion of an epileptic fit
one day early in that month. Tonic and sedative drugs and suggestive
remedies were of no avail. Hypnotism made him worse, and psychanalysis
was, perforce, ineffective through the amnesia. At the end of November
depression and suicidal thoughts set in, with an elevation of blood
pressure to 178 m.m., pulse 80 to 90. Maj. Dawson then thought he was a
suicidal melancholic. Rest in bed and thyroid extract were given, but
the latter threw up his pulse on the fifth day to 140. He grew better
mentally on the treatment, however, and his blood pressure fell to 140
in three weeks. He was now over-emotional, unable to stand or walk or
feed himself or to pull on his socks.

For change of scene he was transferred to Mercer’s Hospital in
February, 1916. He suffered from astasia-abasia. The tremor became
jerky, coarse and persistent. The thyroid gland grew a good deal in
size during the spring and the pulse went up to 120 per minute. There
was also well-marked dermographia and there was a suggestion of the
clinical picture of Graves’ disease. Even a quarter grain of morphine
had little or no effect upon an ineradicable insomnia.

Maj. Purser gave the case up as a bad job and the man was discharged
and sent home September 2, 1916. During the next two months at home he
improved in steadiness, though he flushed if dealing with strangers,
and improved as to memory. He began to be able to read better. He had
begun to be able to get about on his feet without so much support. The
ultimate outcome could not be reported by Maj. Purser.


Shell-shock: Mutism. Cure after killing a snake.

=Case 476.= (JONES, 1915.)

An Australian soldier of 20 went to Egypt, thence to Gallipoli where,
on July 29, 1915, he was almost completely buried by earth from the
bursting of a high explosive shell. He was admitted to hospital August
5 and transferred to Malta, where he did not speak, stared into space
and sometimes made, impulsively, attempts to get away. About September
17 he began to assist the orderlies and played draughts.

The diagnosis there was cerebral concussion. He was sent back to
Australia by transport and had to be put in a padded cell on November
1, having become violent, noisy and destructive. He would assault
anyone who beat him at the game of draughts and threw anything he
could lay his hands on out of the porthole. Hyoscine he resented
and threatened the givers by signs. He was at times restrained. He
threatened to throw himself overboard. Diagnosis: Melancholia.

At Melbourne he was found in good physical shape, but dazed, mute,
apparently deaf, indicating his wants by signs. With pencil and paper
he would draw a ship or a gun and would copy any question put to him in
writing. He played draughts intelligently and made friends with one of
his shipmates. In four days’ time he began to communicate in writing,
answering simple questions correctly. Asked to put a question, he wrote
“Do you think I am mad?” On the appropriate answer he shook hands with
the physician heartily.

He was then sent to a military convalescent home at Highton. Here
he communicated often in writing, and had an appreciation of sounds
without distinguishing words. At a picnic on December 4 he killed a
snake. While returning in the dark he began to whistle a song the
rest of the party were singing. At the end of the song he clapped his
hands and said, “What is the next item on the program?” Thereafter he
was able to hear and speak. Seen four days later he asked to join the
officers’ training school. However, he was discharged as permanently
unfit for the service.


Course in hospital of an oniric delirium.

=Case 477.= (BUSCAINO and COPPOLA, January, 1916.)

An Italian gun-maker, 27 (father neurotic; grandmother and mother,
alcoholic; patient excessive onanist), was called to arms June 14,
1915, and went into artillery service in the Tolmino, early in
September. Some time later, a shell burst about 30 meters away and
killed his lieutenant. The patient, however, was not hurt and did not
even fall. He became mute and inaccessible, and was sent to a military
hospital, and thence to an asylum in Udine, where he was restless and
hallucinatory. October 2, he was sent to Florence on two months’ leave
for convalescence. He was still hallucinated, always seeing his dead
lieutenant. He spoke rarely, slept little, and his conduct became more
and more queer. Now and again, he would act exactly as if he were at
the front. November 5, he started off to find his brother, but was
met by a hospital attendant, who promptly took him to a clinic. Here
he was inaccessible and lived in a hallucinatory way a soldier’s life
at the front: in continual movement, shielding his eyes with his
hands as if looking far into the distance, bending down to turn an
imaginary lever, apparently taking part of his aim, crouching in a
corner, clapping his ears with his palms, and obeying hallucinatory
commands: “Ready,” “Fire,” and the like. As to his interpretation
of the actual surroundings, he would give a military salute at the
entrance of the physician, as if he were the lieutenant. Another
patient near by was interpreted as a spy. Hypodermic injections,
November 6, were interpreted as military antityphoid injections. On
succeeding days he piled dry horse-chestnut leaves for a parapet, which
became the scene of battle. November 12 he had become a little more
lucid. November 14, he evidently heard whistling and made the leaves
ready as a bed for horses. November 15, he rolled up his blanket in a
military fashion and hid in a cell corner. He explained, November 16,
that he was a sentinel and had not been relieved by the corporal. He
had saved everybody’s lives by signaling from a tree the presence of
four airplanes. He could not be convinced he was in an institution for
the insane. November 20, he was virtually recovered but amnestic for
what he had done since commitment. Headaches and dizziness. November
21, he remembered some of his dreams, especially one of being blinded
and another of being tied by a German to a tree. By November 29 he had
become lucid and oriented, but there was an amnestic gap for his stay
at the clinic. Early in December the fields of vision were contracted;
polyopia and a glaring and burning sensation before the eyes (after
each test conjunctival and tear duct inflammation).

December 21, discharged well.

_Re_ the nature of oniric delirium, see discussion under Cases 333
and 450, Chavigny had but two cases out of 260 in which a _rapid_
curability was noted (90 per cent finally curable). Chavigny’s
treatment consists of rest in bed, quiet, purgation if necessary, and
warm or cold shower baths. Chavigny remarks upon the extraordinary
transformation from apathy to lucidity in the course of a few minutes,
brought about by arranging a slight but definite emotional shock to the
patient, namely, by mentioning in his presence something about home or
family. One bit of technic was to get the patient to write or dictate a
letter home.

Régis remarks that battle dreams of this nature occasionally affect
alcoholics in garrison or at home. The victim ought not to be
hastily committed to an asylum, but should be treated in a military
neuropsychiatric service with isolation chambers and open wards.
Régis organized early in the war at Bordeaux a central psychiatric
service along these modern lines. He remarks that the central service
ought to receive not only patients from the military hospitals, but
also patients from the temporary auxiliary hospitals of the city and
district round about. A pooling of the military and civilian issue upon
rational lines is here indicated.

Régis and others have remarked upon the necessity of differentiating
these battle deliria from toxic and infectious psychoses.


Shell explosion: Deafmutism, recovery of speech with electrical
treatment; deafness cured by suggestion in writing.

=Case 478.= (BUSCAINO and COPPOLA, January, 1916.)

A fusileer, 20 (mother neurotic, brother hemiparetic from infantile
disease; patient had extreme otorrhea from an early otitis media),
entered the army January 15, 1915. He was sent to the Isonzo in
May and was slightly injured in the nape of the neck and the left
calf by fragments of a shell that exploded near by. He was picked
up unconscious and taken to the hospital at Servignano. There he
was given electric treatment, and in a period of 18 days recovered
his speech, passing through a phase of stammering. He was sent to a
special hospital in Florence, still deaf, and passed into a state of
mental excitement with visual hallucinations of soldiers. He was given
chloral and bromide. He insisted that he was incurably deaf. August
22, he was admitted to Buscaino’s clinic, completely deaf, slightly
stuporous, somewhat indifferent, and innocent of any effort to make
himself understood (contrary to the habits of an organically deaf
person). Simulation could be excluded. It was possible to awaken the
patient during sleep by auditory stimuli, whereupon he opened his eyes
but could not hear. He talked well and spontaneously, telling about
his accident, reading and answering by signs. He was assured,--always
in writing,--that upon the following Sunday his hearing would be
restored. Upon that day, during the visit of a lady,--one of the
patient’s friends,--hearing was suddenly and almost completely restored
in the left ear. The patient was so moved by this that he cried when
the physician came. Upon the following day, he gradually began to
hear with his right ear. A slight diminution of hearing in the right
ear persisted, however, until September 24, and was associated with
headache and pains in the left ear--pains which the patient compared to
his ear pains in childhood (remains of otitis with retraction of the
tympanic membrane).


Paraplegia: Cured by administration of Iron Cross.

=Case 479.= (NONNE, December, 1915.)

After heavy shelling a soldier fell for two days into a clouded state
from which he waked with complete paraplegia of the lower extremities,
and total anesthesia from the pelvis downward (reflexes and electric
excitability normal).

On the third day after his reception in Nonne’s wards, he was _about
to be_ hypnotized when news came that he had been promoted to a
lieutenantcy and had received the Iron Cross. He fell forthwith into
hysterical convulsions, in the midst of which the hitherto paralyzed
legs worked perfectly well! Even after the hysterical attack was over,
the man could still move his legs in bed normally, but had absolute
astasia-abasia. Next day, with deep hypnosis, markedly improved. After
eight more days of hypnosis the new lieutenant got back his normal gait.


Shell-shock, burial: Mutism. Cure by getting drunk.

=Case 480.= (PROCTOR, October, 1915.)

A patient, 25, nine years in the service, was buried in a dugout by
an explosive shell at Ypres, June 17, was taken out unconscious, and
eventually reached the hospital at Versailles. Consciousness had
returned a few days after the injury. There was ringing in the ears,
difficulty in hearing, and inability to speak. He arrived at the
Duchess of Connaught’s Hospital at Taplow, July 12, when, aside from
the above-mentioned symptoms and a rapid heart action (108 at rest), he
seemed perfectly well. About August 14, he began occasionally to refuse
solid nourishment and remained in bed, eyelids closed but twitching at
times, especially when spoken to. He resisted having his eyelids opened.

August 27, he was allowed to go to the village with companions, and
got drunk, found his voice, for two days talked and sang incessantly.
Discharged September 9, cured.


Shell-shock and burial: Mutism. Cure by work in a vineyard with wine to
drink.

=Case 481.= (ANON, May, 1916.)

A correspondent of the _British Medical Journal_ reports a case of cure
of emotional mutism. This robust young soldier at Verdun was buried by
the explosion of a shell and was thereafter found unable to speak. A
week later he arrived at the ambulance in the interior, and was still
mute. He could understand what was said to him without difficulty,
and was able to reply by signs. He did not even move the lips when
requested to pronounce such words as _mamma_ and _papa_, but was
eventually induced to whisper these words.

The laryngoscope showed complete paralysis of the vocal cords, which
were in extreme abduction (it was possible to see several tracheal
rings). There was no reaction on the part of the pharyngeal mucosa upon
stimulation.

A fortnight passed without restoration of speech, though at one
time, not having bolted the closet door, the patient was startled
when a nurse rushed in, and he said, “Oh, pardon, Madam.” The mutism
persisted. He was then given work in the vineyard, plenty of wine to
drink, and hard work. After a time (not specified) speech suddenly
returned. According to this correspondent, “this indeed is a universal
experience, namely, that hard manual work is the best remedy for such
functional incapacities of traumatic origin.”

_Re_ Cases 480 and 481, compare cures by anesthesia with chloroform,
nitrous oxide, and the like.

_Re_ gradual cures as opposed to sudden ones, Dundas Grant deprecates
violent measures in the treatment of mutism during the period of
exhaustion after Shell-shock. However, Dundas Grant does not advocate
an expectant treatment, but employs a gradual reëducation of the voice
through imitation of the teacher. The voice is sometimes restored at a
sitting, sometimes gradually; see, for example, Case 578 of Briand and
Philippe, and Case 586 of MacCurdy.


Shell-shock, unconsciousness: Deafmutism: Spontaneous recovery of
speech and gradual recovery (several months’ isolation) of hearing.

=Case 482.= (ZANGER, July, 1915.)

A musketeer was deafened and stunned by a near-by shell explosion. On
coming to, he found no wound, but was deaf and dumb.

Speech returned after ten days, and hearing partially, but there was
a tonic stuttering. He had to hunt anxiously for words, talked like
a child in infinitives and telegram style, although he could express
himself in writing perfectly well.

Hearing improved on the right side very quickly, but on the left side
conditions varied from total deafness to subtotal deafness. There was
a general hyperesthesia of the skin, pain on pressure on the temples,
exaggeration of skin and tendon reflexes, marked tremor in both hands.
The man was anxious, depressed, and irritable. During caloric tests
of the vestibular apparatus in the course of the next few weeks, the
man had an hysterical attack of crying twice, following which all the
phenomena got worse.

Rest and isolation from all such influences procured an almost complete
recovery in several months.

_Re_ differential recoveries, see also Case 585 of Liébault, in which
speech was recovered by suggestion and reëducation, and hearing by a
process of reëducation alone.

_Re_ isolation, Roussy and Lhermitte remark that in all the
psychoneuroses of war, isolation is a valuable and indeed an
indispensable aid to psychotherapy. The application of this old
classical method of Weir Mitchell reinforces the persuasive talk of
the doctor on the day of admission, allows the man to think over
the promises made to the doctor, and permits longer observation. It
depends on the case, whether rigorous isolation on limited diet shall
be employed. See below a general discussion of the psycho-electric and
reëducative method employed in French centres.


Marches; battles; slight shell wound of left upper arm: Hysterical
anesthesia of the arm and tremors (NO paresis). Causes slight--disease
obstinate (partly explained by furloughs among sympathetic friends).

=Case 483.= (BINSWANGER, July, 1915.)

A soldier, 26, without heredity, always well, in long marches and
several battles early in the war, August 23 sustained slight shell
wounds of thighs and left upper arm. He was unconscious about five
minutes. In eight days, the wounds were healed, and all movements were
free.

Immediately after the trauma the arms trembled, and at times the legs.
Treatment was instituted (baths, drugs, massage, electricity), but
without result. After a month’s treatment and a furlough at home, the
patient was sent, January 3, 1915, to the Jena Nerve Hospital. He was
a powerful man of middle size, with some small movable scars on the
left upper arm, remains of the shell injury; two similar scars of the
gluteus maximus. The deep reflexes were slightly exaggerated, as were
the skin reflexes. The touch and pain sense in the left arm was absent
as far as the shoulder in typical segmental fashion. Arm movements were
free; there was an occasional tremor in both arms, especially the left.
This tremor would pronouncedly increase upon intentional movements and
with emotion.

He said that about two weeks before, at home, he had waked up in the
night and lain down on the floor beside his bed, feeling giddy in his
head. In a week the tremors had diminished, leaving only a very slight
tremor of the left hand. The patient went to considerable pains to
conceal his tremor, holding his hand in a military position at the seam
of the trousers, on the medical visit. Sometimes he would succeed in
making the tremor quite disappear. February 5, he was busy about the
ward work, going errands and carrying trays. He would intentionally
spare his left hand in this work. Upon trying gymnastic exercises, the
tremors of the left hand and also of the right reappeared. After a few
days these tremors again disappeared, only to come back on the 12th,
when there was a constant tremor also when the patient was at rest. He
had been affected when observing another patient (8[7]). Accordingly,
he was separated from this patient and put in a psychiatric ward. The
tremor remained of varying intensity, sometimes being absent for hours
together.

    [7] See Case 8 of Binswanger’s article.

Request for furlough at the beginning of March was refused with the
statement that it would be granted when cure was complete. The patient
was inaccessible to psychotherapeutic influence. He was always of a
friendly, modest demeanor, sleeping well, and performing all bodily
functions properly. On any exertion the pulse ran to 134. The heart was
normal. There were outbreaks of perspiration.

March 26, he renewed his request for leave, desiring his Easter
furlough. He was told he might expect it. March 31, the tremor was
found to have quite disappeared. Upon his return, April 12, there was
a marked tremor of the left arm, especially of the wrist joint, which
again disappeared after some days. The middle of June he was released
as capable of garrison duty with the recruits.

If there was a mechanical factor in this case, it must have been the
shaking-up of the body by the shell explosion. His skin lesions were
slight. The main factor was doubtless the emotional shock. The tremor
supervened upon a very brief period of unconsciousness. It is hard,
according to Binswanger, to explain the localization of the cutaneous
anesthesia without the development of a corresponding paresis. May it
be, inquires Binswanger, that the wound of the left upper arm at the
moment of the setting-in of unconsciousness, or perhaps at the moment
of waking from unconsciousness, directed the mind forthwith upon the
left arm and in this way produced localized disorder of sensation? If
so, why did the wound of the gluteal region not produce corresponding
disorders of feeling and sensation of an hysterical nature? The
obstinacy of the disease stands in striking disproportion to the
slightness of the causative factors at work.

According to Binswanger, this is perhaps due to the long furlough which
the patient had. According to Binswanger’s experience, as that of many
others, home works badly for these hysterical patients; their friends
sympathize with them too much.

_Re_ furloughs, Ballard states that severe Shell-shock cases should
get analogous treatment to that of civilian psychoneurotics, namely, a
complete removal from the environment in which the illness began. He
advocates three months’ leave, after which the man is to be sent to a
convalescent home, and thence to a command dépôt. He states that if a
relapse then occurs, such a patient will never be a soldier. Ballard
would allow the men to walk about with their “pals (not with escorts).”
Cimbal remarks that German data show that home furloughs should be
avoided in every instance where possible. Fiessinger remarks, on the
basis of English experience, that a Shell-shock patient treated by
rest, suggestion, and manual occupation may go back to the line “and
on a subsequent occasion prove a hero.” (See Case 474 of Gilles.) But
Forsyth remarks that it is probably injudicious to send any cases of
Shell-shock, with few exceptions, back to the firing line, because
their fighting value has been permanently deteriorated, and because, if
the fear of return to the trenches is removed, recovery is more rapid.
The experience here is not unlike that of industrial accident board
cases with rapid recovery after the decree of compensation.


War stress in a volunteer banker: Hysterical seizures. Treatment by
hydrotherapy.

=Case 484.= (HIRSCHFELD, February, 1915.)

A banker, a volunteer (articular rheumatism at three years; at 18, some
form of lung and tracheal inflammation; tendency to fainting spells
on cold days--heart disease was said to have been found), as a result
of the strain and excitement of the war had hysterical attacks during
a fortnight before observation in hospital, consisting of sensations
suddenly developing in the region of the heart, stiffness of the whole
body, disorders of movement, without loss of consciousness.

November 23, 1914, he was examined in bed in the dorsal position,
with the muscles of the legs, back, and neck in a state of tonic
contraction. He was unable to answer questions. The pupil reactions
were normal in the seizure. The attack ceased in two minutes, as the
result of hitting heavy blows on the chest with a moist handkerchief
and the threat of a strong and painful application of the electric
current. The patient then got out of bed at request, walked about a
little incoördinately for a time, but after a few minutes was able to
walk perfectly and to talk once more.

Examined, November 25, he was found to be pale, fairly well nourished,
with a somewhat accelerated pulse, and a melancholy, slightly apathetic
expression. A systolic murmur at the right apex; accentuation of
secondary pulmonary sound; increased knee-jerks; trembling of the lids
(Rosenbach).

By December 12, the patient was completely well. The seizures had not
recurred. The treatment was by hydrotherapy. A preliminary treatment
is advocated by Hirschfeld, to insure peripheral circulation, either
by light baths, hot douches, or packs. More important than this
preliminary treatment is the cooling off process by means of tepid
douches or partial baths. These partial baths are given at 28°C. for
the intense effect of the cold. Sometimes this treatment can be
concluded with a dry pack. The patients are treated by Hirschfeld three
times a week with both the warming and the cooling procedure.

_Re_ hydrotherapy, Mott has found the continuous warm bath of great
value in Shell-shock cases coming back from France. He keeps the
patient in the water from a quarter to three-quarters of an hour, or
longer. A warm bath and a drink of warm milk at bedtime may permit a
man to get on without hypnotics, or to get on with lesser amounts of
hypnotics. The effect of these baths is doubtless largely somatic.
Some writers stress the suggestive value of hydrotherapy as well
as of electricity, radiant heat baths, and the like (Ballard). A
neuropsychiatric center properly equipped with a hydrotherapeutic
plant can do therapeutic work by means of the suggestion afforded by
a cold shower, which may act quasi miraculously, like electricity
(Roussy and Boisseau). In fatigue and exhaustion cases, along with
adrenalin and strychnin, Aimé gives mild hydrotherapy without other
sedatives. Laehr’s free sanatorium at Schönow treats the arrhythmia and
tachycardia cases with rest and hydrotherapy.

Brasch reports rather poor results with hydrotherapy in the cardiac
neuroses. Weichardt has used the continuous bath as a form of
psychotherapy and permits the symptoms of psychoneurosis to subside
therein.


Shell-shock: low blood pressure: Pituitrin.

=Case 485.= (GREEN, September, 1917.)

A lance corporal of the Expeditionary Force, 26, went to France feeling
very fit, February, 1916. He was blown up by a shell July 1, and
faintly remembered crawling out of some water. He came to in a dugout,
dumb and partially deaf, and was blind for a few minutes. August 17, he
was admitted to Mott’s wards at Maudsley, mute but with hearing normal.
The hands were dusky, sweating, cold, and slightly tremulous. He was
given to battle dreams and used to wake in a sweat and terror after
a pantomime of bomb-throwing. He had headache and was depressed. He
complained of feeling cold and the surface temperature was subnormal.
The blood pressure was also subnormal (according to Green, nightmares
are most marked in cases with low blood pressure; these are, in fact,
severer cases of Shell-shock than cases with high blood pressure; only
10 of 27 cases with blood pressure above 120 showed nightmares).

September 25, he was able to speak in a whisper. The dreams had become
less terrifying. The other symptoms had been slowly improving.

November 25-28, all of the symptoms returned upon hearing the death of
his brother in action.

The man was now put on extract of pituitrin gr. 2, t.d.s. (better
results are claimed by Green from pituitrin extract than from
pituitary fluid injections, as these sometimes cause dizziness, of
which no case treated with extract complained). As in other cases, the
extract was immediately followed by an increase in blood pressure, a
general improvement and a diminution of headache and depression. The
bomb-throwing pantomimes still persisted, but the patient was less weak
on waking. The treatment was continued for seven days, whereupon the
surface temperature began to rise and the patient himself felt that
he was much warmer. The pituitrin was discontinued after a month’s
treatment, yet the improvement persisted. The man was boarded out of
the army and in March, 1917, wrote that he was still feeling better.

    SHELL-SHOCK, PITUITRIN, AND BLOOD PRESSURE (EDITH GREEN)

    [Illustration: Blood pressure, surface temperature, and pulse
    in a case of functional mutism. (a) On admission, troubled by
    nightmare. (b) Able to speak in a whisper. (c) Much depressed
    after bad news. (d) Put on pituitrin. (e) Marked general
    improvement. (f) Taken off pituitrin.]

    [Illustration: A-1 Showing the effect of pituitrin on the
    blood pressure and surface temperature. Each dot is one week’s
    interval. + is the pressure when the first dose was given. 𐌈 is
    the point at which the pituitrin was discontinued.]


Various treatments of a contracture of hand.

=Case 486.= (DUVERNAY, November, 1915.)

A chasseur, 22, received a bullet wound in the anatomical snuffbox,
the bullet emerging under the styloid process of the radius, having
traversed the back of the hand without striking bone. Healing was
rapid, but the hand assumed a peculiar position. The second and third
phalanges of the fingers were extended, whereas the first phalanx was
flexed. The four fingers were as if glued together. Both phalanges of
the thumb were flexed, the wrist was in extension, and the tendon of
the palmaris seemed contractured. The fingers could not be moved and
the wrist was very mobile. There was pain on attempts to move the hand
passively, and small clonic contractions were made by the fingers.
There were no sensory disorders, but there was a maceration of the
interdigital spaces.

Mechanotherapy accelerated the contracture, and massage, motor
reëducation, bromides, and sedative drugs, had no effect. Under
kelene-anesthesia the contracture would disappear. In January,
1915, the hand was put up in plaster in a position opposite to the
contracture. The intense pain of the first days was treated by opium.
The patient was sent on leave, and, at the end of two months, the
plaster was removed; but the hand at once resumed its faulty position,
and attempts to alter its position again provoked pain. Elastic
traction was then tried for six weeks, and the bad position was
somewhat modified but not improved by hyperextending the second phalanx
on the first, and putting the third in slight flexion on the second.
Hot compresses were unsuccessful also. May 14, 1915, the position was
still irreducible; there was no R. D. or electrical hyperexcitability.
This was not a question of radial paralysis, since finger extension was
distinct; nor a paralysis of the median, since the thumb was flexed.
The contracture, in fact, does not affect a special nerve territory,
and the disorder is in the ulnar, radial, and median territories.


Orthopedic case.

=Case 487.= (SOLLIER, November, 1916.)

A patient suffered from a rupture of the peroneal nerve in its lower
part, September, 1915, and had operation scars before and behind the
external malleolus. He was immobilized for 45 days at first, and then
for 30 days, with the foot in extension on account of the pain produced
in the endeavor to put it into normal position. A 6 cm. atrophy was
then found to affect the calf, and there was a fibrous retraction of
the tendo Achillis and of the calf muscles. There was no anesthesia,
the toes moved easily, the foot was fixed in equinus, with about 7
cm. of the heel above the ground. He was placed in various orthopedic
institutions and was treated with mechanotherapy, but without result.

At the neurological center, however, in six weeks, he was got to
walk, with his heel on the ground, by means of massage and manual
mobilization. The atrophy diminished a centimeter and the foot became
mobile in all directions.

According to Sollier, mechanotherapy by means of apparatus is apt to
be ineffective, especially in contractures, because its action ceases
the moment it ought to commence, namely, when the patient is beginning
to react a little painfully after recovery from anesthesia. In cases
of retraction, mechanotherapy with apparatus does not allow the proper
combination of massage with progressive mobilization.

_Re_ orthopedic cases, Jones classes the conditions that create an
orthopedic case under four heads (note especially the fourth):

1. Mechanical injury to bone, joint, muscle, or nerve.

2. Atrophy and disease of these structures primarily due to the injury.

3. Incoördination of movement due to disease of the brain--a result of
atrophy and disease of peripheral structures.

4. Psychological conditions which can be overcome by reëducational
processes.

    MECHANOTHERAPY (COLOLIAN)

    [Illustration: ROTATION OF SHOULDER]

    [Illustration: ROTATION OF SHOULDER]

    [Illustration: ANKLE EXTENSION]

    [Illustration: ANKLE EXTENSION]

    [Illustration: FLEXION AND EXTENSION]

    [Illustration: ROTATION OF HIP]

    [Illustration: ELBOW FLEXION AND EXTENSION]

    [Illustration: CIRCUMDUCTION OF THIGH]


Favorable effects of lumbar puncture.

=Case 488.= (RAVAUT, August, 1915.)

An accountant, 20, in the 135th infantry sustained shock from mine
explosion near his trench, March 6. He was kept two days at the relief
station. March 8, at the ambulance, he did not appear to understand
questions and had a fixed stare. He complained of a violent headache
and kept pressing his head between his hands. He kept looking about him
anxiously, and the slightest noise made him jump. He would mutter a
few incomprehensible words, and in reply to a question would give only
the last phrase which he happened to have been saying. Lumbar puncture
showed a very slight excess of albumin. Next day, he answered his name.
March 12, he could speak in monosyllables, and he began to understand
what was said. After the lumbar puncture, the headache disappeared and
did not set in again. March 13, he began to be able to write and say
short phrases. March 16, expression was good though hesitant, and the
patient wrote a letter to his parents, telling about his shock. Lumbar
puncture showed that the albumin was now normal. From the rear, April
5, the patient sent Ravaut a postcard in perfect form, telling how he
was ready to go back to the front.

_Re_ lumbar puncture, Imboden quotes Podmanizky as having used lumbar
puncture as a method of suggestion for the cure of abasia. See also
cases 560 and 561, in which Claude cured two cases of dysbasia by
the device of stovaine anesthesia of the spinal cord. Pastine also
has a case in which a slight improvement was produced on removal of
cerebrospinal fluid, and a sudden and complete cure was brought about
by the second puncture, a very painful tap. Pastine’s case is thought
by him (1916) to be in part at least organic.


Bullet wound of forearm: Hysterical clenching of fist. Recovery by
fatiguing the flexors.

=Case 489.= (REEVE, September, 1917.)

A soldier, 28, was thrice wounded between August 18, 1914, and July 14,
1916. The third time, a bullet passed through the fleshy part of the
forearm, whereupon the hand became clenched and remained so after the
wound was surgically healed. As a case of war neurosis, the man was
treated by electricity, massage, passive movements, and fixation in a
straight splint during a period of nine months, without result. He was
admitted to Maghull Military Hospital, April 18, 1917.

Two days after admission a treatment was given whose principle consists
in producing a condition of fatigue in the muscles responsible for
contracture. This fatigue is produced by continuous passive movements
in a direction opposed to the normal action of the muscles in question.
Many hours of forcible movement are sometimes necessary in the case of
the more powerful muscles before the limp, toneless fatigue condition
is brought about. Relays of men are told off for this purpose. Patients
are got to assist in the work, particularly such as have been cured by
the treatment. Also, the patient is himself told about the nature of
spasms and the relief which the method will bring. This patient was
told that after the flexor muscles were fatigued they would no longer
be able to pull the fingers into the clenched position, whereupon the
antagonistic muscles on the back of the forearm would begin to work.

The fingers were forcibly opened without interruption for six hours,
in each case as soon as the fingers closed into the palm. In a few
hours they began to return more slowly, and at the end of the six hours
remained extended. The extended position was still found the following
morning. The extensor muscles were feeble in action, but improved day
by day. The spasm did not return. The patient was discharged July 2,
1917, about two and a half months after admission to Maghull. The hand
was now strong and useful.


Bullet through shoulder girdle: Hysterical adduction of arm. Treatment
by induced fatigue.

=Case 490.= (REEVE, September, 1917.)

A man, 29, was in hospital more than two years before the Reeve fatigue
treatment was applied to a functional contracture. This man had a
bullet pass through the right scapula and out the pectoralis major,
June 4, 1915, was (according to patient’s story) operated two months
later, then further operated for drainage of septic wounds, and from
August, 1915, had his arm fixed to the side, going into spasm at any
attempt to move it passively. The elbow was extended and at first the
fingers were tightly flexed and wrist extended. The finger flexion and
wrist flexion cleared in March, 1917, and recurred in May. Electrical
massage in June, 1917, yielded free movement, but the spasm returned.

The man was admitted to Maghull, June 12, 1917, that is, a little over
two years after his injury. The arm sprang back to the side like a
clasp knife on being released. The wrist and fingers were moved freely.
Three days after admission the elbow was forcibly flexed for some
hours, whereupon the spasm disappeared. Next day the arm was forcibly
abducted and reabducted: for four or five hours the arm could be
voluntarily abducted. Two assistants were necessary, such was the force
of the adductor contraction. At the end of a week the patient was found
able to lift his hand to the back of his head. There was no longer
spasm.

_Re_ abrupt treatments, amongst which Reeve’s treatment by induced
fatigue may be counted, Babinski and Froment consider that abrupt
treatment is far superior to slower psychotherapy combined with
isolation, whether or not we are dealing with a recent or an old
disease. So far as psychotherapy goes, Babinski wants to obtain
a definite improvement, if not a cure, on the first application
of treatment. According to Babinski, the patient’s faith in his
physician’s power to cure him is most active at this first meeting,
whose emotionality favors the cure.


Burial and bruises of back: Hysterical cross-legs. Treatment by induced
fatigue of contractured muscles.

=Case 491.= (REEVE, September, 1917.)

A man, 32, was buried by a shell and bruised about the back, August 2,
1916. He was bedfast until February, 1917. Every attempt to move the
legs brought on tremors. He was then allowed up; but the attempt to
walk caused one foot to knock the other, and his ankles became bruised,
necessitating cotton wool pads for feet.

He was admitted to Maghull, June 12, with one leg crossed over the
other and the thigh adductors spastic, especially on the right.

The fatigue treatment was carried out in dorsal decubitus, each leg
being pulled by a man, and the separation repeated when necessary. Four
hours a day for three days of this work finally reduced the spasm so
that the patient was able to walk with assistance. On the sixth day he
walked a mile without assistance. The spasm has not returned.

_Re_ leg contractures, Bérard got successful results by continuous
extension combined with injections of 1 per cent novocain into the
sciatic nerve trunk and the contractured muscles. According to Babinski
and Froment, there ought to be an almost certain cure of any genuine
hysterical state. They quote the observations of Souques, Meige, Albert
Charpentier, Clovis Vincent, Roussy, and Léri as proving this claim.

The Reeve method, so far as it is psychotherapeutic, bears a
resemblance to Clovis Vincent’s first stage of what the poilu calls
_torpillage_, namely, the stage of crisis and of intensive reëducation.
But Clovis Vincent uses in his direct and forcible reëducation the
galvanic current.


Bullet wound of neck: Hysterical torticollis. Treatment by induced
fatigue.

=Case 492.= (REEVE, September, 1917.)

A soldier, 20, had a bullet pass through the back of the neck, July 10,
1916, and returned to his dépôt surgically well October 1. A fortnight
later a Zeppelin raid turned his troop out in the middle of the night,
and on the morrow the man’s neck was twisted around and inclined upon
the left shoulder.

Treatment followed in various hospitals, with fixation in the corrected
position by plaster of Paris but without result. The patient was
admitted to Maghull, April 18, 1917, with spasm of left trapezius and
right sternomastoid muscles. Under hypnosis the deformity could be
easily corrected. Unfortunately, it returned.

The fatigue treatment described by Reeve was started a week after
admission to Maghull. The neck was forcibly straightened and
restraightened upon return to its twist. In a few hours the contracting
muscles had become fatigued; the neck was straight.

The next day the deformity returned slightly. The fatigue treatment was
repeated. The patient was discharged well, July 2.


Burial by shell explosion: Abasia, tremors. Claw foot persistent two
years cured by induced fatigue.

=Case 493.= (REEVE, September, 1917.)

A man, 24, buried by a shell, February, 1915, had had a functional
“claw foot” for more than two years, cured by the Reeve fatigue
treatment in less than a week. According to Reeve, claw foot is perhaps
the most common of the war contractures, particularly intractable, and
often seen out of hospital with an “inside splint.”

After his burial this man could not walk, had tremors, was in bed for
four months and on getting up showed strongly inverted foot. Three
months’ splint treatment, strong faradic currents, massage, passive
movements, special boots with leather wedges to tilt the foot over,
were methods of treatment tried, but unsuccessful. At Maghull from
November 18, 1916, he was treated by exercises, passive movements,
suggestive and reëducative measures, and after a few months got about
without sticks.

The claw foot continued. Toward the end of June, 1917, the feet were
forcibly flexed and everted for eight hours. The deformity disappeared,
but returned slightly next day. Further fatigue treatment for eight
hours caused the spasm to cease permanently. He was discharged quite
normal, July 20, 1917. Reeve remarks that this fatigue method might be
applicable to certain hysterical contractures in civil practice.


Skull trauma over right eye: Delirium, febrile? post-traumatic?
exhaustive? Operation: Epileptiform excitement. Later, explosive
diathesis: Operation: Euphoria. Seizures and slight mental change.

=Case 494.= (BINSWANGER, October, 1917.)

A soldier (brother choreic, sister infantile palsy) had had measles
at 13 and in his fever climbed out of bed upon a couch, fell from
the couch and was found by his mother lying on the floor. He was of
moderate intellectual grade, of an emotional, passionate Saxon nature
and had now and then been intoxicated.

In September, 1914, he was wounded over the right eye. He did not lose
consciousness but concluded that he could not get back to his own lines
on account of the enemy fire. Using a knapsack to cover his head, he
lay down for twenty-four hours, until rescued by a passing body of the
sanitary corps who were about to leave him for dead when he called
loudly to them.

He was very weak in hospital and, towards the evening of the day after
receiving his injury, he must have fallen into some sort of psychotic
state lasting ten days. For this he remained quite amnestic, although
he was told by comrades that he had hallucinations and had scolded and
yelled, hearing voices. Apparently there were situation-deliria--the
call to go over the top. Temperature, which had run to 38.8, after ten
days sank to normal, and consciousness cleared up.

Was this a case of protracted febrile delirium? Or of psychosis due
to _commotio cerebri_, that is, an effect of heightened intracranial
pressure? Or was it exhaustion-delirium following loss of blood, sleep
and food?

But this was not the end. The wound suppurated, and in May, 1915,
eight months after the injury, operation was performed to relieve this
abscess. Temperature immediately rose to from 38.4 to 38.6, the fever
lasting three days, and a second psychotic phase with complete amnesia
entered. He went into this phase immediately after recovering from
the operative narcosis, looking wildly about and cursing the sister.
The patient was violently excited and was put in a straight jacket
on the second day. This phase may be regarded as one of epileptiform
excitement with delirium. The operation may have played a part in the
psychosis.

There were no further psychotic phenomena which could be attributed
in any way to _commotio_. There were, however, attacks of cortical
origin and emotional seizures. The patient became emotionally excitable
and lost all inhibitions against expression of emotion, such as
crying. Once he actually tried to suppress his emotion with a noose
about his throat. He became seclusive and withdrew within himself--a
victim of Kaplan’s explosive diathesis, or of Bonhoeffer’s emotional
hyperesthetic defect condition.

A second operation was performed in September, 1916, to loosen the
brain scar, and a large splinter of bone was removed. During the
operation, under local anesthesia, there was a severe cortical
seizure with complete disappearance of the reflexes. Ether was then
administered. Later, in the same day, there were several minor cortical
attacks.

After this operation the man’s emotional status changed; he was no
longer irritable or exclusive, but became slightly euphoric and
contented. He received during the next two weeks four tablets of
Sedobrol and for a long time thereafter two tablets daily. There were
never any phenomena of bromidism or any suggestive effects of the
bromides.

The first attack after the second operation came in November, 1916, and
was followed by slight dysarthria. Repeated attacks followed which were
attributed to contractions in the scar. Accordingly, a third operation
was performed and an attempt was made to bridge over a defect in the
right frontal bone. The man’s emotional status remained good after the
operation, but further attacks appeared six weeks later and there were
spells of dizziness. Occasionally, in process of thinking, he said
something stuck in between his thoughts. Sometimes thinking broke off
sharply as if he had cut through a wire with an electrical current in
it. There was a slight reduction in attention and a slightly increased
fatiguability.


Hard service; shell explosion with loss of teeth: Vomiting. Cure by
restoration of self-confidence.

=Case 495.= (MCDOWELL, January, 1917.)

A married reservist was called up at the outbreak of the war and went
through Mons, the Marne, and the Aisne and was finally blown up by a
shell at Ypres. Early in November, 1914, he lost his speech but got
it back in time to get home for Christmas. A number of teeth had been
lost in the injury. Vomiting began first in England. While on leave at
home he vomited at every meal. Asked whether it was his food or his
thoughts, he said, “You are quite correct, Sir, you know I have always
been with thinking.”

Under medical care, June, 1915, he was found suffering from hesitating
speech, general tremulousness and emotionality. He worried a great deal
on account of money matters at home. He lay awake thinking. A child
became ill and died, and all the while he got worse, “thinking all the
time.”

It was explained to him that the vomiting was a matter of emotions. The
lost teeth were replaced by false ones. As he began to get control of
his emotions, he vomited less and increased in weight. Finally he was
boarded for discharge and was sick again on the day of the meeting. A
fortnight later when sent to sign discharge papers he vomited once more.

According to McDowell, the vagus may possibly be incriminated as a
cause of these gastric disturbances. Practically, the vomiting is a
result of emotional stress. The cure is to produce insight on the
part of the patient, the removal of worry and the restoration of
self-confidence.

Michell Clarke cured such cases with milk diet.

Roussy and Lhermitte find hysterical vomiting to be relatively common
and as a rule without difficulty in diagnosis; but they remark that
there is often some underlying organic condition to be sought for and
treated after the neuropathic element has vanished. They remark, also,
that there is no tendency to spontaneous cure of the disease. They
advocate a strict dietetic régime and psychotherapy.


Cure of self-accusatory (“started retreat from Mons”) and other
delusions by “autognosis.”

=Case 496.= (BROWN, January, 1916.)

Capt. William Brown, in the discussion at the Section of Psychiatry of
the Royal Society of Medicine, January 25, 1916, speaks of a method of
treatment which he calls _autognosis_--a method of giving the patient
self-knowledge, by revealing to the patient through his own confessions
the cause of mental change leading to his symptoms. One of Brown’s
examples is that of a sergeant in the firing-line during the retreat
from Mons. He was admitted to Maghull with the delusion that people
thought he had given the signal for the retreat from Mons on a silver
whistle, a shooting prize of his. German officers used silver whistles
that made a note like his own. In fact, he had other like delusions,
such as that people thought him responsible for an Edinburgh railroad
accident in connection with his troop-train. A German spy might have
heard this.

In the process of procuring autognosis, Capt. Brown found that at the
age of 12 this man had been falsely accused of stealing pork pies from
a shop, and had been brought before a magistrate. In point of fact, he
proved an alibi, but he was greatly worried by the charge. According to
Capt. Brown, this incident of the insistence of the false accusation
was the beginning of his tendency to delusions. In two months’ time
there was a remarkable improvement.

_Re_ psychoanalysis, autognosis and various modifications, Forsyth
remarks that when the acute stage is passed, the Shell-shock case
becomes an everyday neurosis in which war experiences are merely the
latest phases in the patient’s life, and that psychoanalysis may then
become necessary. Eder regards the “mechanisms” of what he terms “war
shock” as the Freudian mechanisms of hysteria, and has commended
psychoanalysis for a few cases, preferring hypnotism for acute
cases. Adrian and Yealland decry psychoanalysis on the score of time
limitations.


Deafmutism in three men shell-shocked at one time.

=Cases 497, 498, 499.= (ROUSSY, April, 1915.)

There were three Zouaves in a first-line trench north of Arras, January
14, 1915, who were blown up by a bomb thrown from the enemy trench
some hundreds of meters away, by a mortar, a _crapouillaud_. This
projectile burst with a great noise, louder than that of a bomb, and
made a very strong windage. A dozen men were blown under the trench
wall, just after entering the trench; two were killed; and the others,
most of whom had been buried to the neck, were pulled out and carried,
trembling, to the nearest relief post. Two of the three Zouaves were
bleeding at nose and ears, and all three were absolutely deaf and
mute. Evacuated to an ambulance, and thence to Paris, they arrived at
Val-de-Grâce, January 17, that is to say, three days after the shell
burst. They communicated with the attendants by signs; one got hold
of paper and wrote several hours in the day rapid notes about the
accident. However, hysteria or pure simulation was suspected in these
three Zouaves, and they were placed in small separate rooms. They
were informed through the physician’s remarks to his staff that these
were cases of nothing but simple nervous shock such as we had often
observed, and the claim was made that they would be completely well
either on the morrow or the day after.

On the morrow, two of them partially recovered hearing and got back
their voices. They became loquacious and began to tell about the
battle. The day after, the third patient began to speak. Two of them
showed traces of auricular hemorrhage, and in fact, actual ear lesions
were found in all three. One had a suppurative right middle ear, with
perforation; another had both drums perforated and a suppurative middle
ear, also on both sides. The third, who recovered his speech after the
others, had perforation of the left tympanum with a little suppuration
of the right ear tympanum and a slight tear of the right tympanum. In
April, 1915, the hearing was cured.

These men had been under fire several months, and had taken part in the
battle of the Marne. It was not a question of their first baptism of
fire, and in fact, each of them had been previously wounded. According
to Roussy, the story is, that the shell-burst produces by displacement
of air tympanic perforation, and at the same time a violent nerve
shock with loss of consciousness for a few minutes. The men come to,
but the ear lesion, probably exaggerated by the nervous status of its
bearer, creates a complete bilateral deafness. This deafness produces
an absolute hysterical mutism.

_Re_ case groups of war neurosis, several writers speak of dangers
of contagion, but also emphasize the values of contact of patients
with one another in the securing of therapeutic results. What
Mott has termed the _atmosphere of cure_ was no doubt present in
the three instances of Roussy just cited. The cure of one may act
heterosuggestively to produce the cure of a second, and so on.
Functional deafmutes are somewhat refractory as a rule. H. Campbell
states that there is some danger attached to allowing large numbers
of functional cases to consort together too closely. He suggests
making use of small wards and screens, and a process of sorting out
patients so that they shall not affect one another injuriously. Steiner
especially stresses the value of individual rooms in preventing psychic
infection, of which, he says, the danger is large in open dormitories.
The psychic contagion is as a rule that of hysterical seizures and
tremors; but complaints about faulty hospital arrangements are also
readily spread. Steiner advocates never questioning a nervous patient
concerning his troubles in the presence of other soldiers. To reach 60
to 70 patients, Steiner had one examining and treatment room. Roussy’s
institution at Salins in 1917 had a service limited to traumatic
hysteria, from which, in three months’ time, 200 subjects had been
discharged cured (see Boschi).


Dysentery: Milk diet persisted in: Vomiting, incontinence, inability to
walk. Cure by persuasion.

=Case 500.= (MCDOWELL, December, 1916.)

A soldier, 25, a low menial when war broke out, developed “dysentery
and gastritis” at the Dardanelles, although even before the dysentery
his nerves had gone bad. He had diarrhoea and vomiting, was sick every
day, found himself unable to walk, and found himself always wet with
urine dribbling day and night. Arriving in England and treated in a
hospital, he still had vomiting. He had lived on milk and custard and
been kept in bed.

Capt. McDowell convinced the patient that his legs were not as weak as
he supposed. He was encouraged to walk, put upon light diet and then
upon ordinary diet. He became an active worker in the ward, later going
for five-mile route marches. Two months later he went back to duty
in good health, weighing seven pounds more than before. This man was
weakminded and, when his dysentery was cured, did not dare to start
eating ordinary food. He was a victim of hospital régime. Individual
attention would have obviated much of the subsequent state.

_Re_ vomiting, see remarks under another case of McDowell (Case 495).

_Re_ incontinence, see Case 384, of Guillain and Barré.


Officer dies in convulsions: Servant develops hysterical convulsions,
which vanish on being explained as such.

=Case 501.= (HURST, March, 1917.)

An officer and his servant were blown up by a shell. The servant ran to
fetch a stretcher for the officer, to whom he was much attached, but
on his return the officer made a few convulsive movements and died.
Immediately after, the servant had a fit. During the next two months he
had eleven more. Hurst made a diagnosis of hysterical fits resulting
from emotion, explained his idea of their origin and nature to the
servant, and the convulsions then ceased completely.

_Re_ hysterical convulsions, see remarks under Case 443.


Course of a case with crises of trembling.

=Case 502.= (ROUSSY, April, 1915.)

A soldier in the artillery, who had been in the lines from August
as a kitchenman, looking after the food of the first line trenches,
with which his shelter was connected by communication trenches, 800
meters away, was on January 17, 1915, with three other men placed in
the shelter kitchen of the trenches but a short distance away from
the French artillery. The firing passed over the heads of these men
but they could feel the windage, which obliged them to lie down each
time. The evening of that day, several hours after firing had ceased,
the kitchenman had a shivering spell, with trembling that lasted all
night; after which these crises came on every day. He had finally to be
evacuated to the rear.

According to Roussy, such patients always have neuropathic taint and
a history of previous crises. Such a patient ought to be handled
with rather severe discipline. In this way, according to Roussy, the
reappearance of a severe attack of convulsions can be prevented. But
these patients cannot go back to the front.

_Re_ tremors, see Cases 224 and 225.


Two cases of lameness cured by persuasion: Russel.

=Case 503.= (RUSSEL, August, 1917.)

A man on crutches, paralyzed completely in the right leg, partially
in the left, developed paralysis in the right arm from the use of the
crutch. There were marked vasomotor changes in the right leg and arm
together with anesthesia to pinprick. Assured that he could move the
legs perfectly he said that he had tried and failed. After a persuasive
talk in private he began to use the arm, and to walk perfectly. It
seems that in the trenches he had a sharp pain in the right knee, after
which he did not use the leg and it gradually became more and more
useless. It had been paralyzed for three months. The reason he did not
use this leg was not on his own account, but on account of his mother
at home. He seemed really grateful for the cure.


=Case 504.= (RUSSEL, August, 1917.)

A sergeant in hospital for a year for shell-shock still had a marked
shaking of the right leg whenever he raised it from the ground. He
walked in leaning on a silver headed cane. The functional nature of
his shaking was explained to him by Russel, whereupon he walked out
normally saying he could do without his cane. Russel suggested that
crutches and sticks thus given up were often donated to the shrine. The
sergeant whose cane must have cost at least three pounds beat a hasty
retreat carrying the cane in front of him.

_Re_ Russel’s general point of view concerning malingerers and
psychogenic cases, see under Case 458.


Hard patrol work: Delirium; head tremor augmented by excitement:
Virtual recovery on bandaging neck, isolation, open air, to-and-fro
transfers to mental and nervous wards.

=Case 505.= (BINSWANGER, July, 1915.)

A metal moulder in civil life, 29, in military service 1907 to 1909 (no
hereditary taint, moderately good scholar), became unconscious for a
half hour after taking a cold drink following a somewhat long practice
march, at some time during his first year of military service.

He was in several skirmishes in Belgium and Northern France early in
the war, being once surrounded in patrol work (November 11) by Turcoes
and Zouaves. There was a lively exchange of shots, in the course of
which five of the eight men on patrol fell. The three survivors hid
themselves for three days in a quarry, and on the fourth were found by
the advancing troops, and immediately went into battle.

But during a pause while on the point of taking coffee, the man
suddenly fell sick, tried to carry on, but lost consciousness and
apparently remained unconscious for about three-quarters of an hour. It
seems that he raved and shouted and tried to bite his fingers, being
held with great difficulty by several comrades. He was removed to a
dressing-station three km. distant.

At the dressing-station, his head began to shake, although he was
unaware of this until his attention was called to it by his comrades.
He said that he felt restless and that his head ached almost
continually. He was carried to the reserve hospital, and from thence,
December 9, 1914, to the nerve hospital at Jena, where he was unaware
of the shaking of his head (which had now lasted for three weeks),
and said that he felt a thick fog in his head (to say nothing of
headaches), and was only free and clear in his head while standing in
the open air.

His sleep was restless and poor; there were war dreams almost every
night. In the process of getting to sleep, his arms and legs frequently
twitched. He would soon tire and feel weak. Also since his dangerous
experience, he had noticed a change in his speech: always fluent
before, it was now hard for him to speak because one had to exert one’s
head so much in speaking.

This head tremor was in fact the most marked symptom of his illness. It
would increase on every active motion of the head, but ceased almost
entirely when attention was diverted. The head would then be held bent
to the right.

During emotional excitement, the shaking spasm would spread over the
entire upper part of the body, but would remain more severe upon the
right than upon the left side. The forearms would fall into a lively
shaking movement of pronation and supination. The hands and fingers
would be attacked by a less marked tremor. After calm had set in,
a fine tremor of the right hand would remain plainly noticeable.
The musculature of facial expression would frequently fall into
spasmodic movement, the left corner of the mouth twitching, the lips
set for whistling, or the upper lip making movements as if snuffing
spasmodically.

Physically the man was of medium height, strongly built, with adherent
lobules, and a somewhat pointed skull. The teeth were defective and
irregularly placed. Both deep and skin reflexes were increased. Marked
dermatographia and mechanical excitability of the muscles: periosteal
reflexes strongly developed; numerous pressure points in the head.
The right temple and back of the head were painful on percussion.
The patient showed no disturbance in touch and pain sensibility.
Outstretched tongue showed marked fibrillary twitching; speech was
difficult, being slow, awkward, stumbling, and sometimes hesitating
(suggesting the speech of general paresis). At other times, the speech
was of a peculiar sighing, tremulous nature, reminding one of the
speech of children complaining or asking for pity. Rest was secured
by injections of salt solution. A few days later, the treatment was
continued by a bandage about the neck. After this the tremor grew
slighter and would even remain absent for some hours. The patient
was told to rest in bed and not to speak much; being “seriously ill,”
he was kept alone. He was often irritated, querulous, and subject to
outbursts of profanity. He took food well and slept well, receiving
sodium bicarbonate.

The bandage was changed after five days. The tremor was very marked.
The patient was furious because visitors were refused to him. He
was especially angry with his nearest relatives and his betrothed,
and wrote defiant letters to all of them. He became one of the most
troublesome patients in the psychiatric division of the hospital. He
complained sometimes of anxiety and feelings of unrest. He received
treatment by pantopon. He continued to be a very disagreeable patient,
feeling himself opposed and not properly considered. He thought himself
seriously ill, behaved much like a spoiled child, and was of the
opinion that he would not get well in the hospital because they were
grieving him so. His appetite became bad; he complained of pains in the
loins and of rheumatism in the legs. A cord was found hidden in the
bed. The patient expressed suicidal thoughts at various times.

At the beginning of January there was marked improvement. The
headshaking ceased almost entirely; the patient walked in the garden
some hours daily. However, in the middle of January, on refusal of
furlough, the head-shaking began again markedly. At his request
a bandage was placed on the head again for a few days. He seemed
emotionally very tender; his head would shake at the sight of a dead
rabbit.

He was transferred to the nerve division of the psychiatric clinic at
the end of January. He had recently begun to complain of flickering
before the eyes. The ophthalmologists established an existence of a
choroiditis disseminata. The eye examination had a markedly depressing
effect upon the patient, and the shaking spasm of the head appeared
again. Upon being told that he would have to be sent back to the
psychiatric section of the clinic, the shaking immediately disappeared
(24 hours after it had begun).

Thereafter slow improvement followed. He stayed in the open a great
deal and walked. March 2, he showed a vehement outburst of anger,
quarreling and using violence with a comrade. He was brought back to
the psychiatric section, and in transit had a severe hysterical attack
with unconsciousness, crying fits, and stepping movements of the
extremities. He was promptly taken to a section for those seriously
ill. The next day, upon his assurance that he could control himself, he
was put in a more quiet division. He began to take part in gymnastic
exercises, worked as a coachman, and then as an experiment was sent to
a gentleman’s estate for recreation. At last accounts he was feeling
well except that he occasionally had headaches during work. He could
not work so hard as before on account of the rapid onset of fatigue,
especially when working in the sun. The head-shaking recurred but
seldom and lasted for a few hours only when the patient became angry or
when there was much noise about.


Rationalization of war memories: Returned to duty.

=Case 506.= (RIVERS, February, 1918.)

A young English officer was wounded just as he was extricating himself
from burial in a mass of earth. He became nervous and sleepless and
lost his appetite. After the wound had healed, he was sent home on
leave, which had to be extended as he got worse. An out-patient in
London for a time, he was finally sent to a convalescent home, still
troubled with insomnia, battle dreams and concern about his recovery.
He made light of his condition and was on the point of being returned
to duty by the medical board, when his sleeplessness led to his being
sent to Craighlochart War Hospital.

He could not sleep without a light in the room, else every sound
attracted his attention. He tried hard all day long to banish all
unpleasant and disturbing thoughts, but at night it took him a long
time to get to sleep and then came vivid dreams of warfare. He did not,
himself, feel that he could ever forget the war scenes.

Rivers, in general believing that the attempt to banish such
experiences absolutely from the mind is poor psychotherapy, narrated
his views to the patient. Rivers advised him no longer to try to
banish the memories, but to try to transform them into tolerable,
if not pleasant, companions. The war experiences and anxieties were
talked over. That night the man had the best night he had had for five
months, and during the following week the sleeplessness was no longer
so painful and distressing. If unpleasant thoughts came, they had to
do rather with home life than with the war. General health improved;
insomnia diminished. He was at last able to return to duty.


Rationalization of war memories.

=Case 507.= (RIVERS, February, 1918.)

An English officer was buried by shell explosion and developed severe
headache, vomiting and disorder of micturition, yet remained on duty
for more than two months. Collapse came when he went out to seek a
fellow officer and found the body blown to pieces, with head and limbs
severed from the trunk. This vision haunted him in dreams. Sometimes
the officer appeared as on the battlefield; again as leprous. The
officer would come nearer and nearer in the dream, until the patient
woke pouring with sweat and in utmost terror. Accordingly, he was
afraid to go to sleep, and spent all day thinking painfully about the
night to come. Advice to keep all thoughts of war out of mind merely
brought the memories in sleep upon him with redoubled force and horror.

Rivers’ therapy was to draw attention to the fact that the terrible
mangling proved conclusively that the officer had been killed outright
and without pain. The officer said he would now no longer attempt to
banish the thoughts and memories of his friend, but would concentrate
on the pain and suffering his friend had been spared. No dreams at all
came for several nights, but one night in his dream he went out into
No-Man’s-Land and saw the mangled body, but without horror. He knelt
down, as he had in the original experience, and woke as he was taking
off the Sam Browne belt to send to the relatives. A few nights later
came another dream in which he talked with his friend. There was but
one more dream in which horror occurred.


Rationalization of war memories: Eventually unfitted for military
service.

=Case 508.= (RIVERS, February, 1918.)

A young English officer, after doing well for a period, was rendered
unconscious by shell explosion. The first thing he remembered was being
led by his servant towards his base, thoroughly broken down. He had
headaches, sleeplessness, war dreams and spells of terrible depression
appearing with absolute suddenness, unlike ordinary “blues.” For ten
days in hospital no such attack appeared, but one evening he came to
Rivers pale and anxious. A few minutes before, he had been writing
a letter in his usual mood, when this causeless depression came on.
In the afternoon he had walked about on some neighboring hills. The
letter dealt with no depressing matter. In ten minutes the depression
vanished. Nine days later another came as he was standing idly looking
out of a window. The attack lasted for several hours, as no physician
was present to meet the issue. If he had had a revolver he would have
shot himself.

Rivers was inclined to interpret these gusts of depression as due to a
forgotten but active experience. As there was no definite tendency to
dissociation, Rivers hesitated to plunge in with the hypnotic method,
nothing short of which, however, served to recall the incident. The man
was gravely apprehensive about fitness for further service, and was
repressing his fear, as he thought it either was cowardice or would
be called cowardice. The patient, by his discussions with Rivers, had
already become familiar with the idea that the gusts of depression
might be due to a submerged experience. Perhaps, however, there had
been no experience, and the patient was advised that possibly the thing
repressed was the idea about fitness for service. Accordingly, the
patient agreed to face the situation. One transient attack of morbid
depression occurred, after an operation. Then the man fell into a state
of anxiety neurosis such that he was passed by a medical board as unfit
for military service.


Rationalization of war memories: Commission relinquished.

=Case 509.= (RIVERS, February, 1918.)

An oldish English officer lost consciousness while looking at the havoc
wrought by shell explosion. Probably there was a second shell that sent
him off. He was eventually admitted to an English hospital with paresis
and anesthesia of legs, severe headache, sleeplessness and terrifying
dreams. Hypnotic drugs and advice neither to read nor to talk about
the war were the measures adopted and after two months in hospital he
was given three months leave. He buried himself in the heart of the
country, away from relatives, with aspirin and bromides. He began to
sleep better and had less headache. When the president of the medical
board asked a question about trenches at the end of his period of
leave, however, he broke down and wept. He again repaired to the
country for two months’ leave, for the chosen treatment by isolation
and repression.

An order was then given that all officers must be either in hospital or
on duty. He was sent to an inland watering place and treated by baths,
electricity and massage, whereupon he rapidly became worse, especially
as to sleep. He was transferred to Craiglochart in an emaciated state,
with an expression of anxiety and dread, paresis of legs, sleeplessness
and war dreams.

He was now advised to give up repressing, to read and talk a little
about the war, and to accustom himself to thinking about war
experiences. He did this but half-heartedly, as he thought the ideal
treatment was what he had so long followed. Nevertheless, he got
distinctly better and the content of the war dreams was altered to home
scenes. He was still loath to acknowledge his improvement and thought
that he would have recovered if he had not been taken from his retreat
and sent to hospital. As it was obvious that he would be of no further
use in the army, he was allowed to relinquish his commission.


Rationalization of war memories, without redeeming feature as nucleus.

=Case 510.= (RIVERS, February, 1918.)

An English officer was flung by shell explosion so that his face struck
the ruptured and distended abdomen of a dead German. The officer
did not immediately lose consciousness and got distinct impressions
of taste and smell and an idea of their source. After a period of
unconsciousness he came to, vomiting and much shaken. He carried on
several days, still troubled by vomiting and haunted by taste and
smell images. Several months later he was observed by Rivers suffering
from horrible dreams, in which the battle experience was faithfully
reproduced. He got no relief except when he went into the country,
far from every suggestion of war. Rivers’ psychotherapeutic plan of
finding a redeeming feature in the experience, upon which the patient
might concentrate, failed because there was no redeeming feature.
Accordingly, it was thought best that the man should leave the army and
seek the conditions that had given him slight relief.

_Re_ psychoanalysis and its modifications, see remarks under Case
496, under which several favorable opinions were mentioned. Boschi
in his report on French conditions gives no reference concerning
psychoanalysis or hypnosis. Bruce has found blended with the war dreams
many episodes quite alien to the war, and considers that the patient’s
ante-bellum history is of importance, since ante-bellum emotions may
be revivified by the war. Craig states that he has not been impressed
favorably by the results of psychoanalytic treatment. Arinstein from
Russian experience gives preference to Dubois’ psychotherapy over
hypnosis and psychoanalysis. Nonne states that the data of the war
prove that hysteria is neither a degenerative disease according to
classical theory, nor a disease based upon Freudian principles.


Post rheumatic “paraplegia” (or abulia?) cured by removal of crutches,
after question of discharge “unfit” had been raised.

=Case 511.= (VEALE, November, 1917.)

A soldier, 23, had fever with swelling of several joints and
temperature in 1915, and was furloughed to England. He complained of
pains in the limbs and shortness of breath, and was put in hospital.
As he did not improve, he was sent to a special hospital for baths and
electricity. There he remained from August, 1915, to March, 1916, with
D’Arsonval baths, cataphoresis, electric treatment and massage.

He was now sent to the second Northern General Hospital to see whether
he should be discharged permanently unfit. Here he shuffled along
on two crutches, very tremulous, and sweating, and suffering from
palpitation on exertion. He wanted to take poison if he could not be
cured.

The crutches were taken away. He was asked to walk up and down. He had
to be supported at first and fell several times. The exercises were
continued. Massage and drugging were stopped. The next day he was able
to stand alone. In twenty-four hours he walked by himself. The other
patients in the ward encouraged him on account of the genuine exertions
he was making to get well. April 7, he returned to duty, smart and well
set up.

Babinski and Froment always give the suspected subject the benefit
of the doubt, never uttering the word simulation in the presence
of the soldier, and proceed to psychotherapy; for psychotherapy
will act to cure simulation or exaggeration just as it acts to cure
hysteria. They say that in their experience, all these disorders of
doubtful nature--that is, that lie diagnostically between hysteria,
exaggeration, and simulation--are as a rule cured by resort to
psychotherapy provided that the due amount of energy, tact, and
perseverance is employed. See also remarks under Case 453. Veale’s case
(511) never showed _mauvaise volonté_, and nothing more than aboulia.


“Trench foot,” “neuritis,” a year of astasia-abasia or at least of
complaint of inability to stand or walk. Treatment by a “cruel though
justifiable” process.

=Case 512.= (VEALE, November, 1917.)

A regular army man, 38, well built and muscular, in Flanders the
first winter, returned to England in January, 1915, with “trench
foot.” “Neuritis” then developed, with loss of power to walk. Baths,
electricity, massage, sympathetic wheeling about in a chair by women,
all failed.

January 11, 1916, he still complained of inability to walk or stand.
The reflexes were exaggerated. He was able to get into a wheel chair
from bed by jerks, associated with palpitation, tremors, flushing and
sweating.

He was told that he had now recovered from the neuritis. Crutches,
sticks and wheelchair were removed. He flopped about and then lay on
the bed exhausted. In a few days he began to shuffle about and was
put on the stationary bicycle. January 29, he left the hospital well,
remarking that though the treatment at first seemed cruel, it was fully
justified.

_Re_ genuine polyneuritis, Mann gives German experience regarding
neuritis as somewhat frequent and affecting a special form which
he terms polyneuritis neurasthenica. He states that the commonest
instances of mononeuritis developing in the war are the sciatic and
trigeminal. The neuritis often outlasts the other symptoms. The
treatment was rest, tepid baths, and electricity. Naturally, alcohol
and syphilis must be excluded in the diagnosis.

Nonne also described non-alcoholic, non-syphilitic, and non-infectious
polyneuritis in neurasthenics, which he, however, finds most common in
the ulnar, median, radial, anterior crural and posterior tibial nerves.

_Re_ “spa” treatment, Turner thinks there may be easily too much
massage, electricity, bathing. He prefers segregation in special
hospitals to “spa” measures in general hospitals, prefers occupation to
rest, and calls attention to the stimulating value of the gratuity to
be paid on leaving the hospital.


Shell-shock paraplegia: Treatment by bed, cigarettes and chocolates
altered to isolation, no tobacco, no visitors, faradization. Recovery.

=Case 513.= (BUZZARD, December, 1916.)

Early in the war, a lad, 19, was blown up by a shell. He was sent home
paralyzed from waist down, and was seen by Capt. Buzzard after he had
spent ten months in various hospitals, “carefully nursed, on the water
bed, constantly using a bed urinal, smoking innumerable cigarettes,
and eating countless chocolates.” He could not move his legs. They
were wasted and flaccid. The knee-jerks could be got with difficulty.
Plantar reflexes flexor. Complete anesthesia from umbilicus downwards,
but preservation of abdominal reflexes. The navel did not shift
downwards when the patient attempted to sit up. The incontinence was
not real; urine was passed into the urinal at appropriate intervals.

Buzzard directed treatment “not to his spinal cord but to his mind;
isolation; the stoppage of tobacco and all visits; the assurance that
he would rapidly get well, together with some suggestive faradization
of his legs.” This brought about a cure in a very short period. The
atrophied legs eventually grew strong enough to walk.

_Re_ cigarettes in Shell-shock, Mott decries the over-liberal gifts of
cigarettes that induced cigarette habits in both officers and men. Of
course, the cigarettes are still more detrimental to cases of soldier’s
heart than to other cases of neurosis. Mott remarks how over-frequent
are the social tea-parties, joy rides and drives given by well-meaning
ladies for the “poor dears,” actually perpetuating neuroses.

_Re_ atrophy, Babinski and Froment again bring up the question whether
muscular atrophy can be brought about by a hysterical motor disorder.
In point of fact, Charcot and Babinski were the first to describe
the true hysterical amyotrophy, but this hysterical amyotrophy is
exceptional in hysterical paralysis, and is slight when it occurs.


Shell-shock blindness, mutism, deafness: Blindness spontaneously
vanished, 24 hours. Mutism, 2-3 months. Deafness cured by “small
operation.”

=Case 514.= (HURST, September, 1917.)

A lance corporal, 26, became blind, deaf and dumb, though without
losing consciousness, when blown up by a shell, August 29, 1916. His
sight returned next day. On reaching England he talked in his sleep.
Encouragement, electricity, etherization failed to effect improvement.
One night in November he woke up and asked the sister for a drink;
thereafter he talked normally.

Seven months after the shell explosion he was transferred to the
neurological section at Netley, March 21, 1917. Deaf to air and bone
conduction, a loud noise behind him caused a slight tremor of hands,
with blinking and dilatation of pupils; but further stimuli of the same
sort failed to produce such reactions. Normal nystagmus and giddiness
on functional tests of vestibular nerve and canals. The internal ear
was then probably free from organic changes. Since shell-shock mutism
is always hysterical, it was probable that the deafness was hysterical.
Under hypnosis (staring at lines for fifteen seconds) he showed no
change. During natural sleep, also, a shout of “Fire” and metallic
noises failed to wake the patient or to produce contraction of eyelids.
Electric suggestion (despite the patient’s belief in electricity) and
reëducation failed.

April 16, he was told that a small operation would have to be done
April 20. To this he readily consented. Two small incisions were made
behind the ear under light ether and suture was inserted. A loud noise
was made during the “operation”; he heard this noise and jumped from
the table. To his intense delight normal hearing returned in a few
minutes. Next day hearing was tested and found normal to air and bone
conduction. He was discharged to duty three weeks later and on his way
to France, June 29, demonstrated his normal hearing to the physicians.


Deafness: cure by stimulating vestibular apparatus.

=Case 515.= (O’MALLEY, May, 1916.)

A private, 20 years of age, lost speech and hearing after the battle
of Neuve Chapelle. Eight days later he came under the care of the
laryngologist in a very excited state, pointing to lips and ears and
carrying a note with information concerning his deafmutism.

Dr. O’Malley wrote on a piece of paper that he would restore the
patient’s speech and hearing. Dr. O’Malley then used the mirror until
the point of retching, and wrote, “You can speak now; count up to ten
loudly.” He did.

Dr. O’Malley next used the cold water douche to the right ear to
the point of giddiness, then shouting through a speaking-tube (see
description below). The patient then found he could hear and the tears
streamed down his face. Thereafter he was able to converse freely. Dr.
O’Malley writes:

    The treatment of functional deafness consists in exciting the
    vestibular apparatus as follows. Cold or hot water is allowed
    to flow in a steady stream into and out of the external
    auditory meatus by means of a tube attached to a receptacle
    placed about one and a half to two feet above the patient’s
    head and continued until he becomes very giddy and an active
    nystagmus is produced. A speaking-tube three feet long is then
    used by placing the ear-piece in the ear so treated, and the
    surgeon shouts into the mouth-piece the assertion, “You hear
    now,” and the answer, “Yes” comes promptly. The tube is now
    dropped and a conversation held as if no deafness ever existed.
    So far I have found the treatment of one ear sufficient. The
    patient is usually very emotional, as the disturbed vestibular
    function, which in these cases responds easily and markedly,
    causes him to feel as uncomfortable as a bad sailor on a
    stormy voyage. This feeling, however, rapidly gives way to one
    of pleasure at the return of his hearing. Where functional
    deafness and mutism co-exist it does not appear to be material
    which is treated first. In two cases of this kind under my care
    I treated the loss of voice first.


Bullet through mouth; Hysterical mutism. Treatment by operative
manipulation.

=Case 516.= (MORESTIN, January, 1915.)

A Colonial infantryman, 32, was wounded December 17, 1914, at the
Boisselle, being struck by a bullet which entered on the right side in
the upper part of the neck and came out behind the left side of the
mouth, having traversed the tongue, broken two teeth, and caused a
good deal of hemorrhage by mouth. The patient felt his tongue swell,
and from this time on he could not pronounce a word. He was sent to
the ambulance, then to Mien, then to Saint Germain, and finally to
Morestin’s surgical service. With wounds by this time healed, the
patient found it hard to open his mouth. There was no trace of fracture
of the lower jaw. The tongue could be only incompletely examined. The
man swallowed liquids easily but could take no solid food. He tried
hard to speak, made pantomime movements, grew emotional and lachrymose.

On the whole, however, it seemed that his inability to articulate
sound could not be due directly to the lesion. There must be either
simulation or hysteria. For four days he was attentively watched, and
not once did he pronounce a word. He grew more and more stricken and
humiliated by his plight. Rigorous diet did not cause his mutism to
cease. Isolation and ennui did not decide him to talk. Accordingly,
it was announced, in the man’s hearing, that an operation was to be
done to restore speech. January 9, 1915, his face was copiously washed
with alcohol and ether. Cocaine was injected to secure anesthesia and
resolution of the muscles of mastication. Six c.c. of a 1-100 solution
on each side. Shortly the surgeon began to open the jaws, against
decreasing resistance. The tongue, which was not spastic, was seized
with a tractor and rhythmic movements were executed with it. After a
few of these movements, joy was painted on the features of the patient.
He said that he wanted to speak and that he was about to speak. He
shook the surgeon’s hands effusively and said, “_Merci_.” Although
the first words came hard, little by little speech became free and a
perfectly sincere elation at having recovered speech set in.

This man was neuropathic, having always been a rather strange,
irritable and restless person, and given to nervous crises in anger, in
which he lost consciousness entirely.

_Re_ pseudo operations as forms of disguised persuasion, almost
countless methods have been used. See Cases 514, 515, 518, 519,
especially 521, 560, 561. Sham injections under ethyl chloride have
been made (Goldstein). See also under Case 484, _re_ continuous bath,
and under Case 488, _re_ lumbar puncture. Very close to these methods
are the methods of _torpillage_ of Vincent and the methods employed by
Yealland in England and Kaufmann in Germany. See under Cases 574, 563,
and 564, and 570.

Léri quotes Babinski as saying, “We cannot fight hysteria in trench
warfare; manoeuvres are necessary.”

_Re_ treatment of mutism, Chavigny remarks that the principle of
treatment for mutism is quite different from the principles of
treatment of paralysis. The reëducation of mutism is psychic. Chavigny
claims probably absolute success in the treatment of mutism through
faradism to the larynx region simultaneously with a signal given to the
patient to make an effort to pronounce the letter A. Garel modifies the
treatment (in case the faradic apparatus is not at hand), by a vigorous
and sudden blow to the patient’s epigastrium simultaneously with the
patient’s endeavor to imitate the movement of the doctor’s lips.


Shell-shock: Impairment of vision (even commanded men to fire on
kindred troops!) Improvement by verbal suggestion, faradization,
injections.

=Case 517.= (MILLS, October, 1915.)

A sergeant-major, 29, in private life a bookkeeper, said that shrapnel
struck the ground in front of him and burst as it struck. Unconscious
for a moment, the sergeant-major thereafter saw everything imperfectly,
led his men in the wrong direction, and even commanded them to fire in
the direction of his own troops.

Seven days afterwards the eyes looked normal, fundi were normal, vision
was reduced to the perception of hand movements; with a plus 10 sphere
the right eye could count fingers at 5 c.m. and with a plus 8 sphere
the left eye could count fingers at 3 c.m. There was a right frontal
analgesia.

Treatment: Sweating; rest in bed for several weeks; assurance of
complete recovery. There was a slow but constant improvement, aided by
faradization and injections of strychnine sulphate into the temporal
region, but the prospect of a return to the front retarded the
improvement.

_Re_ injections into the temple, see also Case 521 of Bruce. _Re_ cure
of blindness, Grasset has a case of a blind deafmute who was cured
by a nurse. She put a pencil in his hand and guided the pencil while
she wrote a question. The patient replied in very good MSS. In blind
deafmutes sight is described as returning first, hearing next, and
speech last.

For other cases of blindness, see especially under Section C, Cases 433
to 438, with discussions thereunder.

_Re_ retardation of improvement by the prospect of further military
service, Lewandowski has insisted upon the strong factor of the wish in
all such functional conditions. Lewandowski wants all functional cases,
however, to be sent to duty in the rear or to be discharged as unfit.


Aphonia: manipulation in larynx.

=Case 518.= (O’MALLEY, May, 1916.)

A corporal, 28, had a bullet pass through his neck from a point in the
middle line at the upper border of the thyroid cartilage to a point
behind the right sternomastoid muscle, two inches below the point of
entry. The corporal lost his voice at the time of injury, spat up a
teaspoonful of blood, and thereafter was able to whisper only. The
laryngoscopic examination betrayed no intralaryngeal lesion. Treatment
as described below enabled the patient to speak. O’Malley describes his
technique as follows:

    The patient is placed in the common position for the
    examination of the larynx, the tip of the tongue being
    seized in a piece of linen by the left hand fingers and the
    laryngeal mirror introduced with the right hand. The patient
    is then requested to say “e” or cough, and if the cords do
    not approximate, they can be made to do so by using moderate
    friction on the fauces and pharynx with the mirror to excite
    secretion. The latter begins to drop into the larynx, and
    acting as a foreign body, a protective reflex is at once
    excited which adducts the cords to prevent the secretion from
    entering the trachea. At the same time an involuntary cough
    is produced to expel the mucus, and if the friction and flow
    of secretion are maintained and the patient is urged to cough
    vigorously, voluntary coughing and a tendency to retching with
    forced laryngeal notes will rapidly follow. It is usually
    best to persist until retching occurs, as the cords are then
    forced together to protect the larynx and trachea from the
    possible entrance of regurgitated stomach contents. Involuntary
    laryngeal sounds are thus produced and the patient is conscious
    of laryngeal effort. Some of these cases are at the moment
    very shallow breathers, which can be demonstrated by X-ray
    screening, but the act of retching causes a wide excursion
    of the diaphragm with a more pronounced expiratory blast,
    to be rapidly followed by deeper inspirations. This method
    of treatment is best carried out just before a meal, as the
    stomach is then practically empty and the unpleasant effects
    of the sudden regurgitation of food are avoided. When the
    explosive sounds accompanying retching have occurred two or
    three times the mirror is withdrawn, the tongue released, and
    the patient is requested to swallow, take a deep breath, and
    cough, and then urged to count up to ten, directing his voice
    to a certain point on the ceiling. This method has given me
    uniformly good results, and was rapidly effective in all cases
    coming under treatment soon after the onset of the neurosis.

_Re_ methods for curing aphonia, Muck has a method called the “ball”
method. A ball is put into the larynx to cause a temporary suffocation,
which produces a reflex that starts the adductors. He would apply
the method as soon as the man was well over the shock that produced
aphonia. Muck states that he has applied the ball method, not only to
cases of aphonia, but to cases of mutism and deafness, with success.

Tilly mentions a case in which the patient refused to open his mouth,
so the device was adopted of passing an electrode through the left
nostril so that it finally reached the larynx. A spasm was produced,
which was carried to the point of considerable cyanosis, but the
aphonia was relieved and for the first time in three months the man
spoke. Incidentally he began to hear also.

_Re_ treatment of aphonia, Schultz has used the electric current
externally over the larynx, all the while carrying on a laryngoscopy.
Schultz remarks upon the fatigue that may come during the first few
sittings. Roussy and Lhermitte remark that, although aphonia sometimes
exists from the outset of shock, it is often a phase in recovery from
mutism.

Liébault notes that, not only cases of true nervous aphonia but cases
of laryngitis, apparently of infectious origin, and cases of true voice
strain, may also turn up for treatment. Some men have been improperly
discharged from the army for aphonia actually due to voice strain.


Hysterical aphonia in a mechanician (war time contributory?). Cure by
suggestive manipulation of larynx.

=Case 519.= (VLASTO, January, 1917.)

A mechanician was refitting an engine valve, when steam was suddenly
put on and the drains were opened out. Some of the steam entered the
throat of the mechanician, who rushed up, gasping, unable to speak.
Oedema of the larynx was thought of; but there was no complaint except
the inability to speak.

A month later he was discharged to the hospital ship at Plassy, where
he got faradic treatment, the effect of which was to cause him pain
without recovery of voice. The man could whisper well enough and
cough fairly loudly. The vocal cords of the larynx appeared normal
on laryngoscopic examination, but adduction of the cords was not be
properly effected. He was now given rest and constant assurances that
he would get well.

Ten days later, another laryngoscopic examination was made, with mild
mechanical stimulation of the air passage. The patient remarked that
he had never been so near being able to speak since his dumbness came
on. The patient was now informed that his muscle of talking was going
to be replaced and that the success of the operation depended upon his
help, so that he was to shout out as soon as he became conscious of
the physician’s working inside his throat. The patient was given ether
lightly, into the second stage. When consciousness was about to return,
the laryngeal mirror was placed lightly on the larynx. The patient was
commanded and encouraged to count out loud and shout. Speech returned
permanently.

It is to be noted that there was no specific war effect underlying
the phenomena, unless we regard the fact of its being war time as
contributory to the shock produced by an incident in every day engine
room duties.


Gradual onset of mutism and amnesia without special occasion. Faradism.
Dream.

=Case 520.= (SMYLY, April, 1917.)

A soldier was slightly wounded in the arm and returned to the trenches.
Later he found himself in hospital at Boulogne, unable to speak and
unable to remember what had happened to him from the time he was in
the trenches. It appears that his voice and memory had gradually
disappeared, according to what was told him by his comrades.

A month afterward, in a London hospital, the patient was roused
suddenly from sleep, and then proved able to speak, although there was
great difficulty in getting each word out. Two months later, he went to
bed, feeling indisposed, in the night had a kind of fit, and remained
unconscious until the following night; the next morning, his voice was
again lost. The aphonia persisted for a fortnight, and the patient
could hear only loud shouting when close to his ear. He was anxious
to get well and requested electricity from the physician, Dr. Smyly,
having heard probably of another case cured thereby. Dr. Smyly applied
faradic current to the larynx externally, instructing the patient to
blow at the same time. At first the patient spoke so low that he could
not hear himself speak, but on suggestion succeeded in speaking up
loudly enough. He was shortly able to speak and hearing improved. The
climax arrived with a bad dream one night, from which the patient awoke
in a fright and found himself able to hear and speak perfectly.

_Re_ nocturnal spontaneous cures, see observations by Mott under Case
473. Note also in this case the presence of what Mott has termed “the
atmosphere of cure.”

_Re_ relapses, see Case 476 as well as remarks under Case 474. _Re_
special cases of mutism, Goldstein has insisted upon a greater
individualization of treatment for functional mutes than even for
other neurotics, and advocates the establishment of schools within
the hospitals and aftercare institutions. He thinks the problem very
serious.


Shell-shock blindness: Cure by a course of injections in the temple.

=Case 521.= (BRUCE, May, 1916.)

A soldier from Gallipoli was admitted to the Royal Victoria Hospital
at Edinburgh, blind. He had been at Gallipoli from May 1, 1915, until
August 12, when a shell explosion blew in his trench and buried him.
He was dug out nervous and tremulous. Shortly afterwards there was
the bright flash of a second shell, and amnesia set in until he found
himself in hospital. He could not see at all with the left eye and the
sight of the other was poor. He arrived in Scotland, October 9. He was
nervous, excitable and now somewhat depressed, complaining of blindness
and pain in the left eye, and headache. The left eyelid drooped. The
fundus was normal. He had not been given an anesthetic.

It was explained to him that the eye had not been injured; that it had
become weak from the explosion; that he would be given a series of
injections into the left temple of a strong drug which would restore
the sight of the eye.

Gradually increasing quantities of normal saline solution were given
every morning. After four days he said that the treatment was doing
him good. A week later he said that the eye was much stronger. After
the fifteenth injection he could not sleep. The headache was worse,
and there was “moving about inside his head.” Early in the morning he
went to sleep after a period of restlessness. He awoke at eight o’clock
able to see perfectly, and was overjoyed at the result. There was some
blurring and four days later he said he was becoming blind again. More
normal saline was injected, causing pain. After that there was no
relapse, and the man was sent back to his unit.

_Re_ Shell-shock blindness, Ormond and Hurst recommend a light
hypnosis; taking the functionally blind man into a dark room and
requesting him to make his mind a blank. Some cases are refractory. An
anesthetic may be used with suggestion in the semi-conscious stage.


Deafness, cured by suggestion in writing.

=Case 522.= (BUSCAINO and COPPOLA, 1916.)

L. G., 20 years old; fusileer. (Mother of neuropathic constitution.
Father died in 50th year of heart disease. One brother had hemiparesis
from infantile cerebropathia.) The patient suffered from infantile
otitis media bilateralis, which was followed by abundant chronic
otorrhea from his fifteenth year. He relates that for a long time he
was obliged to wear a very large handkerchief on his shoulders to
receive the pus, which came from an ear. No sex disease. Nothing of
importance in the physical anamnesis.

Patient entered the army, Jan. 15, 1915. In May, he was sent to the
front (Basso Isonzo). Towards the end of July, while he was in the
trench, a grenade exploded a short distance from him, causing slight
abrasions at the nape of the neck and in the fleshy part of the left
calf. He was picked up in an unconscious state, and taken to the
hospital at Cervignano, where he was admitted as a deafmute and was
given electric treatments. After 18 days or so, first stammering and
then pronouncing with difficulty a few words, he finally regained his
speech entirely. Deafness continued, however.

Being transported to a special hospital in Florence, he was in a
state of psychic excitement for several days, showing also visual
hallucinations--saw “many soldiers,” saw “many soldiers all about him.”
He was treated with chloral and bromide. The suspicions of several
physicians were aroused by the obstinate declaration by the patient
that he was incurably deaf.

On being admitted to the clinic on August 22, he showed complete
deafness in addition to a slight degree of stupor; he remained
impassive to the glance of his questioner without showing signs of
worry about his condition, nor did he make any effort to make himself
understood by making lip-movements (which is in contrast to another
patient affected by organic deafness, who on the contrary made great
efforts to understand anything said to him, clearly showing his great
grief over his incapacity).

He failed to respond to auditory stimuli either by air or by bone
conduction. It was possible from the beginning to exclude suspicion
of simulation; during the day, indeed, it was not possible by any of
the repeated attempts to awaken surprise in the patient by means of an
acoustic stimulus. At night, while the patient slept, it was possible,
however, to awaken him by calling his name, or by making a fairly loud
sound; the patient would then open his eyes but was quite unable to
hear. Neither confusion nor hallucinations were in evidence.

He was able to converse very well and spontaneously (he remembers
having lost consciousness at the explosion of the grenade and not
coming to until after his arrival at the hospital at Cervignano); he
read correctly both mentally and aloud, and answered by signs the
questions put to him in writing. Being face to face with hysterical
traumatic deafness, notwithstanding no other hysterical phenomena
were noticed, a successful attempt was made with suggestive therapy,
the patient being emphatically assured (always in writing) that the
following Sunday his hearing would be restored without doubt. The
following Sunday, in fact, during the visit of a lady (one of his
friends), hearing in his left ear was suddenly and almost completely
restored to the patient. He was in profound emotion on account of this,
and upon the appearance of the physician he had a hard weeping spell.
During the following day, he began slowly to hear with the right ear.

During the latter part of his stay at the clinic, however (until
September 24, 1915), a slight hypo-acusia in the right ear persisted,
along with severe headaches and pains in the left ear (which the
patient compared to the suffering as a child with otitis).

At the otoscopic examination by a specialist, only residuals of the old
catarrhal otitis with retraction of the tympanic membrane were found.


Shell-shock story reproduced in hypnosis. Recovery.

=Case 523.= (MYERS, January, 1916.)

A private had been found wandering in a village, in shirt and socks,
unable to give name, regiment, or number. He was admitted at a field
ambulance, and seen by Major Myers three days later. No Christian
name seemed familiar to him. The past was a blank. He was depressed.
There was numbness over the occiput. The legs, hands and tongue
were tremulous. The left arm and leg and the left side of the face,
chest and abdomen were hypalgesic. The knee-jerks were exaggerated;
pseudo-clonus of left knee and right ankle. There had been a nightmare
of bombs thrown into trenches--one thrown by a German hit him in the
neck and woke him up in a cold sweat.

In hypnosis the dream was repeated, and points about his previous life
were dragged out piecemeal. Next, the names of village and near-by
town, and finally his own name, regiment and number were elicited.
After the bomb-throwing, he said, “I must have gone off my head and
run away. I must have taken off my clothes in a field. I spent the
first night under a hedge. I spent the next two nights in a wood. I ate
nothing. The next night I was walking along a road on the outskirts
of a village and I was taken to a house by two men.” On waking, he
proved unable to remember these things and was promptly rehypnotized,
whereupon the memories became clearer and more ample. More powerful
suggestion was given, and complete recovery of memory followed the
second period of hypnotism. The pupils became larger. The despondency
disappeared, together with the occipital numbness and the left-sided
hypalgesia. He was transferred to a base hospital, and thence after
three weeks to a hospital in England, made an uninterrupted recovery,
and rejoined his regiment.


Shell-shock story reproduced in hypnosis. Recovery.

=Case 524.= (MYERS, January, 1916.)

Private, 29, seen by Major Myers in a base hospital the day after
entrance, was in a stupor from which he had to be repeatedly roused to
answer questions. He could recall neither name, regiment nor age, and
was unable to write or read except a few letters in very large type.
Twice he said the words _war_ and _comrade_, and made a gesture as if
following. He agreed that a shell came and intimated that he had pains
in the forehead. He could not hold his hands out for many seconds
without dropping them. Knee-jerks brisk.

Four days later he was very little better, never having spoken
voluntarily, but replying _yes_ to the utterance of his name, and was
able with great effort to write his name. He still intimated his severe
headache. The next day the names of his two children were given. He
could not read aloud the figure 2 but held up two fingers. Next day, he
gave syllable by syllable his wife’s name from her photograph.

A week from admission he was hypnotized and persuaded to talk about the
events that preceded his disorder, breathing excitedly, gesturing, and
evidently visualizing the scenes. He had been in the trenches, had been
sent to draw water at a camp, and had been knocked down when two or
three shells burst over him. He carried out post-hypnotic suggestions.

He was hypnotized again, two days later, and now described how, after
shelling, he had lain on the ground, dazed; had risen, picked up the
water bottle, returned to the trenches, and then lost all sense and
reason. He recalled how his mates had told him he was silly, but had
lost all intervening memories. But the full details were elicited by
persuasion. Next day he complained that he still wrote with difficulty.
Under hypnosis, his speech and writing were restored to normal. He was
discharged two days later to an English hospital.

He was then passed for foreign service, being prevented from active
service in the field by occasional severe headaches.


Burial after explosion of a “coal box”: Automatism, amnesia,
deafmutism: Recovery by hypnosis.

=Case 525.= (MYERS, September, 1916.)

A sergeant, 18, with nineteen months service in the army, 11 months
in France, was seen by Lt. Col. Myers at a clearing station to which
he had been transferred after three days in another clearing station,
with a note “Found in the streets of B----, asking his way to the fire
trench; could not be got to speak on admission nor since; seems deaf,
but now writes rationally.”

Mute and very deaf at the second C. C. S., he regained a good deal
of his hearing with encouraging talk and also became able to cough
and utter P, B, F and S, finally whispering name, regimental number,
and the like. At the same time he could write fluently. After being
buried he had lost himself until he had asked his way of a military
policeman at the crossroads in B----. There was amnesia again until he
had been 48 hours in the clearing station at B----. The throat hurt
as if it were pulled down when he tried to speak, and his head ached
when he tried to remember. There was much tremor, especially of right
arm. In a quiet room adjoining, the tremors increased and there was
much agitation. Lt. Col. Myers suggested cure and encouraged the man,
finally inducing a mild hypnotic state in which he spoke aloud, at
first hesitatingly, later fluently.

The man eventually remembered what had happened after he had extricated
himself. He had run, as he thought, towards the fire trench, taken
a wrong direction, and met a Frenchman who gave him eggs and bread,
allowed him to sleep on a couch, put him on a cart and drove him to
B----. He was then very giddy and asked his way of the policeman. The
shell by which he was “terribly shaken” was a “coal box.” Posthypnotic
suggestion that the headache would not recur and that he would shake
hands with the orderly was successful. He now talked in a proper voice,
at first hesitatingly. He looked another man as his clay-colored face
resumed a normal aspect. After a good night’s sleep he was evacuated
to a base hospital, thence to an English hospital, whence he wrote six
days later in gratitude for the successful treatment, stating that he
was now nearly well and hoped to be fit for light duty.

Six weeks later he wrote that he was still dizzy. He also remembered
certain further details of his experience; how he had wandered into a
listening sap in front of the Huns’ barbed wire and had had a tussle
with three Huns, after which he was buried during the heavy shelling.

    This case belongs in the group termed by Myers “A Group,”
    namely, the physical group, in which the patient has been
    lifted, buried or knocked over by a shell or otherwise felt
    physical or chemical effects of an explosion (in contrast with
    the B Group, or psychical group, in which fear of the noise
    or emotional response to the mutilation of companions is the
    exciting cause). Predisposing affections occur as often in the
    physical group as in the psychical group. The average age of
    mutism cases seen by Lt. Col. Myers is twenty-five. Mutism is
    rare among commissioned officers. Lt. Col. Myers has heard of
    but one or two cases.

    With respect to the technique of getting these men to utter
    sounds, Lt. Col. Myers states that he first assures the patient
    that he has already cured many cases of loss of speech by the
    method about to be employed. The patient is next asked to copy
    his teacher as the sounds (not the vowels) B, D, finally V, S
    and K are made. The patient is, as a rule, shortly induced to
    make the necessary movements of lips, tongue or throat. “You
    see you are beginning to talk. Now let me hear you cough.” The
    patient coughs. “You see you are able to make a noise. I want
    you next to cough out an A (Continental pronunciation).” After
    a time the patient adds this vowel to the cough. Other vowels
    are now taught him. Eventually a consonant is prefixed to the
    vowel instead of the cough. The patient is now delighted with
    his progress and can shortly repeat surname and regimental
    number.


Mutism: Recovery by hypnosis.

=Case 526.= (HURST, 1917.)

A transport driver, 31, was run over by a loaded wagon at Gallipoli in
May, 1915, and fractured his pelvis. He remained perfectly conscious
but unable to speak for three days. At the beginning of August, when he
was admitted to the war hospital, he still spoke with great difficulty
and with contortions of his face. Even when he did not speak, he had
facial contortions and that mental condition characteristic of tic,
namely: although he was able to control the contortions by will, he
felt uncomfortable during the control and finally gave way to the
irresistible impulse.

Under hypnotism, it was suggested to him that he would be able to speak
without difficulty and would no longer have the contractions of the
face. When he came out of hypnosis he was able to talk quite normally,
sang next evening at a concert, and a few days later he took part in a
play. The facial contortions persisted in hypnosis and even afterwards,
but vanished after a second hypnosis.

_Re_ hypnosis as treatment of mutism, Ballard remarks that a genuine
return of speech and a merely hypnotic speech must be distinguished.

Nonne is the great exponent of the use of hypnotism in treatment of
the war hysterias. He got as good results from high as from lower
classes of men. He remarks that the hypnosis does not protect against
recurrence if the patient again falls under the original conditions
that brought about the first attack. Hypnosis may be used also as a
diagnostic measure between functional and organic cases. Even tics and
tremors have been at times cured.

_Re_ employment of hypnotism, Hurst suggests that it may well be
used, not only in mutism, but in hysterical deafness, blindness,
and occasionally in psychasthenia. It is not a cure-all for the war
hysterias, but is to be used as a not infrequent form of treatment.
Nonne claims cures of 51 out of 63 cases of hysteria major (28 rapidly,
23 more gradually). Ten of his 63 proved refractory to hypnosis
altogether.


Stammering: Cured by hypnosis.

=Case 527.= (HURST, 1917.)

An Australian, 22, wrote the following, August 21, 1916:

    “You may be a little surprised to hear that I am in the Hos.
    suffering from shell-shock, which has taken away my speech and
    hearing. It is some sixteen days now since it happened.… We
    were in the trenches and going for dear life, when two of us
    spotted a German machine gunner in a hole, so we made up our
    minds to have him. We made a charge at him, and I just remember
    getting to him when a high-explosive shell burst at my head; it
    seemed as if it burst inside my head; everything went black.
    I tried to call out and couldn’t, and I could not hear my
    mates--only just a terrible bursting in my head all the time. I
    never remembered anything more until I came to on the boat. The
    Drs. have told me that I will get alright in time. I saw a good
    deal of France.… There is not a young man there who is not in
    the Army. The girls and women work in the fie----”

The abrupt ending of the letter was due to the entrance of Major Hurst.
The patient had been hypnotized but his deafness had persisted during
the hypnotic sleep, so that suggestions could not be effectively taken.
He heard nothing whatever during a very heavy thunderstorm, was unable
to make any sign whatever, and could not even cough.

He was now told in writing that his speech and hearing would be
restored when ether was given. After a few whiffs, he struggled and
before he was under began to repeat the word “Mother.” Etherization was
discontinued before his limbs had even become relaxed. As he was coming
to, he was requested to repeat various words, and when the anesthetic
had passed, he was talking normally and had completely recovered
hearing.

Now, however, his memory had become a complete blank. From a short time
before his shell-shock up to the moment of his regaining consciousness
after etherization, he remembered nothing of his loss of speech or
hearing, nothing about the events in his letter, and nothing about
Major Hurst, whom he felt he had not previously seen. According to
Hurst, this patient had become (_a_) speechless from fright at the time
of the shell explosion, (_b_) deaf from the noise of the explosion,
and (_c_) unconscious from the windage. After he came to at the time
of the explosion, an autosuggestion to the effect that he had lost his
power of speech and hearing occurred. Ether broke down this inhibition
of speech and hearing by interfering with the control of the high over
lower cerebral centers.

_Re_ emotional stammering, Chavigny treats by voice gymnastics,
rhythmical breathing movements, sounds spoken by metronome with
simultaneous movements of arms or trunk, and by singing. _Re_
hysterical stuttering, Roussy and Lhermitte remark that the symptoms
are always very pronounced, come on suddenly, and cease just as
suddenly under the influence of electrical treatment. The history will
differentiate hysterical stuttering. The effects of treatment will also
help. Genuine non-hysterical stammering may, of course, be increased
through emotion or shock. Dundas Grant aids the stutterer by having him
twist a button or carry out some other muscular movement simultaneously
with the attempt to speak. He also has the patient endeavor to expand
the lower part of his chest during the effort.

MacMahon notes that Shell-shock stammering is chiefly a difficulty with
vowel sounds and voiced consonants, and amounts to a speech inhibition,
accompanied sometimes by amnesia for words and suggesting a form of
aphasia. Mild cases of such stammering are cured simultaneously.
MacMahon relies in part upon especially regulated breathing movements
and the attendant sense of repose. The cases of old cured stammering
that have come back under Shell-shock are harder to treat.


Two burials; shell-shock: Mutism and amnesia. Recovery aided by
hypnosis.

=Case 528.= (MYERS, January, 1916.)

Major C. S. Myers recites hypnotic cure in a case of mutism. He remarks
that malingering is sometimes suspected in these cases. There was,
however, in this case a severe constipation which lasted five days from
the shock, and a retention of urine with catheterization during the
same period. This private, 32 years, came to a base hospital, mute but
able to read and write as follows:

    “I was buried alive on ---- and again on ---- [5 months and
    4½ months respectively before admission], and then I had the
    misfortune to have two shells burst over me on ---- [four days
    before admission]. There was shelling for about 20 minutes and
    then two bursted over my head. I did not remember any more
    until you came to see me, but I am still living in hopes to
    regain my speech back.”

It seems that he had wandered off with a lance-corporal for three days
after the first burial, and neither he nor his comrade were able to
find their regiment.

Understanding was slow and look vacant. There were jerky movements of
the arms and a snoring sound from the nasopharynx. Voluntary movements
were restricted, weak, slowly executed, jerky, and incoördinated, but
not tremulous. Station was unsteady; failure in finger-to-nose test. He
could imitate the sound _ah_, and the consonants _s_ and _p_.

Knee-jerks exaggerated; plantars flexor; abdominal reflexes absent;
pupils reacted; eye movements normal; moderate restriction of visual
fields on temporal side; watch not heard even in contact with ear;
heard better by air than by bone conduction.

In the next two days, the patient became brighter and movements became
better. On the seventh day stupor and ataxia had disappeared. Familiar
names could be repeated and the next day could be given on request.
The patient would sweat profusely in giving replies. There was no
spontaneous speech. A week later speech had improved.

Under hypnosis he spoke more fluently though feebly, and became
emotional upon being questioned as to trench life, waking up suddenly
from hypnosis and wiping the sweat from his chest.

The next day, forgotten events of the second burial were recalled
together with what followed. Post-hypnotic suggestion of the
performance of eccentric actions was successful.

Next day his memory had returned save in reference to the two days’
wandering after the first burial; and under hypnosis the events of
those two days were recalled. He was then transferred to an English
hospital.

_Re_ hypnosis for “war shock,” Eder remarks that the usual objections
to hypnosis cannot apply because the majority of cases have no
neuropathic antecedents. Eder, as psychoanalyst, endeavors to level
hypnotic suggestion against the so-called “complexes.” Elliot Smith
and Pear commend Lt.-Col. Myers’ results, but regard the results of
hypnotic treatment as brilliant but erratic. Colin Russel, regarding
hypnotism as an induced hysteria, remarks that a true hysteria can
hardly be cured by adding more, although he has sometimes used the
treatment with apparent success. Podiapolsky notes that some 17
per cent of his functional cases will, at a word, drop off into an
artificial deep slumber. He thinks chloroform should not be given
to these subjects without an attempt to secure this artificial deep
slumber first. Chavigny, highly commending suggestion, notes that the
use of hypnotism is prohibited in military hospitals in France. A
remark of Smirnow indicates that the Russian authorities also look with
disfavor upon hypnosis, but he notes certain patients whom he cured
by hypnosis, so that apparently Russia did not absolutely forbid the
use of hypnosis in war cases. Another Russian, Arinstein, prefers the
Dubois method to hypnosis.

Roussy and Lhermitte definitely state that the psychotherapy of
Dejerine, Dubois, and Babinski beneficially replaces hypnotic
suggestion, “which ought definitely to be rejected.” However, if the
conclusions of Bernheim are sound, there can be no theoretical claim of
distinction between hypnosis and other forms of suggestion.


Fifteen bayonet wounds; recommendation for Victoria Cross: Hysterical
contracture of hand, revealed by hypnosis as the bayonet clutch.

=Case 529.= (EDER, August, 1916.)

A left-handed Irishman, 23, on December 22, 1915, got 15 bayonet
wounds, 14 of which were on the right side of the body. He was in the
trenches with 23 men, when they were attacked by about 200 Turks. He
and a sergeant leaped out of the trench into a bayonet attack with
Turks.

He was admitted to the hospital January 26, 1916, for a hysterical
contracture of the right hand. The fingers were semi-flexed and could
not be passively extended. Col. Purves Stewart noted that there was an
anesthesia and analgesia to pin-pricks and cotton wool on the whole of
the right arm. “At the beginning of the examination, the patient felt
pin-pricks at the wrist; as examination continued, the boundary of
anesthesia steadily increased until it reached the shoulder, by which
time the previously sensitive spots were now anesthetic.” Later there
was a complete right hemianesthesia.

In telling his story, this soldier repeatedly emphasized that “You must
clutch your rifle very firmly and never let it up, guarding yourself
all the time.” This was the explanation of the contracture. According
to Eder, in the unconscious, he was still clutching the rifle, fighting
the good fight, and symbolizing the desire by the grasping hand. In
hypnosis, suggestion was made that the fight was over and the rifle
could be let go, whereupon the hand was immediately relaxed.

The analgesia, thinks Eder, was present during the fight and passed
away subsequently. In fact, the soldier said that he felt no pain
during the fight and did not know that he was wounded until his
attention was called to the fact that blood was flowing from him.
According to Eder, the unconscious mind refused to feel pain. At Col.
Stewart’s first prick or two “the unconscious took no notice, but as
the pricks continued, the former memory was revived and the unconscious
became on guard.” He had been recommended for the V. C.


Gunshot of forearm: Hysterical contracture, wrist and fingers: Cure by
hypnosis, “indecently quick.”

=Case 530.= (NONNE, December, 1915.)

An infantryman, without special hereditary taint and previously well,
was shot September, 1914, in the right forearm. A paralysis of the
hand and fingers persisted after the wound had healed. Several reserve
hospitals failed to cure the paralysis.

Eight months after the injury he arrived at Nonne’s clinic at
Eppendorf, with a flexor contracture of the right wrist joint as well
as of the fingers (exclusive of thumb). The finger tips were deeply
sunk in the flesh of the palm. Extension could only be brought about
against strong resistance. There was a total anesthesia for all
sensations in the hand and fingers. No contraction of visual fields.

The patient, upon suggestion, fell immediately into hypnosis. At
first the contracture was released with some difficulty; then, with
greater ease, and then without any resistance whatever. During the same
hypnotic séance the patient finally became able to extend actively
both fingers and wrist; and next day, after the patient had convinced
himself of his cure, he was able voluntarily to stretch the hand and
fingers with normal amplitude and power. The disturbance of sensibility
had spontaneously disappeared.

This cure was, from the patient’s point of view, indecently quick.
He said everybody must feel he was a malingerer, and in fact he felt
so himself. He went back into service, where he had been for several
months at the date of Nonne’s report.

_Re_ Nonne’s enthusiasm for hypnosis, see under Case 526. Nonne,
contrary to Babinski and Froment, would regard even the severe and
obstinate vasomotor disturbances as purely functional and as not
even “sub-organic.” The basis of this belief is that hypnosis cures
these phenomena as well as various tics and pertinacious tremors.
French observers consider that these tics and tremors may even be
organic in their nature, basing their ideas upon the non-success of
suggestion. (It may be noted [see under Case 528] that the French
military authorities do not allow the use of hypnotism in the army.)
With respect to the present case (530), of course, the French observers
would not deny the power of hypnotism to produce the cure. Babinski and
Froment’s Postscript to the English edition of their work on hysteria,
remarks that, though Roussy and Lhermitte state that vasomotor symptoms
may disappear along with the psychotherapeutic cure of paralyses and
contractures, yet Roussy and Boisseau later admitted that improvement
in thermal and vasomotor control is at best an exceedingly slow one.

More recent personal communications indicate that there is still room
for some question as to the curability by suggestion of such disorders
as tic, tremor, vasomotor imbalance, and the like. In short, the true
scope of the “pithiatic” or suggestion-curable diseases is still
somewhat a matter of controversy.


Shell-shock: “Doll’s head” anesthesia, mutism: Hypnosis.

=Case 531.= (NONNE, December, 1915.)

An officer, mute for five months following shell-shock, had been for
four months treated in a succession of hospitals--field hospital, war
hospital, two reserve hospitals.

He had no acquired or hereditary neuropathic taint, but even in the
period before the critical shock he had been under tremendous physical
and mental strain. The explosion produced a total anesthesia of the
skin of the head, face, neck and shoulder region--in short, what
Charcot called the “doll’s head” form of sensory disorder. Moreover,
there was a marked contraction of the visual fields.

The patient, when treatment was given, fell at once into a deep
hypnosis and began to intone, and then to speak isolated words, and
finally to speak complete sentences. All that was left of his mutism
was a slight over-fatiguability of the speech organs. This also cleared
up in the next few days. He was discharged well, and had already
been--December, 1915--some months in the field.

Case 531, though an officer, responded to hypnosis well, and Nonne
remarks that hypnotizability is independent of the presence of
any neuropathic tendencies, or of any loss of resistance through
exhaustion. One trouble with the hypnotic method, according to Nonne,
is the fatigue of the hypnotizer and his inability to rely upon
assistants.

_Re_ Charcot, Nonne remarks that the work of Charcot on hysteria is not
sufficiently well-known, especially as civilian practitioners in peace
times had few cases. _Re_ taint, Nonne found such tendencies absent
in more than half of his cases with careful anamneses. The absence of
adequate psychogenic cause is a not uncommon experience according to
Nonne. Nonne, finding 26 cases of pure neurosis amongst 1800 cases of
war injury, had a considerable number of odd erroneous diagnoses in the
group. Not only were cerebrospinal paralyses wrongly diagnosticated,
but ischemic paralysis, plexus paralysis, arthritis deformans and
synovitis.


A soldier is put in the Landsturm at 22 and later called “unfit” by
reason of tremors after mine-explosion (history of tremors at 14 after
a fall), but is cured by hypnosis.

=Case 532.= (GRÜNBAUM, November, 1916.)

A _Landsturm_ soldier, 22 (father excitable, family otherwise normal),
had a history of being the best scholar in the class and well up to his
fourteenth year. At 16 he fell from a tree and though he apparently
sustained no injury his head and arm began to tremble. He became unable
to learn and gave up his preparations to be a teacher. The tremor,
however, disappeared in six months and he went into some technical
work. At 16½ years he went as cabin-boy, but in a fortnight he was
sent home by the physician. He then began to breed carrier pigeons
and got first prizes at international exhibitions. He also went into
foundry work and did well as an apprentice. He worked well at home and
busied himself with setting up small electrical and other machines.
He had never been interested in women and loved his pigeons best, and
therefore was regarded by people who knew him as not quite right. He
was also non-alcoholic.

After mobilization he was sent back twice but finally was put into a
_Jäger_ Battalion. After reaching the front he had to have a hernia
operation and on getting well went back to his place and a few days
later a mine exploded near him. He was much frightened and fell down
unconscious. On regaining consciousness he felt a “running” in the legs
and tremors in the hands. The latter grew stronger and began to affect
the arms.

After two months in hospital he went to garrison unrecovered, was
placed in the _Landsturm_ and did four months station duty in Russia.
The tremors persisted and when his comrades played a bad practical joke
on him the tremors got so bad that he was sent back home as unfit for
service.

He was a stocky looking, well-nourished man of middle height, without
visceral disease or sign of organic nervous disorder. The shaking
tremor grew much more powerful in any state of excitement but always
paused sufficiently to permit the execution of any particular movement.
The head movements were continuous, slight rotations. There were a few
regions of anesthesia to touch, but these areas differed at different
examinations. There was a general hyperesthesia. Conjunctival, corneal
and pharyngeal reflexes were absent. The man was slightly excitable,
apprehensive, depressed, complained of sleeping badly, did not want to
sit or stand and felt as if he wanted to run away, no matter where.
In dropping off to sleep he would fall out of bed and talked aloud in
his sleep. He thought he was incurably sick. Intelligence and school
knowledge were very good.

He was hypnotized eight times for periods of about five minutes each.
Hypnosis was extremely easy to accomplish. At the second trial the
manual tremor disappeared. After the third trial there was an essential
improvement in the shaking tremor. Moreover, his emotional state had
become happier. He began to sleep well. He was now free from disease
and regained confidence and looked upon himself as well and fit for
work. Undoubtedly without hypnotism this man would have been released
from service after a few months of inconsequential hospital care
without pension.

_Re_ tremors, see remarks under Case 308, concerning the possibly
organic nature of many of the so-called Shell-shock tremors; an opinion
apparently shared in by Meige and by Guillain. Babinski also found that
these tremors were not influencible by psychotherapy. Yet here is an
instance in which tremors are reported cured by hypnosis, and moreover,
tremors that were recurrent from an ante-bellum attack at 14. See
remarks under Case 530.


Shell-shock, slight injury, unconsciousness: Astasia-abasia: Recovery
under hypnosis, two séances.

=Case 533.= (NONNE, December, 1915.)

A musketeer, without neuropathic taint and without nervous symptoms
before the war (parents both dead of tuberculosis, eleven brothers and
sisters died young), saw four comrades killed by a shell October 27,
1914. The musketeer himself was slightly injured superficially in the
back. He remained unconscious for three hours and on coming out showed
general tremor of the body, felt pressure in the head, was lachrymose
and unable to walk or stand. He was subject to insomnia. He was in four
different hospitals, finally reaching Eppendorf. Diagnosis rendered at
the first hospital and carried on through the others was hemorrhage
into the spinal canal.

For two months at Eppendorf he lay in extension. He was then examined
by Nonne, who found general neuropathic habitus, pronounced “cramp
neurosis” in the lower extremities, psychogenic astasia-abasia,
hyperidrosis of the lower extremities, marked cyanosis of feet and
lower legs, increased tendon and skin reflexes, pseudoclonus, no
Babinski or Oppenheim reflexes. The man complained of pressure in the
head, sleeplessness, a feeling of depression and hopelessness. Pulse
120-130.

Hypnosis proved easy. After the first treatment the man stood and
walked and showed no tremor. The next day the hypnosis was repeated and
the cyanosis of the legs disappeared. Sleep on the second night was
good. Appetite returned and the man fell into a good emotional state.
Thereafter the patient was intentionally ignored by the physicians
and could soon not be distinguished in any respect from the other
non-nervous convalescents.

This case is expressly stated by Nonne to resemble in all respects
those formerly described by Oppenheim as “traumatic neurosis.”


Crural monoplegia: Cured by hypnosis.

=Case 534.= (HURST, 1917.)

A Belgian soldier fell into mud on the collapse of a roof from which he
was observing the enemy. It was an hour before he got his left leg out
of the mud, and found it fixed in extension. He was sent to England,
where for three months the leg remained stiff. The spastic paralysis
did not seem organic as the leg was dragged behind. The knee and ankle
could be bent only by using much force. The entire leg was in all ways
anesthetic. Babinski sign gave additional proof that the condition was
hysterical: when the patient lay with arms folded and legs apart and
then tried to sit up, the normal leg was lifted and the paralyzed leg
remained flat.

According to Hurst, the paralysis and stiffness were due to an
autosuggestion from the legs being embedded in mud. The anesthesia
was probably a matter of medical suggestion produced in the course of
examination during the three months of disability. According to Hurst,
Babinski is right in supposing that hysterical anesthesia is almost
invariably produced by the observer.

Accordingly a strong faradic current was passed through the leg, and
he was assured that sensation and power would be restored. However, he
could still walk only with difficulty.

Hypnosis was therefore resorted to and repeated on several occasions.
He went back to duty in three weeks, although he still held the leg
somewhat stiff when he walked.

_Re_ recurrences after hypnotism, see remarks of Nonne under Case 530.
Howland also notes that cases treated by hypnotism must be followed up
to prevent relapse. In the above case of Hurst’s, it will be noted that
the hypnotic treatment was several times repeated.


Shell-shock, emotional (slight trauma): Tremors and sensory impairment:
Cure by hypnosis, thrice repeated.

=Case 535.= (NONNE, December, 1915.)

A reservist, always well, not neuropathic (mother had had seizures,
possibly epileptic, for many years) was wounded in the left calf by a
shell fragment, about the middle of December, 1914. He was at the same
time, as a result of the shell explosions near by, afflicted with a
tremor of the whole body; this tremor gradually increased and proved
refractory to all treatment for nine months.

At the beginning of September, 1915, the patient reached Nonne’s wards,
showing tremor of head, arms and legs, with pronounced hypalgesia of
the whole body, abolition of frontal and conjunctival reflexes, and
contraction of the visual fields.

The tremor of the head was completely removed at the first hypnotic
treatment. There was a slight recurrence of this tremor two days later,
and traces of it could be observed for nine days. A third hypnotic
treatment swept away this tremor, which did not return.

The patient was discharged after about four weeks, suitable for
garrison duty.

_Re_ traumatic neurosis, Nonne dislikes this term of Oppenheim, because
such a term rather tends to connote unfavorable prognosis. As quoted
under Case 530, Nonne holds that the war data show that hysteria is
neither a form of degeneration nor an affair built on the Freudian
schema.

Nonne in fact maintains that the hysterical syndrome may occasionally
occur with much greater ease in a normal person than ever has been
known before. It is precisely in these cases of normals getting
hysterical that Nonne gets especially good results with hypnosis. If
the development of the hysterical syndrome had extended over days or
weeks, then the hypnotic cure was a slower one. The above reservist
developed his Shell-shock gradually and required three hypnotic
treatments. But although the number of doses of hypnotism required may
be said roughly to depend upon the time which the condition took to
come to a head, yet there is no similar rule _re_ duration. A miracle
cure may be brought about even in cases that have lasted over a year.
This result, if confirmed, would signify that the hysterical condition
once fixated did not especially increase in its tenacity.

_Re_ hypnosis in Germany, it should be noted that Nonne is the chief
protagonist for hypnosis, at least among the well-known neurologists.
Psychoelectric cures, which the Germans term Kaufmann’s cure, are also
greatly in vogue in German clinics. Despite the well-based claims of
Lt.-Col. Myers and of Eder, some English observers appear to condemn
hypnosis as inadequate, or even as dangerous.

A series of relatively successful cases like those here mentioned
might yield a wrong impression of the value of hypnosis (see Feiling’s
unsuccessful case 369).


Hysterical paraplegia of gradual development: recovery only under
repeated hypnosis.

=Case 536.= (NONNE, December, 1915.)

A volunteer, of nervous parents, had for four years suffered from
attacks of uncertain (hysterical or epileptic) nature. These attacks
came on again after strenuous marching in the campaign in Belgium and
France. Released from service at the front and detailed for guide
duty, he proved unsuitable for this work, too, and was sent back to a
hospital at home. Here there gradually developed a paralysis of the
lower extremities. Treatment proved ineffective.

At the end of January, 1915, he came to Nonne’s wards at Eppendorf with
a paralysis that had lasted six months. There was a total paraplegia
inferior, with anesthesia for all sensation from the knees downward.
The lower legs and feet were cyanotic and cold. The tendon and skin
reflexes were lively. There was a moderate contraction of the visual
fields on both sides.

Under hypnosis, the patient proved able to move both joints somewhat,
but very weakly and slowly. The patient was hypnotized daily for a
week, and made slow progress. Only after another week did it prove
possible to get him to stand. After four weeks, his gait had so
improved as to look like that of a tired old man. Three weeks more of
treatment permitted the patient to walk, run and hop normally. Repeated
_waking_ suggestion had failed to accomplish anything in this case. The
improvement followed only hypnosis. It seems to be a general principle
that in cases of gradual development, the recovery by hypnosis will
also be gradual.

_Re_ repeated hypnosis for cases of gradual development, see remarks
under the preceding case (535).


Struck by rifle butt: blindness of an eye already poor. Shell-shock:
dysbasia. Hypnosis.

=Case 537.= (ORMOND, May, 1915.)

A lieutenant, 20 years, managed to get into the army despite the fact
that he had never been able to use his left eye, owing to hypermetropia
and amblyopia. He was hit on the left side of the head by a rifle butt,
and knocked unconscious, in June. On recovering, he found he could not
see at all with his left eye, which he had never been in the habit of
using. August 10, he was wounded slightly in the left thigh. August 23,
while still on duty, with the wound not completely healed, he was blown
up by a shell. He regained consciousness on a stretcher. Feeling the
pain in his old wound, he thought he should be unable to walk.

On shipboard, he found that he actually could not walk. He kept his
left eye covered by a shade on account of headache that would follow
exposure to light. He was much excited and had bad nightmares.

After the journey home from the Dardanelles, it was found that the left
eye was normal except for the hypermetropia, despite the fact that he
was quite unable to see with the eye.

He was hypnotized four times, losing the nightmares and much of the
headache after the first treatment; the eye pain on exposure to
light, after the second treatment; and the blindness, after the third
treatment. He was now able to see with his left eye as well as before
he was struck. He was still unable to walk without crutches. Hypnotized
the fourth time, he was told he could walk, and did so.

For hypnotic treatment of blindness, see under Case 521. _Re_ blindness
of eye already poor, see Cases 294-301 (296 and 297 eye cases). Ormond
states that in the treatment of Shell-shock blindness, he first tried
rest, tonics, cutting off tobacco, confinement in bed, isolation,
persuasion, encouragement, counter-irritation; but that all these
measures failed. Suggestion and hypnosis succeeded.


Shell explosion; concussion; retinal hemorrhage: Blindness. Cure by
hypnosis.

=Case 538.= (HURST, November, 1916.)

An English private, 22, was looking over a parapet, July 18, 1915.
He afterward remembered sand thrown in his eyes and a fall backward,
hitting his head, after a shell had struck the sandbags in front of
him. He was unconscious 24 hours. Upon recovery, he found himself
completely blind, save that he could just tell light from darkness with
the left eye. His eyes were sore and eyelids blackened; there was also
severe headache and partial deafness.

Hearing returned and the headache improved shortly; but the condition
of the eye seemed more permanent. On forcibly opening the eyes,
September 14, they were turned far upwards so that the iris could
scarcely be seen. Some sand grains were buried in the conjunctiva, not
in the cornea. There was no inflammation about the sand grains.

In hypnosis, he was told that he would see on waking. The moment he
woke, this suggestion was repeated forcibly and his eyes were held
open. He cried out that he could see; tears ran down his cheeks; he
fell on his knees in gratitude. Three days later, he said he was able
to see as well as he had ever seen. There was, however, an opacity
of the vitreous of the left eye, the result of a retinal hemorrhage:
doubtless the result of injury at the time of the explosion. September
30, he had perfect vision in the right eye and 6/36 in his left.

_Re_ results of hypnotic treatment, Lt.-Col. Myers, summarizing 23
cases of Shell-shock, got apparently complete cures in 26 per cent, and
distinct improvement in another 26 per cent. He failed to hypnotize 35
per cent, and got no improvement after hypnosis in 13 per cent. Is the
recovery after hypnosis complete and permanent? Lt.-Col. Myers believes
that it may be, but others remark the tendency to relapse (see Case
534). Similar objections may be made to the psychoelectric treatment as
used by Vincent, Yealland, or Kaufmann. See under Case 535.


Appendix operation: Post-operative retention of urine. Relief by
hypnosis.

=Case 539.= (PODIAPOLSKY, August, 1917.)

A soldier, 32, operated for appendicitis, had a post-operative
retention of urine. Hypnotic suggestion was requested to reëstablish
excretion of urine before resort should be had to the catheter.

Somnambulistic amnesia was obtained at once and without questioning him
P. suggested to him directly that he must feel the need of micturition.
The suggestion was unsuccessful. However, bearing in mind psychogenic
obstacles of an unknown nature, P. questioned the patient as to
sensations and learned that in the operation the skin had been burned
about the urinary passage and that the patient feared micturition.
Besides this, micturition was painful on account of the wound above the
appendix. The patient also feared that the sutures would yield.

Accordingly assurance was given that the burned parts would be
insensible and that the bladder could be emptied without effort and
without endangering the sutures. Analgesia was produced by a few
passages of the hand upon the bed clothes. Complying with post-hypnotic
suggestion the patient urinated after a quarter of an hour of sleep,
and in thirty-six hours retention was relieved.

With respect to frequency of immediate somnambulism for the first
trial, P. states that, although authorities set the percentage of
successful immediate somnambulisms at 17-20 per cent, war conditions
yield three or four times as high a percentage. The war has produced a
suitable soil for hypnotism. Hypnosis is impossible in from 1½ to 2 per
cent of cases.


Wound of sciatic nerve: Pains after operation. Relief by hypnosis.

=Case 540.= (PODIAPOLSKY, August, 1917.)

A German prisoner, 33, was admitted to a Russian Hospital, November
11, 1916, with “a bad wound of upper right thigh, marked pains in
right sciatic nerve especially affecting feet.” Morphine and pantopon
did not abolish the pain. Insomnia. November 13, the sciatic nerve
was surgically freed from a scar and laid in the midst of the femoral
biceps. Every evening pantopon was injected; but the pains and insomnia
persisted nevertheless.

November 19, he was hypnotized. The pain stopped. He had an excellent
night, and the next day felt only a slight pain in the toes.

Curiously enough, while giving him suggestion in the German language,
P. had said fingers instead of toes (inadvertently, since the Russian
language uses the same term for both). He slept well to November 29 but
still felt a slight pain in the toes. On November 29 another hypnotic
sitting was given, and the toes this time were named correctly. The
next day the patient said, “You have relieved me of all the rest of my
pain.” He had no pain thereafter and the morphine and pantopon were
dispensed with. Sleep returned.

Incidentally, this patient had his hair grow white in a few months of
war.


Ship blown up by mine: Stereotyped explosion dream by survivor: Cure by
hypnosis (also of antebellum habitual headache).

=Case 541.= (RIGGALL, April, 1917.)

A survivor of H.M.S. T.B. II, blown up by a mine off Harwich,
was admitted to the naval hospital at Chatham, March 3, 1916, a
well-nourished, nervous looking lad, aged 20. After the accident, he
began to dream, always the same dream, of the explosion, waking up with
the cry of the ship mates, and then unable to sleep the rest of the
night. The knee and ankle-jerks were somewhat exaggerated.

April 15, when there had been no improvement, he was hypnotized. The
patient was told to lie back in an arm chair, make himself comfortable
and allow muscles to relax. He was told to fix his eyes and concentrate
his attention on an electric lamp. The suggestion of sleep was made,
and he was repeatedly told in a monotonous voice that he was becoming
more and more sleepy. Then in an emphatic voice he was told that the
treatment would completely cure him. He had no more dreams after this
first sitting.

Hypnosis was continued every other day until April 20, when he was
discharged cured. After the first sitting hypnosis was induced by
simply telling the patient to go to sleep, which he would immediately
do on entering the room, while still standing up. At subsequent
sittings, he was made to write twenty times such phrases as: “I feel
much better”; “I shall have no more bad dreams.”

Once when a tooth was to be pulled a post-hypnotic suggestion that no
more pain would be felt was given, nor was any pain felt. Headache
persisted after the first two or three sittings. Accordingly, during
hypnosis a pencil was pressed to the forehead with the suggestion that
it would burn and that after waking there would be an itching pain for
half an hour, followed by recovery from headache. Curiously enough, a
distinct erythema of the skin was observed over the point of pressure.
Toothache and headache vanished.


Shell-shock from air-craft bomb: Amnesia: Recovery under hypnosis (also
removal of a headache dating from childhood).

=Case 542.= (BURMISTON, January, 1917.)

May 22, 1916, a stoker, 26, was found on shipboard in a workshop
behind oil drums, refusing to come out, looking dazed, not recognizing
messmates, suspicious and complaining of headache. He reached the Royal
Naval Hospital at St. Malo, May 24, answering questions “Don’t know,”
and physically normal except for diminished knee-jerks. At the end of
two or three weeks he would answer questions about his stay at the
hospital, but complained of headache or weight in the head. Wassermann
reaction, negative.

Special examination on May 26, showed an amnesia for everything up to
his arrival at St. Malo. For example, he did not know the name or use
of a hammer or a pressure gauge, though he knew the pressure gauge was
made of brass and glass, having seen brass and glass in the hospital
wards. He had no idea of the nature of a ship. He was sent to the
sick bay at the Royal Naval Barracks at Chatham, July 7, carrying a
recommendation that he be retrained as a stoker.

He was put under hypnosis, induced by gazing at the brass knob of
a paper weight. He went off easily, was told there was nothing to
worry about, taken back to the beginning of his illness, and asked
what happened. He told about a bomb explosion from aircraft, and how
he had lost his memory after a nearby explosion. He told how he was
married and had a child 21 months old. During the narrative about bombs
falling, his worry was such that he was put in a deeper hypnotic sleep,
and was told that he would remember all that had happened. Upon being
ordered to wake up, he remained dazed for a few moments, and then said
that he was all right. Asked about his marriage, he replied that of
course he was married and had a child.

After four days leave, he returned, July 13, without trouble except a
headache, from which it appeared that he had suffered ever since a
fall when a child. He was again put into a hypnotic state and asked to
remember the accident that caused the headache. He was conducted back
through the years, and finally described a white house in India, his
fall in the area, the black people in white clothes, the cut bleeding
head. He was told that he would have no more of such headaches. On
being wakened, he said that his headache was gone, and retold the story
of the accident. August 2, he said he had never felt better in his
life. September 1, he was drafted to a seagoing ship.


Shell-shock, unconsciousness: Convulsions (recollection of childhood
convulsions): Cure by hypnosis.

=Case 543.= (HURST, March, 1917.)

A New Zealander was rendered unconscious for a few minutes following
concussion from a high explosive shell. Convulsions developed,
occurring at least once and often several times a day.

As to the origin of these convulsions, it appeared that the soldier
had had a few convulsions after falling on his head at the age of
8. According to Hurst, recollection of these childhood convulsions
probably led by a process of autosuggestion to the Shell-shock
convulsions.

Captain Crabtree hypnotized the man, suggesting recovery. The fits
immediately ceased and did not recur.


Recurrent hysterical mutism. Spontaneous recovery in (_a_) 18 months
(antebellum incident). (_b_) Hypnotic recovery in a few minutes.

=Case 544.= (EDER, August, 1916.)

A soldier in a mine accident eight years before the war, lost his
speech when his brother was killed, and then recovered his speech
spontaneously after 18 months.

After a shell explosion in Gallipoli, he was again struck speechless
and also deaf.

Six weeks later, he came to Dr. Eder and objected in writing to
treatment, saying that he believed in nature’s methods. God had taken
his voice away before and had restored it. Eder replied in writing
“rather irreverently” that God had taken 18 months, but he could do it
in a few minutes. The patient afterward consented to treatment, and
speech and hearing were duly restored in the time promised, whereupon
Dr. Eder told him that in point of fact his physician was merely the
instrument of Providence.


Neurasthenic symptoms: Cured by repeated hypnosis.

=Case 545.= (TOMBLESON, September, 1917.)

A private, 24, was admitted to hospital with diagnosis neurasthenia,
March 11, 1916. He suffered from vertical headache; general analgesia,
more definite on the right side (patient left-handed); loss of smell
and taste, also more definite on the right side; paresis of right leg,
with dragging of foot (old trench foot); and sleeplessness.

The next day Tombleson put him in a hypnotic state, third stage, and
again, March 13, but without results.

March 14, the somnambulistic stage was reached in hypnosis, and next
day the man’s headache was much relieved as a result of the suggestion
offered. He was again hypnotized and the following day, March 16, the
headache had vanished and the man was in general much improved. In
somnambulism the disappearance of the analgesia was suggested, and it
proved possible to make the man walk about without limp and without
dragging the right foot. Next day the analgesia was much relieved. In
somnambulism the suggestions were repeated.

March 18, the man said he was quite well, and proved to be so on
examination, except that he could not yet taste with absolute normality
on the right side. In somnambulism it was further suggested that the
cure was a perfect one and included the sense of taste. However,
March 25, the expected improvement had not yet occurred in the taste,
whereupon further suggestions were given in hypnotic somnambulism, _re_
taste. Next day taste had become normal.

_Re_ hypnosis, Tombleson says that the most successful cases of
hypnosis are those of Shell-shock psychasthenia, but that he gets
very good results with hyperthyroidism and with neurasthenia also. He
goes so far as to say that practically all cases of war neurasthenia
and psychasthenia can be cured and sent back to work if treatment by
hypnotic suggestion is used in a reasonable time.


Neurotic symptoms: Improvement under repeated hypnosis.

=Case 546.= (TOMBLESON, September, 1917.)

A private, 32, was admitted, April 15, 1916, to Tombleson’s ward from
the Cottonera Mental Ward with the diagnosis: psychasthenia with
paresis of right arm. The man was very suspicious of the medical
profession, melancholy, morose and prone to tears. He had been kicked
by a horse four years before and showed a depressed and very tender
scar in the right parietal region. The right side of the body since
that injury had been getting weaker, but the arm was much weaker than
the leg. Anesthesia was practically complete on the right side. There
was a wasting of the muscles of the right arm and the skin of the hand
and fingers was thin and shiny.

Before his transfer the man was placed in the somnambulistic state,
with suggestions of happiness and confidence in the coming cure. He
arrived at Valletta, April 16, in a cheerful frame of mind, stating
that there was nothing now the matter but weakness. Under somnambulism
the loss of symptoms was suggested and, April 17, the patient was well
except for the loss of power in the arm and leg. Daily training under
somnambulism was given for a period of seven days, with suggestions
especially leveled at the paretic muscles. He was then so far recovered
that hypnotic treatment was stopped. The patient went to England, May
12, 1916, well.


Convulsions, “Jacksonian,” and dysbasia: Cure by hypnosis.

=Case 547.= (TOMBLESON, September, 1917.)

A private, 18, was admitted to hospital, March 22, 1916, with the
diagnosis Jacksonian epilepsy, with marked functional gait. He had just
had several fits--two March 20, two March 21, and several earlier. He
was tremulous and could not stand. Much pain. Knee-jerks brisk.

There was a history of a fall into a harbor at seven, followed
by bleeding from nose and ears and unconsciousness for a week.
Convulsions, involving the face, arm and leg, and attended by
unconsciousness, kept recurring until twelve. Five months before
admission there had been cerebrospinal meningitis. In February at
Salonica he had had pneumonia.

March 23-24 the soldier was hypnotized to the third stage, but he had
two fits. A “funny feeling in the right big toe” was brought out and
suggested away. March 26-27 the patient was able to walk with a typical
functional disorder. Under somnambulism the suggestions were repeated,
but on the evening of March 27 two more convulsions appeared. In
somnambulism he explained that he “had got round” the inhibition of the
aura.

The night of April 2 occurred two convulsions. April 5, the man was
placed in the somnambulistic stage to last three days. During the
night of April 6 he was observed to be restless for an hour, with some
twitching of the right face, yet no fit followed. The morning of April
8 the patient woke feeling well. He was again placed in somnambulism to
last two days. Two hours later, however, a fit started. It was stopped
at once by suggestion, but the patient woke. He was left awake the
rest of the day. April 9, somnambulism: suggestions repeated; sleep to
last for two days. That evening there was a slight beginning of a fit,
which was stopped at once by suggestion, the patient waking April 11 in
another beginning of a fit, stopped by suggestion.

Thereafter no more fits recurred at all. May 12, 1916, well.


Agoraphobia: Cure by hypnosis.

=Case 548.= (HURST, 1917.)

A captain was (with one lieutenant) the sole survivor among his
battalion officers at Ypres. The captain received the D. S. O. for his
gallant conduct in saving the remnant of his battalion. He now felt
he could never face responsibility again and that he would disgrace
himself if he ever got into danger. He developed a terrible dread of
open places and became more and more depressed. When he heard that
there was going to be an attack at Neuve Chapelle, he broke down but
managed to get through the first day of the battle. He was worse
off than ever in the evening, felt that he could not face another
day’s fighting, was invalided home, and arrived in a condition of
exhaustion and feeling of disgrace. He had bad dreams at night. Rest
was insufficient to restore confidence. Hypnosis was followed by rapid
improvement, and the man was soon able to get back to duty.

_Re_ agoraphobia, see Section A, XI, Psychopathoses, and also Steiner’s
case (182) of claustrophobia, in which shells were preferred to safety
in a tunnel.


Stress on Eastern front; cardiac seizures; cellulitis: In
convalescence, manual tremors. Treatment eventually by forcing and
isolation.

=Case 549.= (BINSWANGER, July, 1915.)

A subaltern officer, 24, in civil life a student of mathematics, had
serious hereditary taint on both sides (father, alcoholic; maternal
grandfather, victim of “severe nervous disease”). As a boy he developed
normally, and was a good student. He served as volunteer in 1911 to
1912, but in drill in 1913 he had had to be released from service on
account of nervous heart and difficulty with respiration.

However, he was called to the colors at the outbreak of the war, and
was subjected to tremendous strain in the eastern campaign; and he was
put in the pack train at the end of November for cardiac seizures. He
had a cellulitis with furunculosis following, and at the beginning of
December there was suppuration of the whole right tibia. He was treated
in hospital and slowly recovered.

At the beginning of March, 1915, without obvious external cause, while
sitting in a café, the convalescent officer felt a cramp in his right
hand, and strong movements of the hand to right and left followed. He
was treated with bromides, but unsuccessfully. The tremors became more
marked and then again from time to time grew weaker. Electric treatment
increased the shaking to a maximal degree. April 27, the patient was
brought to the nerve hospital at Jena.

The patient was a fat and muscular man, of average size, with very
small ears and poorly-developed, adherent lobules, and syndactylism
of the second and third toes of both feet; reflexes increased; marked
dermatographia; a static fine tremor with rapid oscillations. The
tremor became a positive tonus if the arm and hand were stretched out
horizontally. Face and chest reddened easily.

Whenever any other voluntary movement was carried out (even slight
finger movements of the left hand or of the right or left foot
while lying in bed) this right-sided convulsive tremor immediately
disappeared. The movements could also be made to disappear by slight
turning movements of the head or of the tongue. Moreover, when the
mind was diverted, as in reading, the tremors ceased. When the patient
thought intensely of some mathematical problem, he could bring his
shaking to a stop. The left grip was stronger than the right. In the
Romberg position there was a marked swaying to the left and backwards.

Subjectively, the patient complained of nothing but a circumscribed
headache in the left parietal region and of sleep interrupted by
frightful dreams. At first the condition remained unchanged. There was
much insomnia, and the slightest noise caused fright. Headaches in
the daytime also were produced by any noise, and these headaches were
localized in the left parietal region. The tremors of the right hand
persisted except as he caused them to stop as above mentioned. He could
write well with his left hand. He would drum with his left hand on the
table until the tremor of his right hand disappeared. He could play on
the piano, playing first with the left hand until the right had become
quiet. He was a very irritable man, passing into anger and extreme
profanity at the slightest occasion, and it was very difficult to bring
him to any kind of orderly activity or persistence in therapeutic
measures. These consisted of baths, massage, and gymnastics, but they
proved quite unavailing.

As the fellow got more and more intolerable, and as upon May 27 at
about 9 o’clock in the evening, he disturbed the quiet of the entire
hospital by a severe paroxysm of scolding, he was placed in a single
room in the psychiatric department. He was placed in bed, cut off from
all communication with others, and forced to carry out his exercises.

For two days he was surly, crabbed and obstinate, but then changed
his demeanor completely; he became friendly and obedient. The tremor
completely disappeared.

Five days later he was able to carry out all active gymnastic exercises
with great energy and without the slightest disturbance in the right
arm. At date of report he was busy in the garden.


Five weeks’ field service: Loss of speech. Cure by verbal and electric
suggestion in three weeks.

=Case 550.= (SCHOLZ, December, 1916.)

A grenadier, 21, of healthy stock, physique, and habits, lost his
speech, April 15, 1916, five weeks after going into the field. May 5,
examination showed him a well-nourished healthy man (lively reflexes
and slight dermatographia), able to communicate only by signs and
writing. The laryngoscope showed almost complete immobility of the two
vocal cords, which lay in the cadaveric position, as in paralysis of
the recurrent nerves. In endeavoring to pronounce the vowels ā and ee
the cords trembled but failed to move toward each other. The patient’s
effort to speak was such that his head soon got deep red and sweat
streamed from the forehead.

Speech exercises were started by passing the electric current through
the larynx during the processes of laryngoscopy. The patient was
meantime assured that his larynx was healthy and that he would soon
learn to speak again. At the first sitting, the patient felt himself
able to cough aloud.

After a few days, the patient was able to speak the separate vowels
tolerably well, and was then made to go on with such words as Anna,
Otto, Hurrah. The vocal cords began to move better. Fatigue was a
feature of the first treatments, of such a degree that words that could
be pronounced during the first part of the sitting were lost toward the
close.

The grenadier assiduously set himself to say over and over again the
words that he had learned, and would come to the sister radiant with
joy at his success. In ten days he was able to speak again perfectly,
though giving the impression of a slight stuttering. After three weeks
hospital stay he was discharged cured and fit for service.


Struck by a rifle butt on right side of head; old wound of right thigh:
Hysterical right hemiplegia and deafmutism. Treatment by faradization:
Return of speech and improvement of hearing. Full recovery by
suggestion. Hysterical CONVULSIONS developed BY HETEROSUGGESTION from
convulsive neighbor.

=Case 551.= (ARINSTEIN, 1915.)

A Russian corporal, 21, was knocked unconscious, September 13, 1915,
by a butt of a rifle which struck the right side of his head. He came
to in a short time. He was examined in hospital, early in October, and
besides a small skin wound of the head, there was evidence of a wound
on the anterior aspect of the thigh. There was paralysis of both right
arm and right leg, and anesthesia of the entire right side of the body,
face and even of the tongue. There were also pains over the whole
right side of the body. The abdominal reflexes were present on both
sides; the tendon reflexes were in excess on the hemiplegic side; there
were no pathological reflexes of any sort. The patient’s hearing was
diminished, and he could not speak at all although he could understand
the speech of others perfectly.

Speech returned after a single séance of suggestion with faradism to
the throat. Hearing began to improve. The patient’s suggestibility
was a favorable factor in his cure, but there were some unfavorable
features. One day, he saw a neighbor go into convulsions and proceeded
to develop convulsions himself. These hysterical convulsions continued.
According to Arinstein, such undesirable complications appear under
conditions of extreme crowding of hospital patients suffering
from shell-shock. Progressive séances of psychotherapy caused the
disappearance of all the signs of paralysis, and at the time of the
report, there was no disability, except that the full use of the hand
had not yet been regained.


Shell-shock and burial; labyrinthine disease on one side: DEAFMUTISM.
Cures, relapses and eventual cure by general anesthesia, more than four
months after shock.

=Case 552.= (DAWSON, February, 1916.)

A private, 30, had been 12 years in the service. July 8, 1915, he was
partially buried by a shell which killed two companions.

On admission to hospital he spoke a few sentences but was deaf, and
next morning could neither speak nor read, nor did he take food for 36
hours thereafter.

Admitted to the King George Hospital, July 18, he was found stuporous,
but started violently if touched, made signs indicating his wants, took
no interest in surroundings, and resisted efforts to arouse him. He was
without signs of organic disease. It seems that he had been a nervous
child, with nightmares and fits.

July 24, he was given gas for dental extraction, partly in the hope
that he would recover speech; but though he struggled violently, he
made no sound. He had by this time become rather intelligent in a
childlike manner, being pleased to see his small boy, but taking no
notice of his wife. It transpired afterward that he did not recognize
her.

Phonation in whisper now began. There was then a relapse, and for a
week or more no food was taken. Such relapses with irritation and
hypobulia and an obstinate constipation recurred; but improvement
came on slowly. He became able to read short printed words, and later
handwriting.

For another month there was no improvement and he lost heart and the
will to get well, brightening up only when offered a motor drive or
something else pleasant. He was transferred to an auxiliary hospital,
against his will, September 18.

November 1, he was brought back to the King George Hospital, excited,
shouting, struggling and evidently drunk. On a day’s leave from the
convalescent hospital he had come up to London, and in alcoholic
elation began to laugh and talk. Morphia did not reduce his violence.
He insisted on seeing the physician, to tell him the good news. Hearing
was still diminished, though if attention were diverted, direct answers
were given to some questions. Sleep followed.

The next day he spoke perfectly but could hear nothing. There was no
further progress for three weeks, though he occasionally caught sounds.
He now became bright and pleasant and had lost all irritability and
sulkiness. Galvanic and faradic current had no effect on the ears.

November 27, after elaborate preparation to heighten the suggestive
effect, the patient was kept in bed and given gas and ether up to the
abolition of the corneal reflex. As he was coming round, the doctor
shouted that he could now hear well. He was overcome with joy and had
hysterical convulsions. He could hear, but with the right ear only. In
point of fact, the left ear on examination showed signs of labyrinthine
deafness. He was placed on home service.

_Re_ etherization for functional deafness and mutism, Ninian Bruce
maintains that ether is more satisfactory than chloroform. The loss
of consciousness in cases of deafness and mutism ought to be a
relatively slight one, and the patient should be suddenly roused to the
realization that he is speaking. Recovery from chloroform anesthesia
is, according to Ninian Bruce, too slow to allow the patient to catch
the point that he is now speaking and hearing when he was formerly dumb
or deaf. A failure with the method is a bad thing for the patient, as
he loses confidence in the method, whereupon some other method must be
resorted to.

_Re_ etherization for deafmutism, see technic of Ninian Bruce under
Case 553. Penhallow has a case in which during primary etherization the
patient reviewed in a loud voice the whole story of his speech loss.
He was found to have recovered speech and hearing after coming out of
ether.

_Re_ anesthesia by gas, Abrahams has used nitrous oxide for cure of
hysterical paraplegia. Proctor also reports the use of light ether
anesthesia for bringing out the voice of functional mutes.


Shell-shock functional deafness (five months). Yes-No test. Cure by
suggestion on emerging from ether anesthesia.

=Case 553.= (BRUCE, May, 1916.)

A soldier was admitted to the Royal Victoria Hospital, Edinburgh,
completely deaf in the left ear. He had been under shell fire a number
of times in France and was eventually thrown down and made unconscious
by a shell explosion on his left. He did not remember the noise of the
explosion or anything until he found himself in hospital. After the
explosion he had begun to stutter, and the stuttering had grown worse.
Examination of the ear indicated that the deafness was functional. He
was given ether and when just under was asked if he could hear anything
spoken in his right ear. He said, “Yes.” With the right ear closed he
was asked if he could hear when his left ear was spoken into. He said,
“No.” This test was repeated several times. After covering his right
ear, he gave his name, regiment, etc., in reply to questions whispered
into his left (previously deaf) ear. The incongruity was pointed out.
He was now suddenly wakened. He laughed hysterically with joy over his
recovery.

But the next morning he was again stone deaf in the left ear.
Blistering and electricity failed to produce benefit. He was, however,
puzzled about himself.

After a fortnight he was again given ether and a little chloroform was
added. The yes-no test was again positive. He was allowed to recover
gradually from the chloroform, but he had now lost recollection of what
had happened. The left ear remained deaf. Ether was again given. He was
asked to close his right ear with his finger. While answering questions
addressed to his left ear, he was suddenly awakened and immediately
said that his hearing had come back. This return proved permanent. He
returned to his dépôt. In the conversations under ether there was no
stuttering. He had been totally deaf in the left ear for five months.


Blow in neck by rifle butt: aphasia, right hemiplegia and
hemianesthesia, and especially (here MEDICAL suggestion) trismus:
Recovery by anesthetic and suggestion.

=Case 554.= (ARINSTEIN, September, 1915.)

A Russian soldier was struck in the head and neck by a rifle butt, and
developed paralysis of right arm and leg with loss of speech. After the
excitement experienced by the patient when exhibited to the students
by the late Prof. M. N. Szukowsky in the neurological clinic of the
Military Medical Academy, trismus developed.

The patient spent a year in various hospitals, the most diverse methods
of treatment by drug therapy, electricity, and suggestion yielding no
results. The patient had to be fed chiefly by nose and rectum, though
small quantities of fluids were fed through the mouth through an
opening formed by the falling out of one tooth in the upper jaw. The
patient became greatly emaciated and weak and was, October 29, 1915,
brought into the nervous wards of the hospital.

He showed flaccid paralysis of left arm and leg, together with
anesthesia, analgesia and thermanesthesia over the whole left side of
the head, extreme general atrophy of muscles, somewhat more marked on
the palsied side. The temperature of the paralyzed half of the body
was not lowered. No knee or Achilles reflex obtained upon either the
affected or the healthy side (general exhaustion?). Abdominal and
testicular reflexes lively. The pupils responded well to light. Corneal
reflexes lively. The neck was held awry to the left, and the head
was inclined somewhat downwards and leftwards; hearing on left side
impaired. The jaws could not be opened even with the greatest effort.
Wassermann reaction negative.

Patient thought himself incurable. Purves Stewart’s case, in which
chloroform and oxide of nitrogen were used, was the basis of
Arinstein’s treatment. It was suggested to the patient that he submit
to narcosis with the proviso that he would not be operated upon. His
consent was secured; with the coöperation of others, the chloroform
was administered November 6. The stage of excitability was not well
marked. 8 gr. of chloroform was used altogether, by the drop system.
Nevertheless, even with the weak initial excitability, the patient
became capable of some movements with paralyzed hand and foot. On
opening mouth, the patient yawned yet uttered no sound. Between the
jaws was put a rubber insertion and upon awakening the patient was
let see with his own eyes that his jaws were open and that therefore
food might be introduced through the mouth. Upon repetition of the
narcosis, 5 gr. of chloroform was used altogether, and the stage of
excitability was this time better marked. To strengthen movements in
the paralyzed extremities, the device of pricking the patient with a
pin on the unaffected half of the body, with the unaffected hand and
leg held horizontal by assistants, was adopted. The patient then made
reflex defensive movements in the paralyzed extremities, especially the
hand. At this point the narcosis was suspended, and the irritation with
the pin was continued until consciousness returned. At this moment, the
patient’s attention was called to the disappearance of the paralysis
and his restored ability to move the paralyzed extremities.

From that time on, the patient’s condition underwent a sharp
transition. Artificial feeding became unnecessary. The patient ate by
mouth; the mouth was opened by the leverage of a small stick held by
the patient between his teeth. Speech returned gradually. In reading
aloud the patient aided the movements of his lips with his hands. At
the time of report the patient spoke well, ate normally, had gained in
weight, and with some effort could sit down and even stand and walk.
All this was attained in a relatively short time after a whole year of
paralysis.

The author felt that the success attained in this case gave him the
right to use the same method where the cause was not a contusion.


Ten months’ field service; severe FEBRILE DISEASE: Afterward hysterical
TRIPLEGIA, MUTISM, “JUMPING-JACK” reactions to stimulation of feet.
Cure by anesthesia, verbal suggestion, faradism to palate.

=Case 555.= (ARINSTEIN, September, 1915.)

A Russian private, 30, brought to a field reserve hospital, June 20,
1915, was in a grave condition diagnosed typhoid. By the end of June
the general condition had improved and the temperature had fallen.

July 9, worse; happening to be in the company of a sanitary in a
privy, he was observed suddenly to fall unconscious, with both feet
and left arm paralyzed. Soon afterward he lost the power of speech.
From September 30 to October 19, he lay in field hospital; but was
then transferred to the nerve hospital with diagnosis: convulsive
paralysis and aphasia. At entrance, complete paralysis of both legs
and left hand; loss of speech and aphonia (speech understood). Upon
touching a foot, strong convulsions developed with legs rapidly drawn
apart and drawn together much in the manner of dancing toys. The mouth
was twisted to the left. Though he silently opened his mouth and made
rapid movements with the lower jaw, he could not utter a single sound,
either vowel or consonant. Left hypalgesia. Hypesthesia of skin of hand
and mucosa of tongue. Knee-jerks absent because of the strain of the
muscles of the legs. Wassermann negative.

The history showed that the speech of the patient had been incorrect
and indistinct from childhood. Moreover, in 1908, in chopping wood in
the forest he had fallen under a sleigh and hurt his left hand, which
had not since fully recovered. He had volunteered for the war.

The psychogenic character of the disease seemed clear. Suggestion was
followed by ether narcosis, during which, on pricks of the healthy side
with a pin, the patient made defensive movements with the paralyzed
hands, and also moved both legs. Speech was not regained either during
or immediately after the narcosis, although the patient gave forth
indefinite sounds. Speech was restored on the same day, September
7, with verbal suggestion and faradic brush applied to palate. The
patient at once began to speak clearly and distinctly, read his prayer
book, and described distinctly and in detail how he went to war. From
that moment the convulsive movements in the feet disappeared, the
region of anesthesia on the left side narrowed, speech was permanently
reëstablished, and the patient began to move with his feet and finally
began to walk after six months of paralysis. Before that time no
medical treatment had had the slightest effect. The effort to stop
mechanically the jerks even temporarily by means of plaster casts had
been unsuccessful. In sleep the twitches ceased, but upon reawakening,
even before full consciousness returned, the jerkings would resume. It
is curious to note that upon falling asleep under the anesthetic the
patient would issue always one and same kind of yells--“_Help, there
goes the German! They are shooting! Russians, do not yield!_”

_Re_ chloroform anesthesia, Milligan remarks that the treatment should
be carried out in a quiet, single room, with the chloroform slowly
administered and the suggestions made by the anesthetist during the
optimal phase for suggestion,--just before the stage of involuntary
struggling.


Shell-shock; unconsciousness: Mutism and musical alexia. Cure by
anesthesia.

=Case 556.= (PROCTOR, October, 1915.)

A private, 23, was admitted to the Duchess of Connaught’s Hospital at
Taplow from Gallipoli, September 10, 1915. A shell had exploded behind
this man. He had been picked up, unconscious, and remained so about a
day. He recovered without the power of speech. Cerebration was slow at
first but improved steadily.

The man had been a professional musician. Curiously enough, though his
ability to read ordinary print was as good as ever, his reading of
music was lost with the speech.

September 20, he was etherized, but being of a phlegmatic type, he
was not readily excited and took the anesthesia very quietly. After
perseverance, however, he was induced to talk. The ability to read
music returned with the voice. He was discharged, October 4, 1915.

_Re_ the use of anesthetics for curing deafmutism, Colin Russel rather
disapproves of this method on the ground that no attempt is made to get
at the genuine pathogenesis of the case and that accordingly there may
be a tendency to recurrence.

_Re_ the peculiar musical alexia, see discussion under Cases 353 and
450 of confusion and amnesia. The most highly selective amnesias
have been found in confusional cases. However, Case 556 had been a
professional musician and the effect may have been a highly specialized
suggestion. See also Case 369 of Feiling for differentiated musical
disorder. Mott has used the retained knowledge of tones as an avenue of
approach in certain mute cases.


Shell-shock; burial (24 hours?); unconsciousness, 13 days: Deafmutism.
Chloroform narcosis cured the deafness (!), not the mutism.

=Case 557.= (GRADENIGO, March, 1917.)

An Italian infantryman was buried under Mt. Zebio after shell
explosion. After 24 hours he was found and dug out. He remained
unconscious for 13 days and came out absolutely deaf and mute.

At hospital he was markedly depressed and cried very readily on being
spoken to. The tympanic membrane had lost its sensitiveness to pain.
As for the speech mechanism, the larynx proved negative. All the
movements of the soft palate, tongue and vocal cords could be normally
performed. The tongue was anesthetic to touch, but the taste function
was perfectly preserved. The cheeks and various parts of the face were
also anesthetic to touch, and the lobules of the ears could even be
pierced with large pins without reaction by the patient.

He tried to pronounce labials, opening and closing the lips rapidly;
but the expiratory movement was too weak, and not a single sound was
made.

At the patient’s request, he was chloroformed. During a very violent
excited phase, he did emit groaning sounds. The narcosis, however, did
not put an entire stop to the mutism, since only a few inarticulate
sounds could be emitted, and those only after great efforts. Curiously
enough, however, the chloroform narcosis had caused the _deafness_
to disappear entirely. Another narcosis upon the patient’s insistent
request was given but remained without results, and at the time of
report, the patient though cheerful and intelligent-looking, was still
mute.


Treatment of two cases.

=Cases 558 and 559.= (SMYLY, April, 1917.)

A soldier was out with a bombing party when a shell burst. He came to
in a casualty clearing station, and was sent on to Salonica, deaf, dumb
and jumpy. Two months later, an attempt at hypnosis failed; faradism of
vocal cords failed.

The patient dreamed one night that if he vomited he could speak. Ipecac
produced vomiting without speech. The patient, however, wanted a second
dose, and while waiting for it, uttered an exclamation, which he did
not himself hear, however. In the meantime, Dr. Smyly had been trying
to hypnotize a second soldier, dumb but not deaf. This man’s dug-out
had been blown in on him seven months before, whereupon the patient
became very shaky, but did not become sick for a week. He was then
sent to hospital, and his voice gradually disappeared. He suffered
from violent headache and spasmodic movements of the arms and legs.
Suggestion seemed powerless, and ether was unexpectedly given to the
patient. While going under the ether, he said, “Oh dear, oh dear”
several times indistinctly. It seems that another physician had already
tried to cure the patient of dumbness by removing teeth without an
anesthetic.

While this therapy was proceeding with the dumb man, the deaf-and-dumb
man disappeared. It seems that the smell of the gas had caused him to
take refuge on an outhouse-roof. The next day he had recovered voice
and hearing completely, partly from shock and partly through suggestion.

The etherized patient did not recover voice but lost the spasmodic
movements and his insomnia. A week later ether was again administered,
and the patient was strapped down; as he was coming to, faradism was
applied to the head and face. The patient then quickly recovered his
voice and still retains it.


Shell wound: Hysterical dysbasia from contracture. Many methods of
treatment fail. Success with “a new measure,” _e.g._ stovaine.

=Case 560.= (CLAUDE, March, 1917.)

A sergeant was struck in the suprapubic region, December 15, 1915, by a
shell fragment and got a large hematoma in the perineal region (shell
fragment visible on X-ray). The man was treated a year in a center for
physiotherapy and was then treated in a neurological center, where a
faulty position of the right thigh maintained in extensor rotation and
abduction was found. The patient walked on crutches, legs wide apart,
balancing with body.

Upon transfer to Bourges, an intraspinal injection of stovaine (after
withdrawal of 2-3 cc. fluid, 1 cc. stovaine, 0.07 to the cc., mixed
with cerebrospinal fluid) was made. This reduced the contracture and
permitted the patient to place his legs parallel. They were then
bandaged in the parallel position. The bandages were removed two days
later and the limbs did not reassume their faulty position. The man was
shortly able to walk with a cane; progress was rapid. This man was very
desirous of cure and refused to be invalided, believing he was to be
cured, and had received medal and war cross. Simple motor reëducation
in competent hands had been without effect. A new kind of measure, such
as stovaine, proved successful.

_Re_ “new measures” for hysteria, see items under Case 516. See also
remarks upon cures by lumbar puncture under Case 488.


Burial: Hysterical dysbasia. Treatment by stovaine anesthesia.

=Case 561.= (CLAUDE, March, 1917.)

A chasseur, buried June 24, 1916, had a number of general symptoms,
apparently got well and was given seven days’ leave at home. On the way
he felt abdominal pain which he thought due to the jolting of the car.
Suddenly he felt his legs trembling on extension. He left the train
and went into a hospital where a diagnosis of radicular and spinal
lesions was made. Two months later he was sent to Claude who found that
he could walk only with knees flexed. If he was requested to stand up
and extend his legs on the thigh, a trembling set in suggestive of an
epileptoid trepidation. Even in the horizontal position the same clonic
trepidation occurred which only stopped if the patient flexed his legs
on the thighs.

However, no sign of organic lesion could be found. There was an
analgesia limited to the ankles. Psycho-physiotherapeutic treatment was
unavailing. January 28, 1917, the stovaine injection method was tried.
After anesthesia had set in, it was found possible still to produce the
spastic state by extending the legs; but a half hour after injection
the spastic state could no longer be produced. The patient was shown
that the trepidation was abolished. During the period of return of
sensibility, the legs were constantly moved and the patient constantly
told to make movements himself. He was convinced of his power. There
was no longer any clonus. The patient remained all day in bed without
epileptiform movements. Next day he complained merely of weakness in
the legs and was got to walk without having convulsive tremors. During
the next few days he began to walk with a cane, later without support,
and there were no more contractions except transiently in the left leg
if the patient walked a little too long. He left the hospital cured.


Shell-shock deafmutism: Psychic treatment.

=Case 562.= (BELLIN and VERNET, January, 1917.)

A soldier in a colonial regiment was sent, August 14, 1916, to an
evacuation post with a diagnosis “deafness following shell-shock, unfit
for service.” The patient asked that he be spoken to very loud because
he could not hear, and he himself spoke in whispers. He kept watching
his interlocutors’ lips and moved his own as if to pronounce the words.

A shell had burst nearby fourteen months before in June, 1915. After
being in several hospitals, he was sent to an oto-rhino-laryngological
service where he had his hearing reëducated and was taught lip reading.
It was soon perceived that he could hear without lip reading and he
was assured that he could be cured at once, but naturally he was not
convinced. He produced a carefully filed paper stating “atrophic
ozenous rhinitis, deafness from labyrinthine shock following shell
explosion, hearing diminished 60 per cent right, 30 per cent left.”

However, energetic psychotherapy was started and in the absence
of electricity, subcutaneous injections of ether were given. Such
patients had always been cured, and a drug injected under the skin,
not dangerous but extremely painful would cure him! This treatment was
carried out in a dugout near enough to the lines to be daily “potted.”
The patient was left for a space to reflect, and he finally accepted
the chance of cure. He was exhorted to stand courageously the pain and
to breathe deeply and to repeat a word more and more loudly. Finally
he was made to speak normally and eventually to cry out loudly. He now
felt much astonished, and in his astonishment forgot his deafness. He
said that he had never spoken or heard since the accident, that he had
been a deafmute from the first month of his illness, and that for the
last three months he had been able to speak only in a whispered voice.

He should have been watched a few days to confirm the cure. This was
impossible in the crowded dugout and no risk could be run of his
escaping. Kept over night he was found next day unable to hear and
talking in the same voice as before.

He was now found to be either an exaggerator or a simulator. He was
given a half hour to exercise his voice in and told that he must
succeed unless he was a simulator. At the end of half an hour it was
found that he had skipped. He was sent back by the division surgeon
with orders to send him to the otological service for inquiry. The
otological service found an atrophic ozenous rhinitis, a normal larynx,
perfect audition. He was given a psychic X-raying and a few electric
sparks were also drawn from his neck. He then began to talk in a loud
voice and to hear normally. August 30, he was sent out completely cured
and rejoined his regiment.

_Re_ treatment of deafmutism by other means than pseudo operations
and anesthesia, see remarks under Case 556 concerning Colin Russel’s
opinion that anesthesia does not get at the true genesis of cases. _Re_
the teaching of lip reading to Shell-shock deafmutes, see discussion
under Case 580.


Brachial monoplegia. Cure by electrical suggestion (physician
bored-looking, brief, and authoritative).

=Case 563.= (ADRIAN and YEALLAND, June, 1917.)

Adrian and Yealland had occasion to treat an officer with a persistent
functional paralysis of the arm, which had successfully withstood
hypnotism, psychoanalysis, rest, massage, anesthesia with ether, and
painful electrical treatment.

This patient knew something of the functions of the brain and was
prepared to discuss his condition exhaustively. He was told, however,
that he had come to be cured and that the nature of his cure would be
explained to him afterwards. Without further discussion, the motor
areas of the cortex were mapped out rapidly. The measurements were
repeated aloud to impress and mystify the patient. He was assured that
as soon as the shoulder area of the cortex was stimulated faradically,
he would be able to raise his shoulder, and that then the rest of his
arm would recover. An exceedingly mild faradic current was then applied
to the scalp for a few moments and he was then ordered to move his
shoulder. He did so at once. In a few minutes, all of the paralysis had
vanished and the patient could raise 30 pounds. Adrian and Yealland
believe that the success here was largely due to the fact that the
patient was not allowed to discuss the case or criticize the treatment
beforehand.

It is essential that the patient should be convinced that the
physicians understand the case and can cure him. No physical sign
should be examined as if it were interesting or obscure. An attitude of
“mild boredom bred of perfect familiarity with the patient’s disorder”
is cultivated. If the case is exhibited it should be exhibited “as a
perfect example” of the type of case that is cured in five minutes by
appropriate treatment. “Rapidity and an authoritative manner are the
chief factors in the reëducative process.”

_Re_ psychoelectric treatment, see Yealland’s book, published while
this compilation was going to press, _Hysterical Disorders of Warfare_,
1918.


Brachial monoplegia following use of sling after bruise or wound.
Technique of electrical suggestion and rapid reëducation.

=Case 564.= (ADRIAN AND YEALLAND, June, 1917.)

Adrian and Yealland give the following typical case of paralysis of the
arm as a very frequent and very curable form of war neurosis, occurring
as a rule after a slight wound or bruise necessitating the use of a
sling. The patient, having received a slight wound of the forearm,
for months had a useless arm, which he could move but slightly at the
shoulder on exerting a superhuman effort. Occasionally he could flex
the fingers through a small angle. There was complete anesthesia of the
hand and arm of long-glove type. This anesthesia was not complained
of, and might not be noticed until suggested to the patient by the
physician. It is well to elicit the anesthesia, however, in view of the
treatment to be applied. There was no wasting of muscles; the sensory
loss was typical of hysterical anesthesia; nor could the whole arm
have been involved by an injury that did not affect the upper arm and
shoulder.

The patient was told that he was very lucky to have come off with such
a slight injury; his arm was to be set right in five minutes by the
application of a special form of electricity. He was then made to sit
on a large pad electrode connected with an induction coil; the other
terminal is connected with a wire brush. The first effect, he was told,
would be the return of feeling in the forearm; power would return with
the feeling. The wire brush with a fairly strong current was drawn
downwards over the forearm from elbow to wrist. He was told that he
could now feel as far as the wrist, and a pin was used to convince him
that he could thus feel. If he had not felt the pinprick, the current
would have been increased in strength until he could feel. The hand was
now treated in the same way.

He was now told that, as feeling had returned to the arm, the power
of movement would be restored shortly. Adrian and Yealland remark
that laymen seem to consider that loss of power and loss of feeling
are inseparably connected. The electrode was now used to produce
contraction in the muscles. Under these circumstances, the arm will be
used hesitatingly, with an appearance of great effort; but the patient
is nevertheless convinced that power is returning.

“Rapid reëducation follows at once. He is given no time to think, but
urged to move the arm more and more strongly, to grip the physician’s
hand, to flex and extend the elbow, etc., and the pressure is not
relaxed until the whole arm has returned to its normal vigor. If
recovery is stationary, faradization is repeated with stronger and
stronger currents. If it seems as though he might relapse on leaving
the hospital, he is told that this is very unlikely, but that if it
should occur, he should report sick at once and come back for treatment
with a current far stronger than that already used.”

Adrian and Yealland claim that they have applied their combination
of suggestion and reëducation in more than 250 cases (including 82
cases of mutism, 34 of deafness, 18 of aphonia, 37 brachial or crural
monoplegia, 46 paraplegia, 16 hemiplegia, and 18 of non-organic gait
disturbance), and that although a majority of the cases have been
of several months’ standing, treatment has been almost immediately
successful in at least 95 per cent of the cases.


Exposure in the retreat from Mons: Persistent hysterical sciatica.
Treatment by faradism and verbal suggestion.

=Case 565.= (HARRIS, 1915.)

A soldier developed pains about the hips and down the right thigh after
getting wet through in the retreat from Mons, August, 1914. He was
treated for a period of nine months in various convalescent homes and
military hospitals, incidentally receiving forty baths at Droitwich. He
hobbled on a stick, leaning upon the left leg and dragging the right
stiffly. The thigh was tender and hyperesthetic.

The proper treatment of cases of hysteria, according to Harris, is
strong faradism, applied by a small electrode or wire brush to the
moistened skin. The stimulus is made powerful enough to force the
patient to admit that he feels. The theory is that the powerful
stimulation “breaks down the psychical auto-inhibition which produces
the hysterical anesthesia.”

Faradism is only the first phase of the treatment. Verbal suggestion
follows. Building on the basis of the feeling produced by the faradism
or on the basis of the ocular evidence of motion in the hitherto
paralyzed muscles, the patient is informed that the electricity will
now be more and more strongly felt and that he will be cured in a few
minutes.

The two elements in the therapy, then, are: encouraging verbal
suggestion and the suggestion afforded by the paraphernalia of a
complex looking, noisy machine. The knowledge on the part of the
patient that a powerful and mysterious stimulus, namely, electricity,
is being employed is a third element of suggestion.

Persistent hysterical sciatica, such as that of the present case, may
require prolonged treatment. In this instance, the man was completely
cured in five minutes, so that he was made able to run across the room.
He said he would now be able to go back to the front, and wondered why
he could not have been cured before.


Prognosis of intensive reëducation in reflex (physiopathic)
disorder--complete recovery (except for the hysterical fraction of the
disease) not expected.

=Case 566.= (VINCENT, 1916.)

A young soldier was superficially wounded in the left knee, in August,
1914. A year later, he showed amyotrophy of the left calf, which
measured 2.5 cm. less than the right, a weak slow Achilles reflex on
the left side, cyanosis and hypothermia of the left foot, weakness and
limitation of movements in the left foot, with slight contracture in
flexion of leg upon thigh.

Thenceforward and for eight months, this soldier was submitted at
the Tours Centre to intensive reëducation. For two hours every day
upon prescription he walked, ran, and hopped upon the left leg. In
September, 1916, after twelve month’s training, there was a certain
improvement in his disorder. The leg was now completely extended upon
the thigh, and the amplitude in the movement of the foot was almost
normal; but the amyotrophy, vasomotor disorder and certain electrical
disturbances remained quite unchanged. The man himself recognized that
his status was greatly improved, but he could not walk more than four
or five kilometers without great fatigue.

In view of the inferior results of reëducation in some of these cases,
should any attempt at all be made to reëducate? Vincent thinks that
that should be; but that it should be borne in mind that sometimes no
results may be obtained. If the reflex disorder (in the Babinski sense)
is minimal and the chief difficulty is hysterical, then sometimes
the man may go back to service after reëducation; but in intense
examples of reflex (physiopathic) disorder, invaliding has often proved
necessary.

_Re_ values of intensive reëducation, Vincent’s technique and results
have logical resemblances to those of Yealland and of Kaufmann. Vincent
established in the 9th district neurological center a method of
intensive reëducation which is particularly suited to _old_ hysterical
cases. He divides the treatment into three stages: First, the stage
called by the _poilu_ by the picturesque name of _torpillage_;
secondly, the stage of fixation; thirdly, the stage of training.
According to Roussy and Lhermitte, there are few cases at the front
suitable for the treatment of Clovis Vincent, which is especially
devised for the old cases. See under Case 574 for further details of
Vincent’s treatment.

_Re_ prognosis of the physiopathic disorder, there has been some
controversy in France. See discussion under Case 530. _Re_ suitable
treatment for physiopathic disorders, Babinski and Froment suggested
the application of heat. The warm bath test is also of value in
diagnosis. Babinski and Froment claim progressive improvements with hot
baths, hot air douches, and light baths--but counsel great prudence.
The improvement is never rapid.


Wound of calf; operations: hysterical contracture with “physiopathic”
features. “Brutally conquered” by reëducation.

=Case 567.= (FERRAND, March, 1917.)

A French infantryman, class of 1912, was wounded, May 12, 1915, in
the upper third of the right calf. His posterior tibial artery had to
be ligated. In a few weeks the wound was healed, but he began to walk
badly, presenting a contracture of the calf with retraction of the
tendo Achillis.

Toward the last of 1915 a surgeon under the impression that the disease
was organic cut the tendo Achillis but the soldier could not walk any
better. As he could not take the position of equinism, he semiflexed
his knee and walked upon a crutch.

Another surgeon was now found to perform a tenotomy on the flexors of
the leg and put the patient in a plaster cast to correct the flexion
and immobilize in extension. This second operation was in July, 1916.
The patient now walked without a crutch.

He was then sent to a neurological center, Dec. 8, 1916, walking
on two canes, right leg in forced extension on thigh, in permanent
and absolute contracture. All movements except leg flexion could
be executed, though slowly and weakly; but positive movements were
impossible, except flexion of the knees. There was no sensory disorder.
Reflexes were normal save that the leg reflexes were a little stronger
on the affected side, and the patellar reflex on that side was
nullified by the contracture. Electrical reactions proved normal. There
were marked trophic disturbances of the right foot and of the lower
third of the lower leg. There was a certain amount of edema, cyanosis,
coldness and thickening of skin; marked muscular over-excitability of
the distal extremity of the leg. In short, Ferrand was here dealing
with a case of Babinski’s group of the so-called physiopathic cases.
The man was somewhat feeble-minded, and anxious and a trembling
suppliant for cure.

He was put, December 15, in a reëducation room and by means of fatigue,
induced by violent physical exercises, was (Ferrand states) “brutally
conquered.” The contracture after a half hour of physical movement of
flexion and extension of the leg ceased. The patient was shown how
he could himself both flex and extend the limb himself; he was then
caused to do this spontaneously. These active movements were aided and
at times provoked by somewhat painful galvanic discharges. The patient
then walked slowly, and flexed both knees to the maximum. He was cured
after a treatment of 2½ hours. There were, of course, some (surgical)
intra-articular adhesions in the knee and it was necessary for the
patient to break these adhesions. An X-ray had shown the bone to be
intact. A slight hydrarthrosis developed the next day, but a few days
later he was able to walk as well as anyone. For five weeks he followed
a training platoon in the reëducation work and was evacuated, January
23, 1917, to his station, though he had entered the neurological center
with the idea that he was to be invalided with a pension.

He had a few relics of physiomotor disorder when he left, including
the abnormal delicacy of skin and muscular over-excitability above
mentioned. On the basis of this and similar cases Ferrand believes
that, although the physiopathic group of Babinski exists, it does not
signify a separate clinical syndrome and the occurrence of physiopathic
symptoms does not contraindicate psychotherapy.

_Re_ this controversy, see remarks under Case 530.


Shell-shock: Paraparesis. Cure by electricity.

=Case 568.= (TURRELL, January, 1915.)

Turrell, in a paper on electrotherapy at a base hospital, narrates
a case of spinal concussion which rapidly yielded to the persuasive
influence of Bergonié’s machine for electrically provoked exercises.
Turrell grants that such a rapid cure would probably be attributed to
suggestion, but thinks that the term _demonstration_ might be preferred
on account of the vigor and amplitude of the muscular contractions
excited.

This soldier was driving an ammunition wagon at the front, when a shell
exploded under the wagon, killing one horse and severely wounding
the other. The patient himself was blown into the air, fell, dragged
himself to a trench where he lay all night, and found himself in the
morning unable to walk or stand. He recalls that pins were stuck into
his legs by the examining medical officer and that they produced no
sensation. When he was finally brought to the Third Southern Medical
Hospital, he was unable to draw up or move his legs, or to stand up
(yet neurologically normal).

After a few days’ rest in bed, he found himself able to walk a few
steps with assistance, and was then transferred to the Radcliffe
Infirmary for electrical treatment. This treatment consisted in
electrically provoked exercises to the back (positive) and seat and
thighs (negative). He was able to walk back to his ward, leaning on
a wheelchair. Next day he walked to the electrical department with
sticks, and after the exercises were repeated, he was found able to
walk without assistance. On the third day, the Morton wave current was
applied to the back, to clear up any persistent stiffness. The patient
was then discharged on sick furlough.

_Re_ the Morton wave and similar applications of electricity,
Zeehandelaar speaks of a high frequency hall fitted up at Berlin.
Touching the walls of the hall with the finger elicited a powerful
spark. The scheme appeared to be on a commercial basis, and it was
proposed to start similar institutions for poor metabolism and neuroses
in other cities.


A year’s field service, gunshot; typhoid fever: Astasia-abasia:
Lourdes-like cure: Residual amnesia.

=Case 569.= (VOSS, November, 1916.)

A soldier in service from the outbreak of war, shot in September,
1915, afterward suffering from fainting spells, was treated in several
hospitals. He developed a typhoid fever at Lindau, which was at first
taken for hysterical fever. Eventually he came to the observation of
Voss, unable to stand and falling hysteria-wise if compelled to walk.

Thorough examination was made. It was emphatically explained to him
that there could be no reason why he should not stand or walk.

A miracle occurred. From the second day of his hospital stay he
not only walked about but began to polish doors and windows with
inexhaustible strength.

But when he was about to be told that he must now be looked upon as
well, the miracle was not so manifest. It now transpired that he had
serious gaps of memory and disorders in recognition, a sphincter
disorder and ever since his typhoid incontinence with fluid feces.

In short, waking suggestion had caused a very prominent symptom to
disappear, but the total personality remained sick. According to Voss,
the procedures of Kaufmann are dubious just because they cannot stand
the test of time. Yet so far as the cure of this man’s astasia-abasia
was concerned, it was not at all unlike the cures wrought at Lourdes.

_Re_ miracles of this sort, see cases of Colin Russel (503 and 504)
as well as those of Veale (511 and 512). Voss’ arguments run parallel
with the contentions of various persons that the miracle cures (such
as those by anesthesia, electric suggestion, and hypnosis), do not get
sufficiently to the bottom of the affections in question. Buzzard,
in the preface to Yealland’s book on the _Hysterical Disorders of
Warfare_, remarks that the question of the ultimate prognosis in cases
thus suddenly cured must be left unanswered.


Dysbasia after a fall: “Kaufmann” cure in six weeks.

=Case 570.= (SCHULTZE, August, 1916.)

Severe dysbasia, due to monoplegia of the right leg of sudden origin (a
fall), was variously treated 64 weeks without effect.

July 15, 1916, the patient walked in on a stick, and fell down on
trying to walk without. August 1, 1916, at 9 o’clock, he was rapidly
examined: Anesthesia to pain and temperature; inability to lift right
foot; the right knee could be lifted about a hand-breadth above the
body if the foot was supported.

At 9:10, a small electrode was applied: sensibility became normal at
once. Second application: leg raised much better. The man was told
that he was better and that his hand could be put under the heel.
Third application: Leg raised 8 cm. The patient showed pleasure at the
advance. Fourth application (slightly increased strength): Patient
able to stand and to lift knee with flexion at 135° while standing.
Walking exercises under direction. At 9:30, five minutes recess was
given for fatigue, whereupon the exercises were taken up again and
transition made from stationary running to walking without aid as well
as a variety of other associated acts (grasping handkerchief instead of
physician’s hand, and the like). The patient became exhausted after 8
or 9 minutes running about, and another pause was given.

The large brush electrode with stronger current was now given to the
back and to the back of the right leg. Practice in slow walking,
lifting knee, and holding hip joint firm. The patient became tired, but
remained very willing. Exercises in pulling on stockings, in climbing
stairs--the whole concluded at 10 o’clock, whereupon it was found that
the patient could walk alone for a distance of 50 meters. The patient
was a very suggestible one. It was striking that the patient in the
time between 9:35 and 9:40 minutes could walk better on the right
(that is, the previously affected leg) than upon the left. Rest in bed
and phenacetine were ordered, with the suggestion that in the morning
he would walk much better. He became irritated after the treatment but
grew quieter in the afternoon.

On August 3, he was found able to walk well, better when not observed
than when observed. August 5, he complained that his leg was worse
and used a cane, without permission. He was roundly scolded by the
physician and threatened with being sent to bed if he did not practice
earnestly. August 7, he was better, and confessed that he could not
walk as well on command as he could alone; the exercises were nothing
but a fraud and he could go out and beat everything up (_alles
zerschlagen_) if he did not have to carry out such exercises.

August 15, he was much better, quiet, and satisfied. The lameness was
practically gone. August 30, there was no sign of lameness, even when
he was observed. According to Schultze, the Kaufmann method is not
merely an Erb tradition, and rather special measures need to be taken
in executing it.

_Re_ Kaufmann’s cure, Imboden sums up this “highly logical and brutal
method” as a method in which powerful electric shocks and loud military
orders to perform certain exercises secure results. Imboden suggests
that relapses may follow, sometimes on the slightest provocation.
Mann states that Kaufmann’s method of suggestion and electric shock
forms very good treatment; yet Mann states there have been two deaths
under this treatment: in both instances there was an enlarged thymus
at autopsy. A better technique, especially the use of the faradic
current alone, might have avoided these deaths. Mann himself prefers
to Kaufmann’s _Ueberrumpelung_ milder methods, such as rest. Kaufmann
keeps up the sitting until the man is cured, even if it takes two hours
of electricity and staccato commands. For similar persistance, see the
treatment by induced fatigue of Reeve (Cases 489-493).


Wound of shoulder: Heterosuggestion of BRACHIAL paresis. Electrical
suggestion of muscular power. Recovery in five days.

=Case 571.= (HEWAT, March, 1917.)

A reënlisted soldier arrived at the Royal Victoria Hospital, as a case
of ulnar paralysis. He had been wounded in France six months before by
a bullet which passed through the fleshy part of the shoulder, above
the middle third of the clavicle. Power in the right arm gradually
diminished; yet two months after the wound he seemed fit enough to be
sent to Egypt. The paresis developed, and in a month’s time he was
invalided home. He had been unable to use a rifle for months.

The healed bullet wounds were found about the region of the brachial
plexus. The patient was sure the bullet had damaged the nerves in
that region. The right arm and hand were limp and over-inclined to
blueness, and the muscles were flabby. Active movements of all sorts
could be carried out with the arm but not against resistance. There was
a definite anesthesia and analgesia throughout, and responses to touch
and pain stimuli were irregular.

By way of treatment, the patient had the muscles of the paretic arm
stimulated electrically, and at the same time he was told that no nerve
of the neck had been injured. He was greatly surprised to see his
palsied arm move vigorously.

A milk isolation treatment in bed behind screens was adopted, whereat
the patient was angry, looking upon the Weir-Mitchell treatment as
punishment.

On the next day, another electrical application secured complete power
in the arm and abolished sensory disturbance. Three days later the man
went back to full duty. According to Fergus Hewat, someone doubtless
had suggested to this patient that he had received a nerve injury.
He had become obsessed thereby and developed a typical functional
paralysis. This was a “cortical misinterpretation,” which disappeared
upon forcible demonstration of the error.


Exposure; intestinal disorder in weakminded neuropath: Camptocormia and
hysterical paraplegia: Cure by psycho-electric treatment.

=Case 572.= (ROUSSY AND LHERMITTE, 1917.)

A French territorial, 45, was observed at the Centre Neurologique,
August 28, 1916. He was a victim of hysterical paraplegia with tripod
gait. There was a stiffness of the lumbar vertebral column which had
lasted six months. This paraplegia had begun spontaneously after cold
and an attack of diarrhoea followed by constipation. The camptocormia
and disorder of gait had come on gradually in the ambulance. He came
on a stretcher. He was found to be able to walk with great difficulty
by leaning both hands on a cane. The two legs were tremulous in a
pseudospastic gait. The next day, after a single psycho-electric
treatment, cure was complete. This patient was mentally somewhat weak
and a constitutional neuropath. He was discharged, cured, October 20,
1916.


Brachial monoplegia, hysterical (or feigned?). Found able to descend
ladder with arms only.

=Case 573.= (CLAUDE, July, 1916.)

Claude had a case of a soldier with right-sided brachial monoplegia,
which had lasted for 18 months and defied efforts to cure. There was a
question of simulation, and Claude handed the case over to Vincent.

The case came on service, June 20, and was seen June 21. He was then
treated and found able to descend a ladder applied to a wall with the
help of his arms only. On June 24, he was found able to lift a weight
of 10 kilos, and could now write with the right hand, although he had
been writing only with his left. This man had looked like a simulator
to many physicians. He may have been a simulator or an hysteric. In any
case, he was cured.


Vicissitudes of treatment of hysterical brachial monoparesis (shell
burial).

=Case 574.= (VINCENT, July, 1917.)

A French private was buried in a trench upon the explosion of a large
shell, November, 1914. He said he had had a “fracture of the occiput”
and had fainted away without regaining consciousness for several hours.

He was evacuated to Dunkirk, then Saint Nasire, and then to
Sables-d’Olonne. He showed no paralysis or paresis of limbs. During the
first month, he had violent pains in the head, spells and vomiting.
There was a slight aphasic disorder. He was treated by cupping upon the
head and by applications of ice.

After the visit of the inspector general, he was sent to Nantes to be
trephined. Dr. Mathieu regarded an operation as useless. He was treated
with bromides and the faradic current by Miraillé, applied to the right
arm, which had become paretic.

June, 1915, he started on a three-months convalescent leave in Paris.

From October to December, he had electric treatment at the Grand-Palais.

December, 1915, he went to the Salpêtrière under P. Marie, where he was
given electric treatment.

January 1916, he went to Maison-Blanche under Laignel-Lavastine, where
he was given electricity 4½ months.

April 4 he went back to his dépôt.

Presented to the invaliding board, May 11, at Decize, he was sent to
the neurological center at Bourges. He was there given massage and
movements. Upon entrance he had a functional inactivity of the right
arm. He should have been cured a long time before by the therapeutics
employed. He was then sent to Vincent at the neurological center at
Tours for special motor reëducation. Vincent found almost complete
functional incapacity of the right arm, without atrophy, with normal
reactions, no R. D., and normal arterial pressure. June 26, 1916, the
patient was able to write, although slowly. He could sign a letter, and
could lift a weight of 10 kilos.

The details of Vincent’s method mentioned under Case 566 are pursued,
to use his own words, with _methodical ruthlessness_. This form of
reëducation consists in manoeuvres that make the patients yield
despite themselves. The galvanic current is used to force a man to
react voluntarily or automatically. See, for example, Claude’s case of
a hysterical brachial monoplegic (Case 574) found able to descend a
ladder with the use of his arms only. After the physician’s victory is
secured, then a sort of consolidation must be obtained by means of the
execution of certain movements on the part of the patient for an hour
or two. As another factor in the situation set up by Clovis Vincent,
is the enthusiasm generated in the moral atmosphere in which the cure
takes place. Mott has also insisted upon this atmosphere of cure, which
Mott believes is in part responsible for the good results of Adrian and
Yealland. Roussy and Boisseau, at Salins, started out with a process
similar to that of Vincent, with a preliminary period of isolation.
Roussy also uses the faradic current instead of the galvanic (see
remarks of Mann concerning deaths with the Kaufmann method in Germany,
under Case 570). Vincent’s three stages are given in Chart 19, page
897.


Struck by shell fragment; run over by shell; paresis and regionary
sense disorder. Treatment by reëducation.

=Case 575.= (BINSWANGER, July, 1915.)

A German subaltern officer, 27, was wounded September 25, 1914, in a
battle in France. He gave the following account:

“We had been firing without interruption four days, and then were sent
back. While going back from cover we were under shell fire. Three or
four horses fell. I got a glancing blow from a shell fragment in the
back of the head, and fell down. I was not quite unconscious. I tried
several times to get up, but I could not, for I had very bad pains
in the head and a confused feeling in it, too. I remember also that
a wheel ran over my foot, and that I got a sharp blow in the chest.
Then I was unconscious for about an hour. When I awoke, there were two
comrades busy over me and they pulled me back of the firing-line. Then
I got to a field hospital.”

The man arrived at the nerve hospital (Jena), October 8, 1914, with
insomnia, respiratory disturbance, sudden perspiration, feelings of
cold in the right foot, and poor appetite. He had had nausea for a few
days. Lungs and heart proved normal. X-ray of the right foot showed
normal relations. The man was a small, powerfully-built man, well
nourished, with lively reflexes, especially the knee reflexes, of which
the right was greater than the left; slight patellar clonus, right;
left plantar reflex greater than right; segmental disorder of touch
and pain sense in the right foot and lower leg, a zone of analgesia
lying above the zone of total anesthesia. Gait was lame on account of
inability to move the right ankle joint. In walking, the right foot was
trailed.

Treatment was suggestive and supported by active gymnastic exercises,
breathing exercises, exercises in moving the right leg, massage,
faradism and local hydrotherapy. The gait gradually improved, the cold
feeling disappeared from the right leg, disturbances of pain and touch
sense disappeared. The patient was released on the 2d of February,
1915, capable of garrison duty.

With respect to this man, who was married, he was from a healthy family
and had healthy children. He is said, however, to have suffered from
convulsions for a long time in early life, but thereafter had never
been sick in any way. He was a good student and had been a post-office
official since 1908. After two years’ military service, he became, in
1910, _Unteroffizier-Aspirant_. Later he was advanced to his subaltern
position in the reserve.

This case seems to be a characteristic example of segmental disorder of
sensations of both touch and pain, combined with a paresis in the same
region. Mechanical and mental factors seem to have been present, and
the case belongs in what Binswanger calls the “hysterosomatic” group.

_Re_ Binswanger’s so-called hysterosomatic group, he defines the cases
as having emotional, mechanical, and toxic (gas) factors. On the whole,
they are best classified as a kind of psychoneurosis. Binswanger finds
all physical and drug treatment without result except as supportives.
He has used hydrotherapy and electrotherapy with the perfectly clear
conception that the procedures were of suggestive value only. In fact,
Binswanger had before defined such procedures as _Realsuggestionen_ or
material suggestions. Common verbal suggestion, says Binswanger, will
work sometimes only when aided by these material suggestions. See also
under Case 576.


Post-traumatic (ANTEBELLUM) seizures with unconsciousness: Further
seizures, astasia-abasia, anesthesias, following no special period of
stress in field service. Recovery by reëducation.

=Case 576.= (BINSWANGER, July, 1915.)

O. F., 26, healthy, of a healthy family, in military service,
1908-1910, a miner in October, 1912, had fallen into a shaft from a
considerable height, and is said to have been unconscious for three
days and two nights and to have had some sort of attack a short time
after waking. Later he had another attack, beginning with violent
headaches, running from the back to the fore part of the head, then
dizziness, then a fall with unconsciousness. The whole attack lasted
about four minutes and was followed by feelings of extreme fatigue.

It seems that in the spring of 1913 these attacks had begun to repeat
themselves two or three times a week. In the spring of 1914 there had
again been two attacks at an interval of two weeks. They had occurred
on the way to work and had been introduced by the same symptoms as
before. They lasted about half an hour.

He was in the war in France from August 6, 1914. While he was cooking,
one day, in the middle of September, he had an attack and this without
special occasion. The next attack occurred a little while afterwards,
at the time of an assault. He said that he fell down and lost his
senses. When he came to his senses again, he found he could not move
his legs.

He was taken to a reserve hospital in Germany, and while there had
several attacks with unconsciousness and spasmodic convulsions--the
last on December 7, 1914. He was transferred to the Jena Hospital on
the 11th.

The Jena examination had the benefit of an inquiry concerning the case.
It seems that he had left the field hospital in the enemy’s country, in
a half-conscious condition, and rode away therefrom aimlessly. It was
only in Germany that he, on his own story, found his bearings again.
However, upon admission the disturbance in walking was very noticeable,
since the patient came hobbling through the garden of the clinic with
the upper part of his body bent forward, and with the support of two
canes. The legs were moved with difficulty; he seemed to take short,
tripping steps, with the toes dragging on the ground. His inability to
walk he explained through the violent pains which he would feel in the
joints of the legs and an extraordinary weakness in his legs.

Physically, the man was a tall, strongly built and well-nourished
subject. Neurologically, the knee-jerks were somewhat decreased and
weaker on the right side than on the left; the Achilles reflexes
were lively. The plantar reflex was not obtainable on the left side;
decreased on the right. The abdominal reflexes were absent on both
sides.

Most remarkable was the general diminution in sensitiveness of the skin
to touch and pain, involving the whole body, up to the neck, where the
sensory impairment abruptly ceased in a sharp line. The anesthesia
was not everywhere complete. In a few places pencil strokes were
successfully localized and recognized. Deep pin-pricks were everywhere
recognized as itching. When the trunk was everywhere examined on both
sides symmetrically, a strong pressure with a pin-head was felt as a
strong pressure on the right side, but was felt not at all on the left
side. Anesthesia and analgesia were total in the legs. Deep folds of
skin could be punctured by needles without reaction.

The legs could be moved freely upon urgent request with the patient in
dorsal decubitus. Still these movements were slow and difficult, as
explained by the patient, on account of violent pains in the joints.
If put on his feet, he would begin to sway greatly and permit himself
to slide down to the ground, stating that he was quite incapable of
standing or walking without aid. With two canes, however, he could move
freely about in the ward and in the garden, and even with considerable
speed, in a peculiar, dragging, shuffling way; in the execution he gave
no sign of pain, contentedly smoking a cigar or a pipe.

While his status was being taken on admission, he became suddenly dull
and irresponsive, with a staring look. He could not state his age or
his birthplace. However, he became clear shortly, upon urging, and
explained the spell by saying that the blood had risen to his head.
A few days later, he was transferred to the psychiatric division. He
was given strict rest in bed, smoking was forbidden, prolonged baths
were used, and the legs were massaged. He felt very comfortable in the
prolonged baths and could then move his legs without pain.

A few days later he was taken out of bed several times a day, the canes
being removed immediately, and he was led about the day-room with the
light support of two nurses. Being promised a cigar as a reward, he
proved able to walk through the day-room supported by but one nurse.
A week later the pains in walking exercises had disappeared. He had
become able to walk alone, supporting himself lightly along the wall
with one hand. Walking was still uncertain and slow.

December 20, the patient could stand free without support, swaying
slightly; improvement became rapid. He could shortly stand and walk
without support though his walk was still awkward and on a wide base
with knees pressed in and body bent forward, soles were kept applied to
the ground. December 22, the patient could walk in the garden without
aid.

December 23, there was a spell of great weariness and complaint of
being sick. The patient lay down on the bed, cried aloud, and had
rhythmic twitchings and sudden movements with arms and legs. He
scratched the right half of his face with his right hand. This spell
lasted about a minute. It was repeated in the same way twice within the
half hour.

He had complete amnesia for these attacks. The pupillary reactions were
entirely normal in the attacks. He had been in bad spirits that day
because a Christmas furlough had been refused. The attacks provoked
no bad consequences and his gait improved. He was on furlough from
the 30th to January 3; on the 4th he was transferred to the nerve
department, but on the 12th of January he was reprimanded for a breach
of discipline, whereupon at 9:15 he had an hysterical attack with the
same coördinate rhythmic motions as before. This attack lasted about 20
minutes. Two hours before the attack he had complained of weariness and
a boiling-hot feeling in the body. Long walks were taken. On February
15 he began to feel very happy. He was informed that the charge against
him for leaving his troop had been dropped. He complained of sudden
weariness and headache and was markedly depressed, but he had no
hysterical attack.

After February 23 he took part regularly in gymnastics, executing the
movements with joy and without special weariness. He wanted to be
discharged. He was discharged as fit for garrison duty and he has since
gone back to field service.

_Re_ gymnastics, Binswanger holds that they have a special value
in overcoming inner psychic resistances and weak-willed persons.
The _Realsuggestionen_ (see under preceding case, 575), such as
hydrotherapy and electrotherapy, serve to concentrate the person’s
attention on certain regions. These regional suggestions then smooth
the way for the curative suggestion, namely, the constant and
monotonously repeated assurance that recovery is advancing. At the next
stage, according to Binswanger, gymnastic exercises may be brought
in to overcome hopelessness, indifference, or exaggeration of morbid
feelings. Binswanger sets methodical tasks for the attention and the
will (a so-called _Uebungstherapie_). If these gymnastics lead to
manifest improvement, then a proper educational therapy is prescribed,
which is no longer a merely exercise therapy, but consists of actions
of actual value in hospital routine. The convalescents are gradually
led to carry on housework, food service, gardening (the latter under
supervision). Hospital clerical work is a suitable occupation.
_Re_ supervision over gardening, mentioned by Binswanger, Canadian
experience indicates that the idea of supervision may be greatly
extended. Particularly is this true in vocational reëducation. Kidner
describes the functions of a vocational counsellor, who has to have
an expert knowledge of industry and methods of industrial training,
as well as an acquaintance with the varying demands for workers, a
knowledge of the seasonal variations in employment, and a knowledge
of occupational diseases. _Re_ occupational therapy, Todd estimates
that from 0.5 to 1 per cent of wounded men in France will require
vocational reëducation. Occupational therapy is the proper vestibule to
vocational training. He lists the following forms of treatment used in
institutions for vocational reëducation:

    Active mechanotherapy.
    Passive mechanotherapy.
    Galvanic, static, and faradic electricity.
    Vibration.
    Hot air baths and blasts.
    Water baths.
    Colored light.
    Massage.
    Gymnastics.

Central specialized institutions such as those developed in France
are necessary, and such centres should be large rather than small,
according to Todd, and should contain not less than 200 beds. Todd
insists that work is, after all, the most important measure of
reëducation; and Turner, speaking of the home for neurasthenics at
Golders Green, says that during a period of three months (the number of
the patients is limited to 100, and three months is the limit of stay),
the vast majority, even of the most obstinate cases, get well through
the effects of sympathy and insistance upon work. Near Golders Green
is the Maida Vale Hospital for nervous cases, so that in case of need
the physicians there may treat the patients. Salmon gives a list of the
occupations which are suitable for these cases.


Blown up by shell; wounds, right side, distention and bloody urine:
Paresis of right foot and spasticity of hip; later rectal and bladder
incontinence.

=Case 577.= (BINSWANGER, July, 1915.)

A Russian from the Ukraine was received at the nerve hospital, Jena,
December 12, 1914. Through an interpreter it was established that he
was a peasant, had been under shell fire in a skirmish at the beginning
of November, and had been hurled (so he said) 1¼ meters into the air
without loss of consciousness. There was a wound of the right shoulder
and also, he thought, of the legs, from the air pressure. Becoming a
German prisoner, he had been treated in various hospitals.

He was a strong man of medium height, with a healthy complexion. There
were two healed wounds of the right shoulder, and near the twelfth
spinous process a third similar scar. There were a number of ulcers and
furuncles over the os sacrum.

Neurologically, the knee-jerks and Achilles jerks could not be
obtained, and the plantar reflex, extinct on the left, was weak on
the right. Sensitiveness to pain on both sides was lost from the
knee downwards but there was hyperalgesia in the thigh. Inaccurate
statements in response to tactile tests were made, apparently on
account of lack of understanding. In lying down, there was a slight
restriction in the movements of the legs, and active movements of
the joints of the foot on the right side were impossible. Gait was
ataxic-paretic, more markedly so right than left. He could walk only
with two canes, and during walking the musculature of the thigh fell
into a spastic tension. The tongue deviated to the left. There were
severe rheumatic pains in the thighs.

It appears that some weeks before, this Russian soldier had suffered
from severe rheumatic pains in both sides and was at that time
absolutely unable to walk or stand. At that time, however, there was no
question of a crural paraplegia of organic origin, since the man could
move his legs well enough when in dorsal decubitus. There were no
signs of paralysis of the rectum or bladder at that time.

Treatment at Jena consisted in regular walking exercises with support
at the shoulders. The lower legs and feet remained weak and paretic.
The decubital ulcers disappeared.

About the middle of December rectal incontinence began, the stool being
discharged without the patient’s noticing it while being led to the
bath. Later there was incontinence of feces in bed. Pains in the legs
were constantly complained of. Nevertheless improvement in walking was
maintained. The toes were dragged at every step and the knee-joints
were thrown outward in walking. The musculature of the lower legs was
weak. Knee-jerks could not be elicited more than before. He constantly
complained of pains in the knees and right hip. The rectal disorder did
not again occur during January.

Toward the close of January, the patient’s right lower leg and left
foot would occasionally feel asleep; both legs felt cold and itched.
In a general way, however, the pains had become less marked than they
were at first. It seemed that he had no sensations at stool, and
consequently had to resort to the closet at a definite time. Moreover,
urine was discharged irregularly and involuntarily when he coughed. It
appears that a few days after receiving his wounds in battle, there had
been pains on micturition as well as blood in the urine, and it appears
that he had been catheterized. It is probable that he had suffered
from distention, as he described his abdomen, thighs and sex organs as
swollen.

In February he began to be able to move alone with two canes through
the ward, but he moved his legs from the knee downward very little, and
dragged them after the rest of the body. Upon galvanic examination, the
peroneal and tibial nerve trunks were found normally excitable. At this
time the sensibility situation had changed somewhat, since complete
analgesia was present only in the foot, and hypalgesia had developed
upon the anterior surfaces of the lower legs. Pin-pricks were described
as touches. The posterior surface of the left lower leg was normally
sensitive. There was an oblong stripe about 3 cm. long, beginning in
the popliteal space and stretching downward on the left side. The
right lower leg was entirely insensitive. The posterior surfaces of
both thighs as far as the gluteal folds were completely insensible
to pain. The Wassermann reaction of the blood was negative. In this
condition the patient was transferred to a prison camp hospital.

_Re_ bloody urine, see Section B, Case 202. _Re_ rectal incontinence,
it might be inquired whether this was possibly functional. Roussy
and Lhermitte devote a chapter to visceral disorders. They do not
list rectal incontinence amongst the disorders noted in this war, nor
have any cases of hysterical anorexia or disorders of sensation in
the intestinal tract been seen during the war despite the occurrence
of these latter disorders in the civilian group. The main digestive
disorder that the war cases show is vomiting (see Cases 495 and 500).


Emotionality: Shell explosion; mutism. Recovery by reëducation.

=Case 578.= (BRIAND and PHILIPPE, September, 1916.)

A plumber, 27, went into the infantry. He was very emotional and was
but a short time in the trenches when the explosion of shells threw him
into a state of mutism. Deafness, rather curiously, did not manifest
itself for several days. He had to go back on horseback, and, as he was
a poor horseman, slipped off the horse, giving himself a bad fright.
When he got up, he had lost his hearing.

He was sent to several hospitals and finally to Val-de-Grâce, in July,
1915. He recovered hearing in fifteen days, but the mutism persisted
several months. According to Briand and Philippe, this is a typical
case, except for the duration of the mutism. The first treatment was
given this patient August 6. His respiration was examined and tracing
was taken. August 15, on the morning visit, he was found able to
whistle very distinctly the first bars of “Au Clair de la Lune,” and
then began to sing the first verses, articulating distinctly, but
stammering a little. He was now left to his own resources, without
special exercises, from August 15 to September 26, and completely lost
the benefit of his previous exercises. A week of special treatment
allowed him to recover speech again, enough to take up every day life.
The patient went out well.

The general lines of the examination in this case took up attitude
in abdominal respiration and the question of respiratory pauses,
especially pauses in abdominal respiration, which, in the above case,
were exaggerated. Expiration was deficient and disordered. The normal
adaptations that had been established during his childhood learning of
speech had failed, and the patient would not have been able by himself
to regain proper balance of respiration for speech.

The examination was continued to learn the difficulties of innervation
of the muscles of phonation whose proper delicacy had been lost. Such
a patient is a kind of bad gymnast, executing an exercise known to be
hard by contracting all the muscles of the region, both the antagonist
and the agonist muscles. Reëducation must, therefore, endeavor to sweep
away the contractions that block sound. Then the patient must be made
to perform the contractions necessary in phonation and articulation
unconsciously. The methods used for teaching children might here be
employed, but more elaborate and designed methods can be used with the
adult, _e.g.,_

    1. Breathing exercises, especially with the idea of making
       respiration complete.

    2. Blowing exercises.

    3. Whistling.

    4. Vowel sounding.

Séguin and Rouma, on the other hand, counsel beginning exercises with
consonants in stammerers and dyslalics.

_Re_ tests for functional deafness, Ranjard states that on account of
the complexity of Shell-shock deafness, exact diagnosis needs to be
made. Examination of the hearing by speech alone, or by the watch-tick,
yielded poor results; and an accurate mathematical acoumeter (_Sirène
à voyelles_, Marage) is recommended. See especially chapter on the
functional examination of audition in Bourgeois and Sourdille’s _War
Otitis and War Deafness_, a work translated and highly recommended by
the English otologist, Dundas Grant.


Three days’ skirmish on East front: Unconsciousness, later delirium,
still later (six weeks) stammering, hysterical stigmata: Recovery by
isolation and reëducation.

=Case 579.= (BINSWANGER, July, 1915.)

A traveling salesman in civil life, 36, as a non-commissioned officer
took part in severe fighting in the East shortly after the outbreak of
the war. He was under violent shell fire at one time for five hours at
a stretch. In the middle of November, after a skirmish in the woods
which had lasted for three days, he was found unconscious. According
to his own story, he was awakened from this unconsciousness about a
week later in a hospital. He described himself as quite unable to say
anything about what had gone on during that week.

The medical report on the case stated that he arrived at the hospital,
November 18, in a dormant state of mind. He had appeared markedly
excited and kept incessantly talking about military matters, such as
the placing of machine guns, the occupation of the edge of the woods
by his company, addressing the nurse as “Captain,” and the sister as
“Mrs. Captain,” making as it were an official report to them. He showed
shyness, and always an extreme excitement. His hands and legs were in
constant motion; he complained of headaches and itching finger-tips.
Sleep could be achieved only by drugs. This mental state lasted till
November 26, when he became oriented. Sleep improved, but he complained
of pains in the back of the head.

Upon transfer to a convalescent home, December 5, he was still
occasionally excited and sometimes sleepless. On December 30, the
patient began to stammer; his speech had before this been somewhat
difficult, but the stammering began suddenly; speech was indistinct and
slow; syllables failed to follow one another at like intervals. The
headache at this time radiated from the middle of the top of the head
to the side of the neck. There was a complaint of vibrating pains on
the two sides of the vertebral column, and a feeling of weakness and
unsteadiness in walking. The patient would sway with eyes closed and
turn sidewise. The heart action was tumultuous, the pulse irregular and
uneven.

The patient was transferred back to the reserve hospital on January 2,
1915, whereupon the stammering became worse, sleep restless, and arms
and legs subject to spasmodic pains and twitching. On January 25, he
was removed to the Jena Hospital. He remarked that at the convalescent
home he became very much excited at the Christmas celebration and had
to cry, whereupon his speech became more and more difficult; he could
not find the beginnings of words and had to stammer. Upon admission
he also complained of sharp pains in the soles of the feet and in the
finger-tips.

Neurologically, there was marked dermatographia, the deep reflexes were
increased, abdominal reflexes were absent; there were points of pain
on pressure in both supra-orbital regions, and there was a general
hypalgesia with the exception of the head, the lower legs, the feet,
the scrotum, the penis and the anal region. Pin-pricks were recognized
on the right side only, when the patient was tested bilaterally. They
could be recognized on both sides when the patient was examined on one
side at a time. There was a static tremor on both sides (?). He could
move his arms, but in dorsal decubitus he could move his legs only
jerkily and uncertainly. His gait was waddling with dragging of toes.

There was a marked photophobia. The palatal and swallowing reflexes
were in excess; speech was hesitant and stammering. The first letters
of words, especially initial consonants, could be pronounced with
difficulty, explosively with cheeks blown up, after several attempts.
The consonant would be repeated several times before the vowel could
be added. The patient’s name was Singer, and he would pronounce it: _S
… S … S … Si … n … n … ger_; the last syllable (_ger_) being brought
out with a strong accentuation. The whole process took five seconds.
The word _Flanelllatten_ took 14 seconds. It seems that the patient
had already suffered (in 1907) from nasal catarrh and disturbance of
hearing from stoppage of the Eustachian tubes. Another attack in 1908
had been accompanied by an irritating cough, and there seems to have
been catarrh on the right in 1913, as well as cerumen on the left side.

Treatment: The patient was isolated; in the next few days there was
improvement in the headache. The patient complained of muscular
twitchings, which would occur suddenly in different parts of the body.
On February 1 there was a subjective feeling of happiness since all
pains had disappeared.

The patient was given regular exercises in speaking and there was
gradual improvement in speech. Body-weight increased, regular walks
were taken, and the patient occupied himself with garden work.

By June, 1915, he had still further remarkably improved, working now
all day long, partly in the garden, partly in the hospital office.
Disturbance of speech was not noticed except for hesitation before the
last syllables of long words during comparatively long conversations.
All trace of difficulty in walking had disappeared. In this patient no
hereditary taint could be proved. He appears to have been of normal
development, serving in the army from 1901 to 1903. In his life as a
traveling salesman, there was frequently catarrh of the throat, and
in 1912 there was a marked swelling of the vocal cords with extreme
hoarseness and inability to speak, which condition was cured after
local treatment.

_Re_ hysterical speech and voice disorders, Binswanger has found them
amongst the most obstinate conditions, often persisting when all other
hysterical phenomena have dropped away. He states that apparently the
cure of some of these cases must be postponed until the end of the war.

_Re_ general results of the therapeutic treatment of the war hysterias,
Binswanger states that he has been able to send some cases back to
the front that have successfully stayed there. He has had failures,
however, even amongst men who have had no _mauvaise volonté_ and have
themselves desired to be sent back to the front.

Gordon Wilson observed 250 cases of Shell-shock at the Ypres salient
and on the Somme. Fifty of these cases complained of deafness, and 17
of the 50 were found to have actual nerve deafness. Wilson treated
“fixed idea” cases by hypnotism, and sometimes by cold water run into
the ear. He, in general, divides the cases in to (_a_) cases of nerve
deafness, (_b_) fixed idea cases, and (_c_) malingerers.

Marage states that frequent exposure to the noise of shells for long
periods may produce a permanent deafness, as has long been known
in naval gun-makers and boiler-makers in peace times. He advocates
obturators, a good form being plasticine wrapped in gauze moulded to
the shape of the internal meatus. Celluloid plugs, sometimes used, have
been known to be set afire by the flash of a shell. Cerumen sometimes
protects against deafness, but Mott speaks of the driving of the wax
into the tympanum as a dangerous effect in certain shock cases.


BURIAL by shell explosion: DEAFMUTISM. Treatment: phonetic reëducation.

=Case 580.= (LIÉBAULT, 1916.)

A machine gunner, 26, was buried at Rheims, January 5, 1915, by the
explosion of a large shell bursting over the dugout. He was unconscious
three days and deafmute on coming to, without amnesia but with a
feeling of constriction in the throat.

After fifteen days in the ambulance he was sent for four months to the
Maritime Hospital at Brest, and treated by hypnotism. Seven or eight
sittings had no other result than to fatigue him. There were then three
months of convalescence. Returned to Vannes, September 20, 1915, he
was put into the auxiliaries. As he could not work much he was sent,
December, 1915, to the Hôtel-Dieu at Nantes. Here electric vibratory
massage was given, which secured a few hoarse sounds.

Phonetic reëducation was then undertaken at Prés-à-goutrière, May 10,
and his respiratory capacity increased from 170 the first week to 250
and 300 the following weeks. His blowing strength was raised from 15
to 20 to 25 at the same time. In a few weeks he was much improved and
June 27 passed on to his auditory reëducation. The respiratory capacity
in this man was insufficient. He could not speak, but his respiratory
movements were good and he learned again to speak in a voice as good as
ever.

According to Liébault, it is a general principle that, if the
respiratory capacity is increased, the voice will clear or become
better; but, if the respiratory capacity remains stationary, the voice
will not improve. It is the same with normal persons. A subject with
a very subnormal respiratory capacity cannot speak loudly, but, if
his respiratory capacity approaches normal, he can speak normally.
According to Liébault, all cases of this sort have had some respiratory
anomaly and each case must be systematically examined with the aid of
anthropometric tables, including weight, height and chest capacity.
The vocal disorder is proportionate to the degree of functioning of
the phonating apparatus taken as a whole. It is not merely that the
larynx should be examined, but the motor side of the apparatus, the
respiratory muscles, the resonating apparatus, the lips, the mouth, the
nasal fossæ and the pharynx.

_Re_ curability of different types of war deafmute, Roussy and Boisseau
maintain that the type (_a_) that comes gesticulating, pointing to the
ears, and desirous of writing, is the type that responds most rapidly
to psychotherapy. There are two other types less responsive: (_b_) is
an apathetic type, with impassive and stupid facies, lies immobile
in bed, or sits in a chair in mental confusion; type (_c_) shows a
facies of terror, looks haggard and anxious, confused, disoriented, and
possibly delirious.

_Re_ general treatment of deaf cases, Zange suggests that emotion
should not be aroused by intense auditory impressions, that he
should not be reminded of his shock, and should be kept as cheerful
as possible. Zange states that he found the static electric current
of service, and got good results in hysterical deafness of sudden
development by applying a strong faradic current.


A year’s service; leave: Hysterical aphonia developed at home.
Respiratory gymnastics.

=Case 581.= (GAREL, April, 1916.)

A soldier, 35, went on leave August, 1915. Arriving at his farm, he had
a violent feeling of moral perturbation and suddenly lost his voice.
When he returned from leave he seemed stupid, spoke very few words
and seemed to look about in a vague and undecided way. He was several
months in this state and sent January, 1916, to Saint-Luc.

The vocal cords were there found of a normal color and without
paralysis. “It was, therefore,” remarks Garel, “a nervous aphonia
susceptible of instantaneous cure.” The patient was made to make a
sound in the lowest tone possible. While he was making this attempt,
sharp pressure was exerted upon the lower part of the sternum, to
provoke expiratory reinforcement. The sound emitted was loud, to the
great astonishment of the patient, who, thus aided by suggestion,
shortly began to talk aloud.

In this particular patient a temporary return of voice was readily
obtained, but not maintained. Special exercises had to be instituted,
whereupon the patient immediately fell back into a complete aphonia. He
was then made to scan words, syllable by syllable, executing with his
arms classical movements of respiratory gymnastics, or sometimes with
the utterance of every syllable the epigastrium was manually compressed
or the shoulders suddenly lowered. The patient could now read a book
in a jerky manner, and after a few lines he could read without his
shoulders being pressed.

Another plan was to have the man read or talk while walking. As soon
as he was stopped and accosted, however, he lost his voice again. Up
to the time of report it was impossible to secure a definite return of
voice, as the patient was not willing to associate words with peculiar
movements. It might make him ridiculous. Accordingly, the nurses were
requested not to fulfil requests unless they were made aloud. Recovery
was to be hoped for from this measure.


Wounded: Recurrent stammering: Reëducation.

=Case 582.= (MACMAHON, August, 1917.)

A young English officer, previously cured of stammering while a boy,
fell to stammering again after being twice wounded. The impediment was
of the laryngeal type. When spoken to he was often quite speechless. In
Shell-shock stammering, the chief difficulty according to MacMahon is
in the production of voice consonants and vowel sounds. In mild cases
the trouble is best left alone.

This officer was anxious to pass into the regular army from the reserve
to which he was attached. The stammering prevented this. He was treated
nine months and improved rapidly. He passed through the trying ordeal
of the medical board successfully and went to his regiment.

In severe cases the patient is taught how to fill his lungs properly.
He is taught to acquire an inferior lateral costal expansion in
inspiration. During expiration the abdominal muscles are trained to
contract slowly and strongly, pressing the diaphragm upwards and
drawing the lower ribs downwards and inwards. This steady breathing
produces a sensation of repose in the stammerer. He is not to raise the
upper chest and not to tense the throat, tongue or jaws.

The main vowel sounds are now taught. The main vowel sounds are oo,
oh, au, ah, a and ee. They combine in six ways, oh and oo in the word
wound, ah and ee make the long i, au and ee in boy, oh and oo in road,
a and ee in rain and fair, ee and oo in new and you. There are also
words in which no main vowel or compound sounds appear, which may be
placed either on the open ah position or the closed ee position. Such
words as long, abbot, among, which are on the position of ah and such
words as it, sister, minister which are in the position of ee. The
voice consonants are b, d, g, j, l, m, n, r, v, w, y, z, w being oo
sound and y the ee sound. The breathed consonants are c, f, h, k, p, q,
s, t.

The treatment of stammering intensified by Shell-shock is more
difficult than that of Shell-shock stammering de novo.


Wound of face: Speech disorder. Recovery by reëducation in two months.

=Case 583.= (MACMAHON, August, 1917.)

An officer was wounded under his left eye, October 7, 1916. His speech
was affected only five days later in a casualty clearing station.
Observed by MacMahon, November 5, he was found to speak with great
difficulty and became exhausted after a few words. He was tensing all
the muscles in attempting to speak. Breathing advice was given and
counsel how to relax in the abnormal efforts.

November 12, the officer, who was at Number One London General
Hospital, began to speak with more freedom. “I am getting a bit better.
I feel I must keep quiet, and it comes after a bit. I think far quicker
than I speak.” He said that the breathing exercises had helped him most.

November 15, he still spoke in a rather staccato way; but the words
did not check as they had. In a week further there had been so much
improvement that he was discharged with a prognosis of complete
recovery.

January, 1917, he had recovered.


Shell wound and burial: Camptocormia (psychoelectric treatment
successful in one séance) and lameness (long reëducative treatment
successful).

=Case 584.= (ROUSSY and LHERMITTE, 1917.)

At a Neuropsychiatric Center, September 2, 1916, arrived a chasseur,
29, showing lameness of a pseudocoxalgic type on the left side,
combined with an anterior camptocormia. The whole situation had lasted
a year. The chasseur had been wounded by shell explosion on the left
side and was buried on July 29, 1915. He lost consciousness and had
respiratory trouble and mutism. His arched walk and lameness began
August 20, 1915.

He had a number of terms in hospital and six months at the dépôt. He
was sent back to the front, June 20, 1916, being proposed for auxiliary
work. There was some mental weakness. After one séance of electric
treatment, the improper attitude of the trunk was corrected. The
lameness, however, persisted and required long daily reëducation.

The patient was discharged cured, October 20, 1916, without lameness or
camptocormia. There were a few persistent lumbar pains.

_Re_ treatment of war psychoneuroses, Roussy and Lhermitte recommend
rational and persuasive psychotherapy after the manner of Dejerine,
Dubois, Babinski, and others. Hypnosis, they say, should definitely be
rejected. Mental contagion must be staved off, and Roussy and Lhermitte
believe that almost all cases are curable and should be sent back as
competents.

They maintain that the medical officer himself plays the leading part.
Many patients are “cured” when they find “good masters”; this mastery
of the combined confessor and educator is greatly aided by prestige.
He must speak with authority, with “iron in the velvet glove”; but
with patience and persistence. If a long sitting fails, postpone work
on the pretext of resting the patient. The patient must not be early
threatened with discipline. Even exaggerators and malingerers must be
talked to as if neuropathic.

A careful medical examination, besides correcting false diagnoses and
demonstrating hystero-organic associations, will give the patient
confidence in his physician.

A new patient is more easily cured than an old one. In general,
patients should be treated as soon as possible after the shock.
Contractures are habitually more persistent than paralysis; tremors and
tic are more pertinacious than deafmutism; ante-bellum psychoneuroses
are less easy to treat than cases developed by the war alone.

The neurological centers near the front, with their discipline,
inaccessibility to friends, and nearness to the front, present a
situation which yields easier and quicker cures than the interior; but
after the two-years’ experience which proved this fact, according to
Roussy and Lhermitte, many cases still get sent back into the interior
for many months,--cases that ought to be cured near the front. Cases
having convulsive attacks get confinement in separate rooms; chronic
neuropaths are kept in bed on a milk diet.

The general features of the treatment of psychoneuroses commended by
Roussy and Lhermitte are summed up in what they call the psychoelectric
and reëducative method, divided into four stages: A stage (_a_) of
persuasive conversation; (_b_) isolation; (_c_) faradization; and
(_d_) physical and psychical reëducation. Roussy and Lhermitte got
during six months in one of the army neurological centers, 98 to 99
per cent of recoveries. Clovis Vincent, in a special interior hospital
(see for Clovis Vincent’s treatment, a summary under Case 575). _Re_
the first stage of persuasive conversations, Roussy and Lhermitte
discuss on the day of admission the general nature of the patient’s
condition, and place him in the atmosphere of cure, in contact with
recovered patients. The conversation takes place in the physician’s
consulting room. The patient is gotten to promise on oath that he will
submit to any methods of treatment. Although one may pass from the
first stage to the third or electrical stage, forthwith, Roussy and
Lhermitte recommend several days of isolation. The patient is placed
in a separate room, and kept in bed on a milk diet. This isolation
treatment of Weir Mitchell allows reinforcement of the suggestion by
talks on the medical rounds, allows the patient, perhaps, to beg for
the electrical treatment, which he may have refused at first, and
lengthens the period of observation. According to Roussy and Lhermitte,
spontaneous recovery not infrequently takes place during this phase of
isolation. Lameness of long standing, tremors, and deafmutism disappear.

The third stage is that of faradization, executed by the physician
with only such attendants as may be necessary to support the patient.
At first, the man lies nude upon the bed, but later may be treated
while sitting, standing, walking, or running. Feeble currents are used
at first; later stronger ones. The poles are applied to the affected
parts, and sometimes to especially sensitive parts of the skin, such as
the ears, neck, lips, soles, perineum, and scrotum. Energetic treatment
by the rapid method is indicated in the vast majority of cases,
especially at the front. If a case is seen early, the rapid energetic
treatment almost always cures at once. The success of the method
depends upon the production of a crisis, which ought to be produced
at the first sitting. Sometimes this sitting has to be continued for
hours. Some patients require two or three sittings; some, still more.
Instead of faradism, a cold jet of water, or even painful subcutaneous
injections of ether, may be used.

The fourth stage is that of physical and psychical reëducation,
important in long-standing cases. The various forms of physiotherapy
are carried out by special assistants or head nurses, accompanied by
psychotherapy, and if necessary by electricity. According to Roussy
and Lhermitte, these reëducative methods used alone, without previous
faradic treatment, are not successful. Relapse follows premature
transference from the front to hospitals in the interior, and too early
sick leave.


Shell-shock deafmutism. Speech recovered by suggestion and reëducation;
hearing by reëducation.

=Case 585.= (LIÉBAULT, October, 1916.)

A corporal, 20, was exposed to the shock of an aerial torpedo, January
18, 1916, at Souchez. The torpedo fell a meter away. There was no loss
of consciousness, but the patient was agitated for several hours, not
knowing what he was doing. Evacuated to hospital, he remained several
days in a stupid state. He was completely deaf and remembered poorly
what had happened. He made every effort to speak, but could not. His
head felt on fire. He could not open his mouth well and his lower jaw
was almost in a state of contracture. He felt that his tongue could not
move easily. In this status he remained until February, always trying
to talk, but not succeeding.

He then arrived at Hôtel-Dieu. The mouth was now opening better and
he was in a better general status, though always feeling fatigued.
Vibratory massage was given to the laryngeal region. He was gradually
got to emit a few sounds in a low voice. He was sent, April 26, to
Prés-à-goutrière. He was now somewhat vocal, but at times would become
completely aphonic once more. The voice during the first few weeks of
treatment became better, and the respiratory capacity was increased
from 450 the first week to 460 and 500 in the next two weeks.

May 12, he suddenly lost his voice again and wanted to commit suicide.
However, in three more days he was able to speak normally again and has
had no relapse. He was then put under auditory reëducation and at the
time of report his hearing had slightly improved.

Liébault remarks that during the time when the patient could not speak
his jaw muscles were contracted and his tongue could not mobilize well.
He could think words but could not articulate them. It was accordingly
important to cultivate the normal functioning of these muscles.


Gassing; tracheitis; crash from airplane; unconsciousness: mutism;
stammering. Reëducation; hypnosis.

=Case 586.= (MACCURDY, July, 1917.)

A lieutenant in the Royal Flying Corps, 23, described as “unusually
normal,” a successful business man, athletic, socially popular, had
been for a year in the Infantry. He was caught suddenly in a gas
attack, and, though he recovered after a few days in bed, had a severe
tracheitis and laryngitis. The lieutenant had been very proud of his
voice and its carrying power. He went to a laryngologist in London, who
said that he would never be able to sing again--a matter of some worry.

He soon became an expert airman. In the spring of 1917 he was shot
at by antiaircraft guns in a trip over the enemy’s lines. One of the
wings was hit and so weakened that in landing the lieutenant crashed to
the ground. He was unconscious for three hours and on coming to tried
to shout to his servant in the distance, who, on arrival, found the
lieutenant quite unable to speak.

According to MacCurdy, there was here a conversion hysteria with
regression to the tracheitis that followed the gassing. The mutism
MacCurdy regards as a pathological degree of an effort of protection
for his voice. In hospital three weeks later he learned to whisper a
few words, though with great mental effort. He regained the voiced
sounds by coughing and then saying “ah.” Stammering now developed.
Not more than one or two words could be said at a breath. Training to
say two, three, four and then five letters in one expiration yielded
improvement in the stammering. Under mild hypnosis, to the degree
merely of distraction, normal speech was re-attained. There was no
relapse. Singing was then practiced and in a period of six weeks the
singing voice was virtually as good as it ever had been.


Shell-shock: Loss of consciousness, possibly hemorrhage from head:
Spontaneous gradual recovery from anesthesias in three months: Recovery
from paralysis by reëducation in a few more weeks.

=Case 587.= (BINSWANGER, July, 1915.)

A German youth of 19 volunteered at the outset of the war as a motor
cycle rider. About the end of October, he was hurled from his wheel by
a shell which struck close beside him and exploded, knocking his back
against a pile of beams. He lost consciousness. There may have been
hemorrhage.

He came to, two hours later, in the dressing station, hardly able to
move his limbs. Such movements as he could make were painful. There
was an evident contusion of the back. He had a fainting fit after his
bath in the field hospital and then could get to bed only with support.
Severe pains in the legs, especially in the knee.

In the reserve hospital, there was a second similar fainting spell,
followed by buzzing in the head, feelings of pressure in the chest and
an irregular pulse; all of which phenomena disappeared the morning
after the fit.

A careful examination about the middle of November showed the
persistence of a severe paresis of the left arm, and a less marked
motor weakness of the right arm. Both legs were paretic, and there
were no spontaneous movements of the leg. This paresis of the legs was
combined with complete anesthesia and analgesia. Sensory impairment was
found only in the right arm and trunk, and there was no evidence of
sensory impairment in the left arm. Both motor and sensory disturbances
of the arm disappeared rapidly.

However, at the beginning of December, 1914, the complete insensibility
of the lower extremities up to the groin still persisted. The
anesthesia then began to retreat, so that four days later, the upper
limit of anesthesia was somewhat below the groin. There could be found
a circumscribed area of anesthetic skin over the os sacrum up as far as
the second vertebra of the os sacrum; but the skin around this area,
as well as over each tuber ischii, gave normal sensation.

The anesthesia continued to retreat: to the middle of the thigh at the
middle of December; to a level 3 cm. above the knee-cap at the end of
December; to the upper end of the knee-cap on the right side and the
middle of the left knee-cap, January 1. January 11, the anesthesia had
retreated to a level 10 cm. below both right and left patella. February
8, sensibility in the legs had entirely returned.

While the anesthesia was pursuing this favorable course, the motor
symptoms failed to improve to any marked extent, although active motion
of the legs with the patient in dorsal decubitus had gradually returned
to a limited degree.

The diagnosis upon arrival at the Jena Nerve Hospital was “rheumatism
of the left side of the body and dislocation of the spine.”

The treatment consisted at first of rest in bed and moist dressings of
the legs, but the treatment had to depend greatly upon the diagnosis.
The patient complained of difficult micturition; yet there were no
other positive signs of organic disease, of spine or cord.

Hysteria was the diagnosis preferred to rheumatism, despite the fact
that examination at the Jena Hospital failed to show any disorder in
pain or tactile sense.

The patient was a rather tall man of slender build, with a slightly
accentuated second pulmonic sound, decidedly increased tendon reflexes,
weak plantar reflexes, and many points painful on pressure in various
parts of the head, over the spine, and in the sciatic regions. The
vertebral sensibility to pressure was most acute in the region of
the third, fourth, and fifth thoracic vertebrae. There was a marked
dermatographia. There was no other sensory disorder and no motor
disorder of the arms, though the left hand-grasp was weak. All passive
movements could be successfully carried out with the legs. Upon bending
at the hip, there were subjective feelings of tension in the posterior
parts of the thighs. In active motion there was a marked limitation in
leg movements, which appeared to be executed with great difficulty with
but small excursion and with considerable trembling. The knee-joint
could be flexed only when the sole of the foot had support. The lower
leg could not be extended. The excursion in the joints of the feet and
toes was slight. Muscular strength was in general decreased. There
were no feelings of pain in muscular action but merely feelings of
great effort. Gait was slow, shuffling, unsteady, hesitating and only
possible with support. Fatigue set in after a few steps. In walking,
the legs could hardly be bent at the knee. The soles of the feet
dragged on the ground. The patient was unable to stand upright, and
when placed upon his feet, anxiously and stiffly clung to some support.
Without support, he fell over backwards. When supported he could move
his legs at the hip and lift the feet from their base by bending the
knee-joints. The patient could not sit in a chair or in bed except with
support; otherwise he would fall to the right side. In dorsal decubitus
he complained of pain in the loins.

With this hysterical picture, treatment of a psychotherapeutic nature
was carried out. The patient was given methodical exercises in walking
and standing, during which affirmative suggestions about his new
capacity to walk and stand were given with monotonous repetition.

For the first fortnight he walked with the support of two nurses for
a half hour every day. He was very industrious and willing to execute
this treatment; and later began to exercise with a cane. Two days
later, he omitted the cane and found himself able to walk about without
support. He was shortly able to stand without swaying, although for
some time the walk was upon a rather wide base and somewhat slow and
suggestive of spastic paresis.

The general condition of this patient remained good. His appetite and
sleep were good. After the middle of March, 1915, there were no more
peculiarities in walking, and the patient was able to take somewhat
long walks in the city and vicinity. He applied for work in the airship
division, for which he already possessed some experience.

The youth appears to have been of a normal mental and bodily
development, though his mother is said to have been nervous and a
sister died of convulsions in childhood.


Shell-shock with loss of consciousness: Deafmutism, rhythmic head
movements, anesthesia, asymmetrical areflexia. Recovery by suggestion
with faradism, massage and reëducation.

=Case 588.= (ARINSTEIN, September, 1916.)

A Russian private, 30, literate, lost consciousness upon the explosion
of a large shell, November 10, 1915. He was brought to hospital,
November 14, completely deaf and dumb, and with his head rhythmically
swaying sidewise 60 to 70 times per minute. The swaying ceased during
sleep. The head was carried inclined to the right; there was complaint
of headache. The left leg, the trunk and the hairy part of the head
were anesthetic. The knee-jerks were obtained with difficulty, the
Achilles jerks were lively; the throat and conjunctival reflexes were
absent; the abdominal and cremasteric reflexes were lively. The right
plantar reflex was absent; the left normal. The vision of the right eye
was impaired, and there was a monocular diplopia of this eye. The drum
membranes were pulled in, and the disorder of hearing was explained on
the basis of labyrinthine shock.

After a séance of written suggestion with faradism to neck and small
palate and vibratory massage to throat, speech returned. November 26,
the patient read in a loud voice a written phrase. He did not speak
again independently until early in December, when he read aloud written
matter. The return of spontaneous speech was gradual. Hearing returned
December 5, when he was able to hear in the right ear by means of a
tube. In the sitting posture there was less swaying of the head. If the
patient lay down, rhythmic movements of the head became stronger and
more rapid (120).


Shell explosion; unconsciousness: Amnesia; paralyses. Reëducation.

=Case 589.= (BATTEN, January, 1916.)

A corporal in the Belgian army was mobilized when the war broke out,
and was in action continuously in the retreat from Liège, in the siege
of Antwerp, and finally on the Yser until October 27, 1914, when the
explosion of large shells rendered him unconscious. He recovered
consciousness only in hospital at Calais. Though he was able to see and
hear well, he was dazed and remembered nothing of what had happened. In
fact, he did not understand what was said to him.

In a week’s time, his memory and intelligence returned, save for
periodic attacks in which he was dazed. From the very beginning he had
been quite unable to move his legs, and at first the arms were weak. He
had a series of attacks of violent struggling in November and December,
1914, which the corporal himself called fainting attacks, claiming
that he did not move his legs in the attacks but only his arms. In
fact, he claimed that he could move neither head, body, nor legs, but
only the arms. He said, “Sometimes I try hard and set my teeth, but
I do not know how to move my head and my legs; I try but they do not
move.” Sphincter control was maintained. Although he could see, when he
attempted to read, everything went black.

He was finally admitted to the National Hospital for the Paralyzed and
Epileptic on July 8, 1915, on the service of Major Walshe. He was thin
and wasted. He was firmly convinced, according to the notes of Major
Walshe, that he was seriously paralyzed. He said he could not lift his
head; when his body was lifted, his head fell back, or rather perhaps
was definitely thrown back, lolling about alarmingly. However as he lay
in bed he frequently lifted his head unconsciously and placed his hands
under it. When asked to lift his head, the sternomastoids were strongly
contracted, but at the same time the neck extensors also, so that the
head was stiffly and strongly held in an extended position. Despite
the patient’s statement that he could not move the trunk muscles, he
could turn over readily in bed, and when trying to move the head the
trunk was fixed in a strong opisthotonos, and the abdominal walls were
rigid. When requested to move his legs, he made no movement whatever,
though during head movements the legs were strongly fixed in extension.
On passive movements, there was no active muscular resistance. There
was an indefinite blunting of all kinds of sensations. Reflexes were
normal.

Major Walshe worked hard with the patient, inducing him first to lift
his head from the pillow, and finally to move the legs. In three weeks’
time, the corporal could just sit up, and at the end of another month,
he was able to stand in the walking machine. At the end of a third
month, he was walking upon crutches, and at the end of another, he
could walk upon two sticks with his feet wide apart, moving as if glued
to the floor. To quote Batten, “The corporal will eventually get well
but not, I think, before the end of the war.”




E. EPICRISIS[8]

    Così od’ is che solava la lancia
      d’Achille e del suo padre esser cagione
      prima di trista e poi di buona mancia.

    Thus I have heard that the lance of Achilles,
      and of his father, used to be occasion
      first of sad and then of healing gift.

                        Inferno, Canto XXXI, 4-6.

    [8] Material is here drawn _passim_ from the compiler’s
    SHATTUCK LECTURE on =Shell-shock and After=, read before the
    Massachusetts Medical Society, Boston, June 18, 1918.


TERMINOLOGY

=1.= =Shell-shock, a lay term, usually refers to the medical entity or
disease-group: functional neurosis, or more briefly, neurosis.=

The history of the term Shell-shock will repeat that of Railway
Spine in the last century; the term will fall into disuse when the
cases subsumed thereunder get their exact medical diagnoses--which,
_statistically speaking_, will prove to be as a rule psychoneuroses,
either hysteria (pithiatism), neurasthenia (nervous exhaustion,
“prostration”), or psychasthenia (obsessive neurosis).

=2.= =But the laity cannot be got to use the term Shell-shock in this
exact sense, because the laity cannot make exact diagnoses.=

In the post-bellum and reconstruction period the physician will need
to guard against regarding all cases _called_ Shell-shock as really
neuroses, merely on the ground that Shell-shock is _probably_ neurosis.
Laymen will in the reconstruction period succumb to the lure of the 100
per cent and gossip about cures and failures in the same loose manner
that is but too familiar in discussions of Lourdes, Christian Science,
the Emmanuel Movement. It will be worth while to preserve a certain
generality and comprehensiveness for the term Shell-shock, which will
stand to medicine as the term weeds stands to botany.

=3.= =In short, keep the connotation but try not for any denotation of
this lay term Shell-shock in the lay mind!=

The dangerous history of the term _dementia praecox_ may be recalled.
Neither _dementia_ nor _praecox_ is an exact term except for the
statistical majority of cases of schizophrenia. Yet does not the layman
hearing the term _dementia_ feel entitled to assume that a victim must
be _demented_ or become so?

=4.= =The term Shell-shock appears to be a perfect term for the
ordinary man, as it means much and little, connotes enormously and
denotes a minimum and casts the lay hearer back upon the expert.=

But confronted by the term _Shell-shock_, the ardent social worker or
the ordinary man fails to get any incorrect notion about the nature,
and especially about the prognosis, of the condition. If there is any
suggestion of prognosis, it is the correct suggestion of curability
possibly conveyed by the suddenness implied in the term shock; but
I defy the ordinary man to get from the ordinary term Shell-shock
very much that denotes anything in particular. All he gets is an
enormous connotation. This connotation may run back for the race into
tree stumps, savages brandishing spears, palatial decorations, the
protrusion of animal spirits, the Leyden jar (sometimes familiarly
known as the “shock bottle”), and the aspen shaking of the man in
fear or its interior equivalent. But whether the slang runs back so
far or no, and whether the shell is a shell of powder or a shell of
fear, and whether the shock is of solid particles or in a moral sense,
the problem is implicitly laid down in the slang (see historical
discussion, Shattuck Lecture).

=5.= =The terminological difficulties are clarified somewhat by the
French distinction of états commotionnels and états émotionnels in the
Shell-shock group.=

The French very neatly distinguish what they term _états commotionnels_
from _états émotionnels_. They think of the _états commotionnels_ or
commotional states much as we think of _commotio cerebri_, that is, of
a physico-chemical happening in the brain of an essentially curable
(or reversible) nature; that is, of something that falls short of
being, as they say, _lésionnel_, namely, as bringing about a structural
lesion. That is, they distinguish a brain with a visible focal lesion
from one which has sustained a physical jar or commotion, and they
distinguish the effects of both of these from the _états émotionnels_
or emotional effects of an injury. The nomenclature here brings out one
of the most fundamental difficulties in the whole field of so-called
Shell-shock, namely, the distinction between structural conditions,
microscopic or macroscopic, on the one hand, and functional conditions
of a psychopathic nature, on the other. The _commotion_ would affect
the neurones themselves in some perhaps invisible but still genuine
physico-chemical way, whereas the _emotion_ would affect these neurones
merely after the manner of the normal emotional life, except that the
neurones would perhaps deliver an excessive stream of impulses.

=6.= =Terminology, especially in the matter of explanations to laymen=
(Americans demand monosyllabic explanations as a preliminary to taking
suggestions!), =is not always assisted to clearness by physicians= on
account of the old ontological fallacy that Charcot insisted on.

Would that the medical profession understood neuroses at their
true value! Only too frequent is the impression on the part of
the profession that _imaginary_ symptoms are by the same token
_non-existent_! I have even heard a physician well-trained in somatic
lines say that Shell-shock did not exist because Shell-shock was
nothing but neurosis, and neuroses were characterized by imaginary
symptoms,--accordingly neuroses, being imaginary, do not exist! All of
which reminds us that many of the profession were entirely skeptical
when Charcot made his original observations. Some men here in America
felt that, whereas hysteria might occur in Paris, it did not occur to
any extent in America. The Shell-shock data of this war will abundantly
prove to the profession the existence of the neuroses, and I feel
that physicians will have to brush up their ontology to the extent of
conceding that _a symptom may be_ in a sense _imaginary and yet not_ in
any sense _non-existent_.

=7.= =Babinski points out a case of hysterical paralysis of a leg
which led the patient to lean so heavily upon his arm as to produce an
organic crutch paralysis.= It would be to no point to argue that the
hysterical paralysis was here non-existent. Of course we shall have to
meet the false analogies drawn from methods of cure. If a paralysis can
be cured in a few minutes by the electric brush, or by hypnosis, or on
emergence from chloroform, or by some other modern miracle.

=8.= =Is it too much to ask the profession not ever to say that this
rapid and seemingly miraculous cure was brought about because the
disease was non-existent?=


DIAGNOSTIC DELIMITATION PROBLEM

=9.= =The delimitation problem=, taken up in Section A, =is not
identical with the differentiation problem=, taken up especially in
Section C but _passim_ in Sections B and D; by delimitation we may
refer to the process of localizing the diagnostic battle through
exclusion of the other great groups of mental diseases that _à priori_
=ought= not to come in question, but do come in question sometimes,
before we slice down to the question.

=10.= =Is there or is there not evidence of destructive lesion in the
nervous system of this so-called Shell-shocker? Is this man a victim of
organic or of functional neurosis? This latter is what may be termed
the differentiation problem.=

Confining ourselves now to the delimitation problem, what are the major
groups of _mental diseases_ that might come in question?

I shall enumerate these. We think of mental diseases as I, syphilitic;
II, hypophrenic (that is, feeble-minded in some of its phases,
including even slight degrees of subnormality not entitled to be called
feeble-minded in the ordinary sense); III, epileptic; IV, alcoholic
(or due perhaps to some drug or poison); V, encephalopathic (in the
sense of some focal brain disease); VI, symptomatic (in the sense of
some somatic disease); VII, senile (or presenile). The seven groups
so far enumerated, I believe, the general profession is pretty well
equipped to consider, at least roughly to diagnosticate and to handle
with due respect to the interests of the patient and of the community.
I am bound to say that some of my colleagues would not go so far as
to the competence of physicians in general in these fields, and one
is aware that a plenty of mistakes have occurred even in these groups
through the bad judgment of practitioners. Nevertheless, I hold to the
conception that our profession is reasonably well equipped to handle
these greater groups, having in mind all the while the appropriate
temporary calling-in of the specialist. But there are two more groups,
in addition to these seven, in which I am not so sure that the
general profession knows as much as it should. I refer to VIII, the
schizophrenic group, commonly known as the dementia praecox group; and
IX, the cyclothymic group, sometimes termed the manic-depressive group.
It is the victims of the diseases that constitute these latter groups
that ought unconditionally to be excluded with few exceptions from the
army; and it is the study of these conditions which ought to be carried
out as a part of every man’s post-graduate training, not merely for his
work on draft boards, but for his work in civilian and reconstruction
practice. There is another group of, X, psychoneuroses, with which the
profession regards itself as familiar, and with which it doubtless is
familiar, in what might be called _blooming examples_ of hysteria,
neurasthenia, and psychasthenia. But the nub of the situation lies in
the fact that the diagnosis of instances which are not such blooming
examples is difficult, and hence it was that I qualified my statement
as to the competence of the practitioner in this tenth group. It is, of
course, the tenth group, of psychoneuroses, into which the majority of
the Shell-shock cases fall.

=11.= =Now a study of the literature of the belligerents having
Shell-shock in mind as its special topic and aim proves to require a
study of war literature in all of these groups.= There are cases of
so-called Shell-shock which even well-prepared medical men have placed
in the neurosis group, when they should have been placed in one or
other of the groups mentioned.

=12.= In short, =whereas the Shell-shock delimitation problem deals=
with groups, I, II, III, IV, VI, VIII, IX and (as our compilation
shows) =especially with groups I, III and VI=, on the other hand =the
shell-shock differentiation problem= deals primarily with groups V and
X.

To clear the decks for action _re_ the differentiation problem, let
us dismiss the major troubles of the delimitation problem as shown in
groups I (syphilitic), III (epileptic), VI (somatic) and thereafter
very briefly refer to the residue of the delimitation problem. For
convenience of reference, a few out-standing remarks concerning the
general relations of these divisions to war and peace conditions are
inserted here. We dealt in the diagnostic order of exclusion with
190 cases, distributed as in the table below (bear in mind that the
method of this book precludes attaching great statistical weight to the
comparative figures, since the various authors published their cases
for their special rather than their typical interest).

       I. Syphilopsychoses                                      34
      II. Hypophrenoses (feeble-mindedness and imbecility)      18
     III. Epileptoses                                           33
      VI. Pharmacopsychoses (alcohol; morphine)                 17
       V. Encephalopsychoses (focal brain lesion cases)         15[9]
      VI. Somatopsychoses                                       29
     VII. Geriopsychoses (senile--a null class)                  0
    VIII. Schizophrenoses                                       16
      IX. Cyclothymoses                                          7
       X. Psychoneuroses                                        12[9]
      XI. Psychopathoses                                        15
                                                             -----
                                                               196

    [9] The numbers of focal brain lesion cases and of
    psychoneuroses must naturally be considered in relation to the
    great groups of these cases in Sections B and C.

=13.= =The neuropsychiatric side of syphilis in the war= is presented
in 34 cases (Cases 1 to 34). The syphilitic basis of sundry military
difficulties, quite unsuspected by the laity and probably not too well
understood by service men, is suggested by Case 1, a case of desertion
by a French officer of high rank. Nor is Case 2, in which visions of
submarines proved syphilitic, without its warning. Such cases point
only too obvious a moral:

=14.= =Neurosyphilitics have no place in the army or navy.=

Eight cases (Cases 3-10) follow in which the aggravation or
acceleration or liberation of neurosyphilis has come about under the
conditions of war. Some of these cases suggest the gravity of the
problems of compensation, allowance and pension that may arise. We
might ask,

=15.= =Should not a government which enlists a syphilitic pay
full allowances to him when under war conditions he becomes a
neurosyphilitic?=

For the government was theoretically able to learn at the start
(within a small margin of error by means of the serum test) whether
the man was syphilitic. If a one-eyed man loses his remaining eye in
an industrial accident in civil life, his damages are often fixed at
damages for total blindness; for the industrial firm should not have
employed a one-eyed man in an industry dangerous to eyes. The principle
cannot differ with a man hired in a spirochete-bearing state: The
company has hired a man who may under traumatic conditions become an
incompetent neurosyphilitic, and should pay damages accordingly when
the aggravation begins.

=16.= =What are the responsibilities of government if the neurosyphilis
is due to a syphilis acquired during the war?=

Often such infection may be due to a tragical form of “negligence.”
But, as pointed out in a work on Neurosyphilis, 1917, I believe
that any form of licensing system, official or virtual, which would
permit the purchase of syphilis in or near military zones, abolishes
the argument of “negligence.” A man acquiring syphilis under the
connivance of government ought to stand as well as a syphilitic hired
by the government, when it shall come to the question of compensation
for incapacity. Yet, it may be argued, the man might have remained
continent after all. The point is left to the mercy of jurists.

=17.= =The share of neurosyphilis in the “crimes” and disciplinary
problems of the army= is intimated in three cases (Cases 11 to 13).

=18.= The latter part of the series (Cases 14 to 31) embraces =problems
of a more medical nature, touching traumatic paresis and “Shell-shock
paresis.”= Unusual, these cases may be readily conceded to be; but
their infrequency is not such as to put them out of the field of
consideration in the “Shell-shock” group.

Very intriguing to the diagnostician would be the cases of
_pseudo_tabes and _pseudo_paresis (Cases 23 and 26 of Pitres and
Marchand), were such cases at all frequent.

Case 28, in which shell-shock (the physical event) apparently caused
recurrence of a syphilitic (!) hemiplegia, is particularly instructive
and might better belong with the series (under Section B: Nature and
Causes, Cases 286-301) in which _ante-bellum_ weak spots were picked
out by shell-shock and war conditions. But Case 28 is placed here for
its syphilitic interest.

Case 29 stands out as a warning example not to crowd the hypothesis and
try to make syphilis sponsor for everything, even when it plainly is at
work.

Cases 32-34 are cases in which syphilis played a part, though possibly
a minor part, in certain peculiar mental reactions.

To sum up the part played by syphilopsychoses and syphiloneuroses in
the war, we find, that

=19.= =Syphilis may have occasionally a serious military effect=, as in
the case of desertion by a French officer of high rank.

=20.= =Important problems of pension, retirement, and compensation
are brought out=, and as no previous war has had the benefit of the
Wassermann reaction and other exact tests bearing upon the nature,
progress, and curability of neurosyphilis, we may hope for a far more
scientific determination of these questions by review boards during and
after the war.

=21.= We find a few instances in which neurosyphilis has played a
part in the discipline of troops. According to one author (Thibierge,
1917), syphilis has become a genuine epidemic among French soldiers
and mobilized munition workers. In Germany, also, it may be remembered
that Hecht has claimed that no less than an equivalent of sixty army
divisions has been temporarily withdrawn from fighting on the Teutonic
side for venereal diseases. In this connection, Neisser had recommended
the giving of salvarsan and mercury in the trenches. According to
Hecht, the appearance of syphilis should be a signal for sending a man
to the front. Hecht also made the somewhat bizarre suggestion that
special companies of syphilitics should be formed, for convenience of
treatment, on the firing line.

=22.= A more solid foundation is laid for the theory that =general
paresis= may be =evoked by trauma=--a conclusion already fairly well
established by civilian cases, notably those of industrial accident.

=23.= The question whether shell-shock (the physical event) can produce
general paresis is probably to be settled in the affirmative, for it
may always prove difficult to show that the physical shell-shock did
not actually produce mechanical molar lesions of the brain, permitting
the rapid advance of spirochetes. It is perhaps easier to prove that
shell explosion may precipitate neurosyphilis in the form of tabes
dorsalis (take, for example, Cases 21 and 22). The cases of most
importance in the question of traumatic neurosyphilis and traumatic
paresis are cases 20, 21, 22, 24 and 25.

=24.= The picking out of preëxistent weak spots by Shell-shock is given
clear illustration, as in the case of Shell-shock recurrence of an
old syphilitic hemiplegia (Case 28). Only on such a basis could the
syphilitic ocular palsy of Case 19 be satisfactorily explained.

=25.= =The coexistence of functional phenomena with organic syphilitic
phenomena is demonstrated= by Cases 29 and 30; perhaps also in Case 16.

=26.= It must be said that presumably there will be, unless our
authorities are more successful than in the past, a considerable
increase in venereal disease as the result of army life in wartime.
There will be a certain number of cases of neurosyphilis a number of
years after discharge from the army caused by infection acquired during
service. (Germany is said to have got its crop of neurosyphilis after
the War of 1870, in the early eighties of the last century.) The names
of all soldiers acquiring syphilis and not considered cured at the
time of discharge should, under ideal conditions, be given to health
organizations in their home states so that they may be accorded proper
care and treatment.

=27.= =Shell-shock and epilepsy.= The authorities have been somewhat
surprised by the number of epileptics that have gotten by the draft
boards. The statistics are not yet ripe, but certainly the enlistment
of an epileptic is not a rarity. There are some singular instances
in the war literature showing how hard it sometimes is to bring
out epilepsy. There is the English case, for example, of a man, an
epileptic’s son, who had himself been epileptic from 11-18, who
entered the Expeditionary Force at the outbreak of hostilities, went
through the retreat from Mons and through two years of active warfare
without having a single epileptic convulsion. In fact, in September,
1916, he was put in charge of eight men on guard duty. Apparently the
new responsibilities worried him, and two months later he had become
epileptic to the extent of petit mal.

Another man who had never been epileptic (though his sisters had been)
was wounded four times, was never worried by shell fire, got somewhat
depressed after the death of his father and five brothers in the
service, but did not become epileptic until finally he was blown up and
buried three times in one day, and it was a whole month later when he
became epileptic, although treatment by rest and bromides apparently
resolved the affair.

Other cases seem to show that war experiences can bring out epilepsy,
although in most instances it would appear that there was an epileptic
or otherwise neuropathic heredity in these cases.

=28.= There is one author, Ballard, who has actually propounded a
=theory of Shell-shock as epileptic=, pointing out the occurrence
of epilepsy long after the early symptoms of Shell-shock have
disappeared.[10] There does not appear to have been any increase in
epileptics as the result of the war, either from the standpoint of
Shell-shock or from the standpoint of brain injury, so far as the
records of the National Hospital for the Paralyzed and Epileptic in
London are able to show.

    [10] In one instance, fugue and other minor symptoms were
    later replaced by epilepsy; in another, an epileptic confusion
    developed eight months after an explosion, and in a third,
    a case of mine explosion, stammering resolved into mutism
    and mutism finally into epilepsy. Of course there is a
    so-called general resemblance among all forms of hyperkinesis
    or irritative discharge of the nervous system. If we term
    epileptic all the things that various authors have termed
    epileptoid, we may be doing nothing more than to say that we
    believe these cases all subject to epileptic hyperkinesis.
    In that direction, of course, it has long been said that
    dipsomania was really a form of epilepsy. Whether Shell-shock
    is ordinarily subject to recurrence in such wise as to imitate
    the recurrence of attacks of dipsomania, of manic-depressive
    psychosis or of epilepsy, is, to say the least, doubtful at
    this time.

=29.= As in all other instances of mental or nervous disease, when an
=epileptic returns from the war=, whether or not he was potentially or
actually an epileptic before the war, his relatives are bound to term
him a case of =Shell-shock=. I am familiar with a case in a hospital
in a certain Atlantic port, a case of pronounced and obvious epilepsy.
In the wards he is treated as the hero of every occasion. Not only the
nurses and attendants, but the other patients and often the physicians
can hardly resist thinking of him as somehow a case of Shell-shock. It
is a comment upon the status of mental hygiene in general that this
self-same epileptic, had there been no war, would have been, as it
were, a common or garden epileptic, mute and inglorious on some sunny
hillside.

=30.= In passing I may note how many instances in the medicolegal
part of the war literature there are of =epileptics who come up for
courtmartial= or for medical examination pending courtmartial. We may
suspect that many a case of epileptic fugue has been regarded as a
case of desertion. There is the case of an epileptic who left camp one
morning and got drunk. Investigation showed that he left camp before
anything epileptoid had happened. He developed in his drunkenness a
pretty clearly epileptic crisis with great violence, for which he had
a complete loss of memory. The French Council condemned him to five
years of labor, not admitting in this instance that responsibility was
diminished by reason of the man’s being epileptic. In short, from the
military point of view, he should, so to say, have known enough not to
have gotten drunk, and so have avoided getting his epileptic crisis. Of
course the decision was here very close, and a like decision would not
always be rendered. To add to the complication of this particular case,
the very first epileptoid crisis which caused it to be known that the
man fell into the epileptic group was due to Shell-shock, or at least
developed immediately after the bursting of a shell nearby. On the
whole, however, the relation between epilepsy and Shell-shock is not a
close one.

=31.= =The question of epilepsy in the war= is considered in a series
of 33 cases (Cases 53-85). The considerations range from banal cases
developing quite incidentally, up to cases regarded by one author
(Ballard) as illustrating a theory of Shell-shock as epileptic (Cases
82-84). First are considered two cases actually syphilitic. In the
first (Case 53), the diagnosis had to be revised from epilepsy to
neurosyphilis (the convulsions of this neurosyphilitic were brought
out by alcohol, and the reporter, Hewat, remarks that the serum of any
patient developing epileptiform seizures between 35 and 50 years of age
should be subject to test). In Case 54, the soldier got his syphilis
in wartime and the syphilis acted to bring out an epilepsy with which
the patient was hereditarily tainted (epilepsy syphilogenic, _i.e._,
reactive to syphilis).

Case 55 might perhaps better have been considered in the group of
hypophrenoses, as he was epileptic and imbecile. He was at first
condemned by court martial to five years’ imprisonment for leaving his
post in the presence of the enemy.

Another mixed case is Case 57, in which another feeble-minded subject
showed seizures of a psychogenic nature, which he was able eventually
to stop by clenching his teeth.

Seven cases (Cases 58-64) are cases of a disciplinary nature, amongst
which attention may be called to Case 62, the “specialist in escapes.”
The medicolegal questions of responsibility in the drunken epileptic
(Case 58) are particularly perplexing.

=32.= Case 64 is one of =epilepsy following antityphoid inoculation
one-half hour=. There were five attacks during a fortnight and then
no others. The antityphoid inoculation came eight weeks after a shell
wound of the thigh, which had not served to bring out the epilepsy in
this patient. Bonhoeffer had three other instances of the sort: one in
a severely tainted subject, and the others in alcoholics.

=33.= The next group of cases, 66-77, yields a series of the most
interesting =medical problems=, some of which scarcely belong in
an account of psychoses incidental in the war. Case 66 is one with
recovery from Jacksonian seizures after decompression of the upper
Rolandic region, which was edematous following an (apparently very
slight) scalp wound and shell-shock.

=34.= The cure by studied neglect (in Case 67) is one of
=hystero-epileptic= convulsions occurring in series. Case 68
demonstrates the superposition of hysterica phenomena over a genuine
epilepsy, a case therefore with two diagnoses: not hystero-epilepsy,
but epilepsy =and= hysteria.

=35.= The theoretical implications of Case 69 are striking: The
case was one of musculo-cutaneous neuritis (gross enlargement), in
association with which =Brown-Séquard’s epilepsy= developed, waxing
and waning with the disease of the nerve. Another case of possible
reactive epilepsy is Case 70, and a case of epilepsia tarda brings up
the same issue (Case 71). Cases 72-74 are cases with strong psychogenic
components, of which Case 74 is particularly instructive on account of
the gradual building up of a remarkable visual aura of an approaching
fire-wheel, this aura developing after scotoma from looking at the sun.
Cases 75 and 76 are cases of somewhat doubtful epilepsy, one of fugue
and the other of a solitary epileptic episode following 38 artillery
battles in two months.

=36.= Friedmann discusses =narcoleptic seizures=, regarded as due to
the =brain fag of trench life= (Case 77). Sham fits and epileptoid
attacks controllable by will appear in Cases 78 and 79 respectively.
Case 80 is a striking case of a man with epileptic taint, which two
years’ service, four wounds, the death of a father and five brothers,
and eventually Shell-shock and burial thrice in one day, served at last
to bring out.

=37.= =Shell-shock and bodily disease.= In civilian psychopathic
hospital practice, if a case is not syphilitic, not feeble-minded, not
epileptic, not alcoholic, and without signs of intracranial pressure or
disorder of reflexes, then we, as specialists, must consider whether
the disease in question is not due to some form of bodily disorder
outside the nervous system; for example, we think in practice of
infectious psychoses, of exhaustive states such as the puerperium,
of toxic states such as may be found in cardiorenal cases, and of
glandular phenomena such as we are familiar with in the thyroid
disorders.

Under the war conditions, it might be thought that these somatic
disorders yielding the so-called symptomatic mental diseases would be
frequently found.

Aside from these rarities in puzzling diagnosis, we find more commonly
in the literature evidence of

=38.= =The soldier’s heart, the so-called “D.A.H.,”= or disordered
action of the heart, of the English army reports. This soldier’s
heart is sometimes associated with hyperthyroidism, and sometimes
hyperthyroidism is found alone, with symptoms suggesting those of a
sort of diffuse Shell-shock.

One author claims rapid cures of hyperthyroidism by the relatively
simple process of hypnosis. Perhaps this is not too unlikely in view
of the still obscure relations between mind and hormones. A little
more surprising, perhaps, is the assertion met with that psoriasis is
sometimes a Shell-shock phenomenon.

The literature clearly shows, however, that, as in most special
problems, the internist is still in demand. I recall how one internist
was misled on the witness stand into stating that he was a “general
specialist.” This is what we would all need to be, were we to solve the
problems of Shell-shock in the time allotted to us by the war.

=39.= Following are =special cases= to show how near the somatic
(“symptomatic”) may be to Shell-shock.

The somatic group of psychoses, sometimes termed symptomatic, is
illustrated in 29 cases (Cases 118-146), and comprises cases ranging
all the way from rabic phenomena to those of hyperthyroidism. Possibly
the first two cases (Cases 118 and 119) might better be placed among
the encephalopsychoses. Case 118, one of _rabies_, was that of a farmer
without history of having been bitten by a dog, who eventually came
to autopsy and received the Pasteur Institute diagnosis of rabies. A
diagnosis of angina was at first made. When the symptoms became more
serious and masseter spasm developed, a question of tetanus arose.
Later the diagnosis of meningitis was suggested. At this point, the
symptoms became predominantly psychotic.

Case 119 was one of seven cases reported by Lumière and Astier, in
which delirium and hallucinations appeared as a complication of
_tetanus_. The case in question had been given anti-tetanic serum.
(Another case showed identical symptoms without having been given
anti-tetanic serum.)

That a local tetanus could be mistaken for hysteria might seem _à
priori_ unlikely, but Cases 120 and 121 indicate as much; and Case
121 is interesting on account of the officer’s own description of his
local tetanus and its treatment. A psychosis apparently related with
dysentery occurred in Case 122. Hysteria followed typhoid fever in Case
123. Another form of typhoid fever complication is perhaps shown in
Case 124, wherein the diagnostic question lay between dementia praecox
and a post-typhoid encephalitis.

_Paratyphoid fever_ has diagnostic complications, as shown in Cases 125
and 126, wherein the mental symptoms outlasted the fever (Case 125),
and psychopathic taint was brought out (Case 126).

_Diphtheria_ was also represented in the matter of nervous and mental
symptoms in Cases 127 and 128. In Case 127 the nervous symptoms
appeared eight days after evacuation for diphtheria. There were a few
sensory symptoms (hypalgesia, hypoacusia, and peculiar bone sensations)
in this subject. The phenomenon in Case 128 was apparently one of
hysterical paraparesis; nor does it appear in this case that the
hysterical paralysis was preceded by polyneuritis.

_Malarial effects_ are present in three cases (Cases 129-131), of
which Case 129 showed an amnesia, Case 130 a Korsakow syndrome, and
Case 131 anterior horn symptoms. Case 132 exemplifies 15 instances of
acroparesthetic disorders in so-called trench foot. This case, like
several others, is inserted in this group, not because the symptoms
are psychotic, but because they might cause diagnostic difficulty as
against hysterical phenomena.

Case 133 is an autopsied case of bronchopneumonia following bullet
injury of the spine. Microscopic examination of the spinal cord
showed small cavities in the first and fourth dorsal segments. This
myelomalacia was doubtless related with the bullet injury of the
spine, although the spinal cord was not itself directly touched by
the bullet. Case 134 might be regarded perhaps as one of Shell-shock
and should be considered in relation with the cases at the head of
Section B (Cases 197-209). The case might be regarded as functional,
except for a decubitus that developed. Despite this decubitus, there
was recovery. The case is placed in the somatic group on account of
_pulmonary phenomena_ which it seemed well to relate with those of Case
133. Compare also Case 136, in which reflex phenomena are associated
with a bullet wound of the pleura. Case 135 is a many-sided case,
with ante-bellum hysteria and certain Shell-shock phenomena. While
under observation, the patient caught typhoid fever and then developed
neuritis. This neuritis was very probably not post-typhoidal so much as
hysterical. Accordingly, the case should be considered in connection
with the ante-bellum weak spot series, Section B (Cases 286-301). There
was in this case a cure by reëducation.

The reflex hemiplegia with double ulnar syndrome in Case 136 seemed to
have followed a bullet _wound of the pleura_. According to the authors,
Phocas and Gutmann, there is considerable literature upon nerve
complications of pleura trauma, including syncope, epilepsy, and (more
rarely) hemiplegia.

_Heart cases_ are illustrated by Cases 137-139: the first one of
hysterical tachypnoea, and the others of the so-called soldiers’ heart.

_Diabetes mellitus_ seems to have followed war strain and shell wound
in Case 140.

It is doubtful whether shell-shock and burial had anything to do with
the appearance ten days later of _lipomata_, which proved to be the
initial phenomenon in a pronounced Dercum’s disease. (Case 141).

_Hyperthyroidism_ is illustrated in four cases (Cases 142-144).
The first (Case 142) appears to have been cured by inducing deep
somnambulism (Tombleson claims cures by suggestion in eight cases of
hyperthyroidism). Neurasthenia or questionable Graves’ disease (Case
145) followed Shell-shock. That of Case 144 followed 10 months’
service, at times under protracted shell fire. A _forme fruste_ of
Graves’ disease is shown in Case 145, in which the phenomena followed
gassing and shelling.

A somewhat curious _somatic complication_ in a case of Shell-shock
hysteria was the finding of a needle in the left upper arm, which was
then extracted. (Case 146).


THE NATURE OF WAR NEUROSES

=40.= Regarding our rough delimitation of the Shell-shock group as
well in hand, having put upon one side three of the most disturbing
groups (save one) in our process of demarcation, =we must proceed to
the Shell-shock material itself: a material now definable as assuredly
non-syphilitic, non-epileptic, non-somatic=,[11] as beyond question
without narrow relations with feeble-mindedness, alcohol and drug
states, schizophrenia and cyclothymia, and =as probably of the general
nature of the psychoneuroses=.

    [11] In the limited _non-encephalic_ sense of the term somatic
    (“symptomatic”) of some writers.

Note that in this epicrisis I have designedly not followed the order
of presentation of the text materials. The process of _diagnosis per
exclusionem in ordine_ which I find most serviceable in civilian
psychopathic hospital practice is the elimination of possibilities in
the order presented in Chart 1 or in Paragraph 10 of this epicrisis.
Because this book will find its greatest use in peace times as a
kind of illustrative commentary on the peace material that presents
itself in general practice or in psychopathic hospital voluntary,
temporary-care, and out-patient practice, I chose to arrange the
delimiting material according to the order of the practical key devised
for civilian practice. We may now profitably change our order of
consideration and consider whether

=41.= =The most practical key or sequence of consideration in the
endeavor to delimit Shell-shock neuroses is probably: Exclude (1)
syphilis, (2) epilepsy, (3) somatic disease= (of a sort able to produce
“symptomatic” effects somewhat like those of Shell-shock).

Below I shall still permit myself some general words concerning
the other more easily excluded groups because of the light which
feeble-mindedness, alcoholism, schizophrenia, cyclothymia, and even old
age can theoretically throw on the nature of Shell-shock.

=42.= Suppose then that syphilis, epilepsy, and somatic (non-nervous)
disease are out of the running, =we come practically down to the
psychoneuroses=, knowing that knotty problems are at hand in telling
them from structural traumatic effects: =But, after all, what are
functional neuroses?= What do we really know about the neuroses other
than to say that they are _not_ distinguished by the existence of the
structural lesions which characterize organic disease of the nervous
system? Is not the definition of neurosis purely by negatives? However
true this definition by negatives may be from the genetic and general
pathological viewpoint, the work of Charcot and in particular of
Babinski has yielded a number of positive features from the clinical
viewpoint, which to some degree make up for the lack of anything
positive in the neurones themselves as studied post-mortem. An eminent
German has recently declared that the data of this war itself go far to
prove some of the long dubious contentions of the Frenchman, Charcot;
and the work of Babinski during the war has strengthened and developed
the conceptions of his master, Charcot, as well as the ante-bellum
conceptions of Babinski himself.

=43.= Let me insist that =the problem is practical enough: Organic
versus functional neurosis=. The point I want to make is that, when so
much theoretical doubt concerning organic and functional neuropathy
holds sway, the practical doubts in the individual case under the
varying conditions of civilian practice and in the upheavals of
military practice, must be still more in evidence. Case after case
described in the literature of every belligerent has passed from
pillar to post and from post to pillar before diagnostic resolution
and therapeutic success. Colleagues meeting, for example, at the Paris
Neurological Society, find themselves reporting the same case from
different standpoints,--the one announcing a semi-miraculous cure of
a case which another had months before claimed only as a diagnostic
curiosity. In the midst of such discussions and controversies, there
must inevitably be a renaissance in neurology.

=44.= =In cases of alleged Shell-shock, the hypothesis of focal
structural damage to the nervous system or its membranes has to be
raised.=

Shell bursts and other detonations can produce =hemorrhage in the
nervous system and in various organs without external injury=. Thus a
man died from having both his lungs burst from the effects of a shell
exploding a meter away. Hemorrhage into the urinary bladder has been
identically produced. Lumbar puncture yields blood in sundry cases of
shell explosion without external wound, and Babinski has a case of
hematomyelia produced while the victim was lying down, so that the
factor of direct violence through fall can be excluded. In sundry
cases, not only blood but also lymphocytes have been found, sometimes
in a hypertensive puncture fluid.

=45.= Moreover, =in cases of alleged Shell-shock there may be a
combination of structural and functional disease=.

A herpes or the graying-out of hair overnight can suggest organic
changes. A case may combine lost knee-jerks (suggesting organic
disease) with urinary retention (suggesting functional disorder).

=46.= Again, =there is a group of war neuroses=, especially clearly
brought out in cases of ear injury, =in which the functional disorder
surrounds the organic as a nucleus=. But these “periorganic” neuroses
are no proof that the neuroses in question are organic in nature.
Hysterical anesthesia, paralysis, or contracture may occur on the
side of the body which has received a wound: =the process of such a
peritraumatic disorder is, nevertheless, a functional process=.

=47.= But, when the problem is statistically taken, =the majority
of cases of alleged Shell-shock without external wound prove to be
functional, as indicated by their clinical pictures=. Thus, after
a mine explosion, a man was hemiplegic, tremulous and mute. After
sundry vicissitudes, the tremors were hypnotized away. Then the mutism
vanished, to be supplanted by stuttering. Finally the hemiplegia
remained. So far as the mutism and the tremors went, this man might
belong in the =majority group of Shell-shock cases, namely, the
functional group=. Assuming the hemiplegia to be really organic, we
should regard this man as a mixed case, organic and functional.

=48.= =But do we not know all= we need to know or all we are likely
to know =about the neuroses already= from old civilian studies? There
are some cases without very close relations to the war: Thus, we
conceive of (_a_) psychoneuroses incidental to the war and such that
they might very probably have developed without the entrance of war
factors; and on the other hand, we conceive of (_b_) psychoneuroses
(to be dealt with _in extenso_ later) in which war factors (either
physical Shell-shock or other factors) forcibly enter. There are in
this group of incidental psychoneuroses 12 cases. The first, described
as a constitutional _intimiste_, a psychasthenic _en herbe_, was one
in which a hallucination was developed in the field, and in which
three phases of a psychopathic nature--(_a_) over-emotionality, (_b_)
obsessions, (_c_) loss of feeling of reality--developed. In this case
the war work at first seemed to better the man’s general condition,
and he gave two years of effective service. This officer in effect
=invented his own Shell-shock equivalent= in a hallucination of Germans
appearing in his trench. The case may be compared with one described in
Section B, namely, Case 347: that of a Russian soldier who developed
perfectly characteristic war dreams, though his entire service had been
rendered in the rear and he had not had experiences in action.

Possibly Case 171, that of _hysterical fugue_, might be regarded as one
of Shell-shock, since two shells burst near him prior to his fugue. The
man had had analogous crises, certified by Régis, in adolescence, and
had received the diagnosis hysteria. In this instance, we are dealing
merely with an habitual somnambulist who has a characteristic fugue
following explosion of two shells. The war is in a sense responsible
for the fugue, yet not directly, and the fugue would, without the
stress and strain of war, probably never have developed (see sundry
cases in the group in which ante-bellum phenomena are newly evoked in
war: Cases 286-301).

The hysterical psychosis of an Adventist (Case 172) might be regarded
as liberated by military service; the terrible fear of the guns shown
by the psychoneurotic (Case 173) proceeded to the point of fugue. A
Shell-shock victim whose war bride was pregnant, developed fugue with
amnesia and mutism (Case 174). Under hypnosis, it appeared that his
fugue began with his running away from shells. Case 175 was that of a
neurasthenic who volunteered and had to be sent back from the front
after three months. In this case, war dreams were supplanted by sex
dreams, and the fear of insanity became ingrained. The phenomena here
were largely ante-bellum and the war brought them out once more, as
might other disturbing experiences.

Case 176 is here introduced to show that =neurasthenia may develop in a
man without hereditary taint= or acquired soil. There was a very slight
shrapnel injury of the skull, which somewhat clouds the diagnosis in
the case. Five months’ war experience brought out the neurasthenia.
Case 177 deals with a point in the diagnosis of psychasthenia, which,
according to Crouzon, shows arterial hypotension, a condition important
to distinguish from that of pulmonary tuberculosis and of Addison’s
disease. Compare this case with Case 169: a case of depression treated
by pituitrin. Case 178 is a case of psychasthenia following several
months’ service by a man who probably should never have entered
military service.

Another case of ante-bellum origin is Case 179. _Antityphoid
inoculation_ appears to have been the initial factor in the case of
_neurasthenia_ No. 180. Compare Case 65, epilepsy after antityphoid
inoculation. Case 181 was that of a non-commissioned reserve German
officer whose neurasthenia was distinguished by _sympathy with the
enemy_. He did not want to let his men shoot at the enemy because
the idea came forcibly to him that the enemy soldiers had wives and
children. This symptom of sympathy with the enemy was also shown by
another German (Case 229). Compare the sentiments of a Russian under
narcosis (Case 555).

To sum up concerning the small group of psychoneuroses presented in
the section on Psychoses Incidental in the War, we are dealing with
cases in which the phenomena are either continuous with ante-bellum
phenomena, or are of such a nature that they might well have been
brought out by other factors than those of war. These cases by the
design of their choice throw little or no light upon the relation of
physical shell-shock or its equivalent to the psychoneuroses, though
in a few instances the factor of shell explosion is not entirely
to be excluded, and in one instance (Case 170) a hallucination may
be regarded as a virtual equivalent of an emotional shock of great
compelling power.

Examples are available of hysteria (Cases 171, 172, 173, 174), of
neurasthenia (Cases 175, 176, 179, 180, and 181), and of psychasthenia
(Cases 177, 178, and possibly 170).

=49.= =Let us now contrast with these specified ante-bellum or non-war
cases= the situation which will face us in =the war group=.

Section B contains 174 cases (Cases 197-370). Autopsied cases (Cases
197-201) are put first and are followed by cases in which lumbar
puncture data are available (Cases 202-207). A third group of cases
is that in which so-called organic symptoms are much in evidence,
either independently or in association with functional symptoms (Cases
208-219). There follows a small group of three cases with shrapnel
wound (Cases 220-222), in which hysterical symptoms were prominent, as
against the prevalent and correct conception that wounded cases are not
so prone to psychoneurosis as non-wounded cases. Three cases specially
marked by tremors (Cases 223-225) follow, the last of which gives the
victim’s (a French artist) own account of his feelings. The next two
cases (Cases 226 and 227) give respectively a German and a British
soldier’s account of Shell-shock symptoms.

There then follows a great group of =cases= (Cases 228-273) =arranged
according to the part of the body= chiefly affected by hysterical
symptoms. The arrangement is one of toe to top, or as one might more
technically say, cephalad. This =cephalad arrangement= naturally begins
with cases with symptoms affecting one leg or foot (Cases 228-235).
Then follow cases of paraplegia (Cases 236-241). As we proceed cephalad
then follow four cases of the so-called hysterical bent back, or
camptocormia (Souques). Then come walking disorders (Cases 246-248).
Still proceeding cephalad, disorders of one arm and hand are considered
in a series of six cases (Cases 249-254). Bilateral phenomena,
symmetrical or asymmetrical, follow in Cases 255-258. Now reaching the
head, we deal with cases of deafness (Cases 259-260), of deafmutism
(Cases 261-263), of speech disorder (Cases 264 and 265), with two
special cases (Cases 266 and 267). Eye symptoms are dealt with in a
series of cases (Cases 268-272), and Case 273 deals with cranial nerve
disorder supposed to be due to shell windage without explosion.

The idea of the above arrangement of 46 cases (Cases 228-273) is that
the reader dealing with cases of hysterical disorder due to physical
shell-shock, or some equivalent thereof, may inspect the data in a few
analogous cases described more or less fully in the literature. By
reference to the index, the reader will be able to find still further
cases to illustrate the symptom in question.

The next series of cases (Cases 274-281) are to illustrate the
contentions of Babinski concerning the elective exaggeration
of reflexes under chloroform, and the =conception of reflex or
physiopathic disorders= based thereon--a topic to which return is made
in Section C on Diagnosis, and elsewhere. A small group of cases (Cases
282-285) illustrate the delay of Shell-shock and kindred symptoms in
certain instances, cases that suggest a refractory period of greater
length than usual, or the interposition of some unusual factor.

The next group of cases (Cases 286-301) is of special note, bringing
out what is discussed below, namely, =the emphasis, reminiscence,
or repetition of antebellum phenomena=, and the picking out of weak
spots in the organism by Shell-shock. Possibly Cases 302-303 belong
in the same group of illustrations of the driving in of ante-bellum
effects. Cases 304 and 305 are definitively cases in which hereditary
instability is a factor, whereas Cases 306 and 307 form a foil to
these, in that the phenomena develop in subjects confidently stated to
be without hereditary or acquired psychopathic tendency.

The next series of cases (Cases 308-320) shows =peculiar phenomena=;
_e.g._, monocular diplopia, shell-shock psoriasis, synesthesia,
puerilism, and the like. Shell-shock equivalents of various sorts are
placed in a group of cases (Cases 321-325). The next series of cases
(Cases 326 to the end of this Section: 370) show tendencies to general
neurasthenic, psychasthenic, and other psychopathic phenomena, rather
than the more definite phenomena discussed in the early part of this
section in the series arranged “cephalad.”

=50.= Rehearsing more briefly these findings, what is the nature of
these disorders? The literature is practically unanimous on the point:
=We have to do merely with the classical problem of the neuroses=, and
when all the data are some day united, we shall doubtless know a great
deal more about the neuroses.

=51.= =Locus minoris resistentiae.= That the process, whatever else
it does, is rather apt to pick out pre-existent weak spots in the
patient (the habitual gastropath becoming subject to vomiting; the old
stammerer stammering once more or even becoming mute; the man always
“hit in the legs” by exertion, now becoming paraplegic) is obvious.
The striking instances in which an old cured syphilitic monoplegia, or
an old hysterical hemichorea, comes back under the influence of shell
explosion in precisely the limits and with precisely the appearance of
the former disease, indicate how various a factor may be the =locus
minoris resistentiae=.

=52.= But, =without= weak spot, =without= acquired soil, =without=
heredity, we must now erect the hypothesis that, =the classical
neuroses may= in some, though certainly a minority of cases, =afflict
normal men=. Under the war conditions of investigation touching the
family and personal histories of the men, perhaps we should not be too
sure of this hypothesis; but the army records will after the war allow
us to make or break the point forever and thereby throw the clearest
light upon the vexing problems of industrial medicine, wherein progress
in general has been so slow on account of the partisanship of the
corporation and plaintiff’s attorneys.

=53.= =Purely psychogenic war cases exist=: Though Shell-shock denotes,
to say the least, _shocks_ and _shells_--yet we know Shell-shock _sans_
any shock and _sans_ any shell, nay _sans_ either shell or shock.

The fact that a soldier may get war dreams though he has never been in
the fighting zone and never by any chance observed the circumstance of
war, or the fact that a man can become mute on the second day after
a shell explosion because the night before he had dreamed of some
hysterically mute patients in his ward--these facts again, although
they argue a psychogenic origin for the phenomena of so-called
“Shell-shock,” do not at all mean that actual physical explosion in
other cases may not be tremendously important.

=54.= This is shown by the exceedingly interesting phenomena of
=localization or determination of symptoms= to a given region under
the special local influence of the explosion. Thus, in the schematic
case, an explosion to the left of the soldier produces anesthesia and
paralysis on the left or exposed side. Now and again a case will show
such anesthetic and paralytic phenomena upon the side exposed to the
explosion and some hypertonic, irritative phenomena upon the other
side. One gets the figure in one’s mind of an organism fixed, immobile
and numb, on the spot by the explosion--and the other half of the body,
as it were, attempting to run away from the situation. One side of the
body, as it were, plays ’possum, the other tends to flight.

=55.= Of course these physical phenomena should not blind us to the
emotional ones. Now and then the multiple causes of a case may be
analyzed, as, for example, one of blindness in which a =series of
factors= emerged, such as =excitement, blinding flashes, fear, disgust
and fatigue=. I cannot here go further into these details, and I
need no longer insist upon the fact that =surrounding the problem
of Shell-shock means surrounding the problem of nervous and mental
diseases= as a whole, and that thus to be a Shell-shock analyst means
to be a neuropsychiatrist.

=56.= The organic problems of the nervous system are brought up
constantly in differential diagnosis, but the functional problems
divide themselves up in a perturbing manner into a fraction properly
termed the “psychopathic” (that is, after the manner of hysteria), and
“non-psychopathic” (that is, after the manner of reflex disorders of
Charcot, newly named “physiopathic” by Babinski).

=57.= For the moment we are not discussing differential diagnosis,
but are merely trying to circumscribe the features we wish to call
=Shell-shock features: We have concluded to call them functional--but
what is it to be functional?=

Too simple is the reply:

                       FUNCTIONAL = NON-ORGANIC.

Inaccurate and misleading is the reply

                         FUNCTIONAL = PSYCHIC.

We may more correctly express the situation, pathologically speaking,
in the following categories (see chart, page 870):

    ORGANOPATHIC (Lesional, destructive):

    (_a_) gross, or (_b_) microscopic, or perhaps (_c_) chemical.

    DYNAMOPATHIC (functional, irritative, inhibitory,--but
    reversible _ad originem_):

    (_a_) psychopathic; (_b_) physiopathic (“reflex”).

=58.= As to the high psychic functions, we had thought of them as
split in hysteria, in dissociation of personality. And we had roughly
distinguished these conditions as =psychopathic= from conditions we
called =neuropathic=, regarding the latter neuropathic disorders as on
the model of the effects of cutting off or destroying certain necessary
neurons. However clear or unclear we were as to the nature of the
neuropathic, it does not here matter. Babinski’s point is that there is
another kind of dynamic disease that operates, not after the manner of
hysteria, but after a manner reminding one of the forgotten “reflex”
disorders of Charcot--disorders that fitted the textbooks so poorly
that the textbooks dropped them out. In short, what you might call
=the dynamopathic or functional in nervous disease has been shown to
fall into two parts=--a =psychopathic= fraction and a non-psychopathic
fraction. Babinski calls this non-psychopathic fraction =physiopathic=
or reflex. And these reflex or physiopathic disorders have a different
order of curability from that of hysterical or psychopathic disorders.
By what simple device did Babinski prove this? By chloroforming the
patient. Under chloroform, when all the other reflexes were stilled,
Babinski could bring out, in relief as it were, certain reflexes, or
even hypertonuses, that were in the waking life wholly concealed,--yet
at the same time consciousness, in the usual sense of that term, had
vanished. Accordingly, the proof of a new type of functional disease,
at times concealed by the overlay of higher neurones, was now plain.
Does not this offer new leads of the greatest value in that most
intricate of fields, psychopathology? Is not the model here offered of
diseased =nervous functions=, =non-psychic= in nature (in the ordinary
sense of psychic) =but of almost equally complex nature=:

Whoever wins the great war from the military point of view, there
can be no doubt as to what writers contributed most from the war
data concerning the doctrine of hysteria, especially concerning the
theoretical delimitation of hysteria from other forms of functional
nervous disease: There can be no other answer than that, in theoretical
neurology at least, the French have already won the war, if only by
means of the remarkable concept set up by Babinski of the so-called
_physiopathic_ (that is, non-neuropathic and non-psychopathic).

But how has this splitting of functional neuroses into psychopathic
and physiopathic been rendered certain? By the tremendous modern
sharpening of differential diagnosis dating from, _e.g._, the discovery
of the Babinski reflex. This brings us to the brink of considerations
concerning the differential diagnostic problem.

First it may be well to regard the whole problem in the light of those
mental diseases that we slid over when we were delimiting Shell-shock
as against syphilis, epilepsy and somatic disease.

=59.= =Why do some authors think of Shell-shock as an “officer’s
disease”?= It is clear that they cannot be thinking so much of the
physiopathic cases as of the psychopathic ones. But psychopathic
conditions are obviously more readily brought about in complex and
labile apparatus. This point comes out strongly in relation with
the =comparative stability of the feeble-minded=, at least of most
feeble-minded, that get into war relations.

The possible relations of Shell-shock to feeble-mindedness are of some
interest. We know that Shell-shock picks out certain nervous and
mental weaklings and indeed that one author claims as high a percentage
as 74 for war neuroses having a hereditary or acquired neuropathic
basis. How far does feeble-mindedness itself count among these
supposedly susceptible nervous and mental weaklings? Is a feeble-minded
person especially in condition for Shell-shock?

There are rumors of experiments to show that if in an aquarium
containing some jelly fish alongside bony fishes, you explode a
substance, the jelly fish ride through unscathed whereas the bony
fishes are killed by the shock. The jelly fish presumably had too
simple an organization.

There is something to be said for the idea that in man also the higher
and more complex specimens are more susceptible to Shell-shock,
that is, to the neuroses of war, than are the lower and more simple
combatants. Some statistics indicate that officers, who are in the main
of a higher and more complex organization than the private soldiers,
are much more susceptible than are private soldiers to the neuroses of
war. Doubtless we shall not be able to verify these statistics until
long after the war and, so far as I know, no very inclusive statistics
have been presented.

On the whole, I judge from the case history literature that the
feeble-minded, unless they be of that very high level sometimes called
subnormal, are not particularly susceptible to the neuroses. It is
obvious that idiots and, for the most part, imbeciles, do not get
into military service. As for what the English term the feeble-minded
or what we in America are now terming morons, it may well be that
our draft boards do not always exclude. High French authorities have
specifically determined in certain instances that the high-grade
feeble-minded would be perfectly suitable for certain branches of the
service. There is the case, for example, of a sandwich man of Paris
who somehow got into the French army and was being perpetually sent
to look for the squad’s umbrella and the key to the drill ground, but
sang and swung his gun with joy as he went to the front, and apparently
did very well there. This man had been a state ward and, as you know,
well-trained state wards are frequently exceedingly good at elementary
forms of drill.

Then there is another case of an obvious imbecile who was quite without
any idea of military rank and often got punished for treating his
superiors like his comrades and was the butt of his section, but on the
firing-line remained cool, careless of danger--a magnificent example
to his comrades--at last surrounded and taken prisoner. Here the story
might have ended and the folly of enlisting imbeciles in the army might
have seemed perfectly plain, except that our imbecile forthwith escaped
from the Germans, swam the Meuse and got back to his regiment!

Here then are cases in which the slight degree of hypophrenia--it seems
unwise to give it the opprobrious title “feeble-mindedness”--would have
been entirely inconsistent with the development of Shell-shock. Such
men are, perhaps, =too simple to develop neuroses=. On the other hand,
it would appear that certain of the slight degrees of hypophrenia, such
as we might find in so-called subnormal or stupid persons, would prove
capable of “catching Shell-shock” as it were, and then find themselves
entirely incapable of rationalizing the situation. In short, =there
may be a group of psychic weaklings, just complex enough to fall into
the zone of potential neurotics, but just simple enough to render the
processes of rationalization= (or what one author terms _autognosis_)
=and of psychotherapy in general entirely unavailing=.

After the war we may be confronted with a number of persons with
their edges dulled by the war experiences. One has met even brave
officers who, after months of furlough, still maintain that they will
never get back to their normal will and initiative. Whether these
=hypoboulic persons= have not been reduced to subnormality so as to
resemble the slighter degrees of hypophrenia or feeble-mindedness
can hardly be determined now. They will form =important problems in
mental reconstruction=, for with the best will in the world, the
occupation-therapeutist with all her technic, may be unable to force
or coax the will of such hypoboulics into proper action. Nor will the
ordinary environment of home and neighborhood turn the trick properly.
Expert social work in adjustment, both of the returned soldier to
his environment and of the environment to the returned soldier, may
be necessary. I speak of this problem here not because these persons
are hypophrenic or feeble-minded in the ordinary sense, but we must
constantly bear in mind our experience in the teaching of hypophrenics
(both in the schools for the feeble-minded and in the community) when
we are facing problems of mental reconstruction.

=60.= As for =alcoholism=, Lépine’s figures bespeak its importance
as a hospital-filler and a good deal of prime interest surrounding
alcoholism has been developed in the war; but on the whole, so far
as I can determine from the war case literature, there is little or
no direct relation between alcoholism and Shell-shock, despite the
fact that in a number of instances alcohol has complicated the issue
and very possibly helped in a general demoralization of the victim.
However, the alcoholic amnesias and particularly a few instances of
the so-called pathological intoxication have exhibited a certain
medicolegal interest, recalling what was just said above about the
responsibility of a drunken epileptic. Alcohol remains, I should say,
pending exact monographic work upon this topic, purely a contributory
factor for the war neuroses.

It must be that the exigencies of the war have prevented full reports
of alcoholic cases; or perhaps they are regarded as of such every-day
occurrence as not to demand case reports. The alcohol and drug group is
represented by 17 cases (Cases 86-102).

The so-called pathological intoxication is illustrated in Cases 86
and 87. Case 86 was entirely amnestic for an attack of hallucinations
in which he tried to transfix comrades with a bayonet. Cases 87-97
are cases of disciplinary nature,--the majority from a German writer,
Kastan. Case 88 illustrates desertion in alcoholic fugue, and Cases
90-92 are three further cases of desertion in alcoholism.

Cases 94 and 95 give a =partial explanation of some German atrocities=.
At least, here are cases in which the atrocities, with attempted
murder and rape, are described more or less fully in transcripts of
medicolegal reports. Case 98 throws a curious cross-light upon the war,
in that a drunken soldier got an unmerited long leave after paying 100
sous for an injection of petrol in his hand. Cases 99-102 are cases
of morphinism, illustrating the effects of the war upon the fate of
morphinists.

=61.= =That war makes nobody go mad= in the asylum or lay sense of
the term =has been abundantly proved by the data of this war--and
this conclusion is of value in our medical endeavors to establish a
proper lay conception of the nature of Shell-shock=. Consider first
schizophrenia (dementia praecox).

That the causes of dementia præcox, still unknown as they are, lodge
more in the interior of the body or in special individual reactions
of the victim’s mind, seems to be shown by the phenomena of this war,
since there seems to be no great number of dementia præcox cases
therein produced. To be sure, some schizophrenic subjects do get into
the service, and sometimes their delusions and hallucinations get their
content and coloring from the war. Thus a Russian, wounded in the army,
developed delusions concerning currents running from his arm to the
German lines and felt that he was, so to say, the Jonah of the Russian
front, as he could determine shell fire to the spot where he was by the
arm currents.

Now and then a case shows a scientifically beautiful admixture of
ordinary dementia præcox phenomena with the effects of shell wound or
shock. A picturesque case from the standpoint of German psychiatric
diagnosis is one of a soldier who boxed the ear of a kindly sister
who tried to steer him from a room where the examination of another
patient, a woman, was going on. On the whole, the eminent German
psychiatrist who examined him felt that the case was really one
of psychopathic constitution, as he had shown somewhat similar
irascibility on a slight occasion before. However, much to the
astonishment of all, the patient developed further symptoms. His ego
got terribly swollen. At last he was fain to utter a denunciation of
the entire _Junkertum_ and of the Kaiser: he said in fact that he was
an Inhabitant of the World and not of Prussia merely. Over here we
allow such persons to edit newspapers and write books with impunity,
but the eminent German psychiatrist, before mentioned, was constrained
to alter his diagnosis of this cosmopolite from psychopathic
constitution to dementia praecox!

The group is represented by 16 cases (Cases 147-162).

=62.= There are four cases (Cases 148-151) of a =disciplinary= nature.
The first (Case 148) was actually arrested as a spy because he was
making drawings near a petroleum tank. Of two cases of desertion, one
was due to a fugue of catatonic nature (Case 149), and the other (Case
150) was one of desertion with behavior suggesting schizophrenia.
However, this man was determined to be responsible for his act,
and condemned to 20 years in prison. This latter case might be
considered also in connection with Group III (the epilepsies), Group
IV (the pharmacopsychoses), and possibly Group XI (the unresolved
psychopathias).

Case 151 was likewise alcoholic and disciplinary: the man went so far
as to keep a cigar in his mouth while the captain was rebuking him
and was, in fact, an old sanatorium case, afflicted with some sort of
degenerative disease, presumably dementia praecox.

=63.= That =schizophrenic symptoms may be aggravated by service= is
shown likewise in the case that follows, namely, Case 152, a man
who had been hearing false voices for some two years, had heard his
own thoughts, and felt his personality changing. The military board
decided that the mental disease had been aggravated by service. Case
153 might offhand be regarded as a malingerer, as he shot himself
in the hand. Upon military review, a delusional state set in, and
in the course of no very long time a state of schizophrenic apathy.
In point of fact, however, this man had already been in several
hospitals for previous examination, and had served in the army in
relatively normal intervals. Case 154 is that of a dementia praecox
who volunteered for three years in French infantry but forthwith gave
indications of mental deterioration. This case of a dementia praecox
volunteer may be compared with Case 36: that of a superbrave imbecile
who swam the Meuse, back from a German prison; with Case 47, that
of the feeble-minded person with an insubordinate desire to remain
at the front; with Case 163, a maniacal volunteer; and Case 175, a
neurasthenic volunteer.

=64.= =Diagnostic questions= are brought up by Cases 155-166, in the
former of which Bonhoeffer made at first a diagnosis of some form of
psychogenic disease, possibly hysterical, but had eventually to alter
the diagnosis to hebephrenia or catatonia. Case 156 was possibly one
of Shell-shock, though the man remained on duty for a month with but
one symptom, trembling of the arm. For nine months he showed a variety
of symptoms apparently consistent with the diagnosis hysteria, but
then developed catatonic and paranoic symptoms clearly warranting the
diagnosis dementia praecox.

=65.= Schizophrenia may not only be aggravated by service, but as Case
157 shows, =war experience may have a definite effect upon the content
of hallucinations and delusions=. Thus, a man wounded in the left
shoulder built up the idea of currents running from his left arm to the
Germans, such that if anything were touched by the arm, bombardment of
the Russians would at once start up. The arm, in short, was charmed.

=66.= =Psychopathic bravery= is not shown in the feeble-minded
only: Case 158 is that =of an Iron Cross winner= who, after an
hysterical-looking attack with hallucinatory reminiscences of a Gurkha
whom he had bayoneted, turned out to be =hebephrenic=. Case 159 might
at first sight have been placed among the encephalopsychoses on account
of the trauma to the occiput, and in fact the mystical hallucinations
shown were of a visual nature (a rainbow-colored bird with the face
of the Holy Virgin). In point of fact, there was probably no causal
relation between the mystical delusions and the brain injury.

=67.= Case 156, above mentioned, might perhaps be interpreted as
one of =Shell-shock dementia praecox=, but the interval of nine
months, though filled with hysterical symptoms, is decidedly long
in which to suppose that shell-shock factors could be in process of
causing dementia praecox. Cases 160 and 161 are more suspicious. Six
German soldiers were killed by a German shell within the zone of
German fire, two steps away from the subaltern officer (Case 160),
who carried on for some hours, made his report duly, but thereafter
developed tremors and lost consciousness. According to Weygandt,
the case is one suggestive of dementia praecox, but very possibly
should be regarded as one of psychoneurosis. At all events, it would
be dangerous to found a doctrine to the effect that dementia praecox
can be initiated by shell-shock upon such a case as 160. Case 161 is
similarly doubtful. There are a number of symptoms in this man (the
sole survivor of an explosion in a blockhouse) consistent with the
diagnosis Shell-shock, and a number of others which hardly can be given
any other interpretation than that of catatonic dementia praecox. But
the available medical data do not begin until five months after the
shell explosion. We must conclude here also that no definite evidence
exists that dementia praecox can be initiated by the physical factor
shell-shock. Case 162 is one in which there are shell-shock factors and
fatigue factors in a man who had once ante-bellum shown signs of mental
disorder, and who developed delusions subsequent to a fugue following
shell-shock. The most one could make of this case would be to say that
a latent schizophrenia had been liberated by shell-shock.

=68.= To sum up concerning the schizophrenias (dementia praecox
group), there are =cases of great disciplinary interest= in which
alleged espionage and desertion =turn out actually to be schizophrenic
phenomena=. Again, there are interesting diagnostic problems in the
differential diagnosis of hysteria and catatonia. There is evidence
that experience in the war may be woven into the hallucinatory and
delusional contents of cases of pre-existent psychosis.

=69.= As to the important question whether shell-shock can initiate
dementia praecox, the evidence from these reported cases is against
the hypothesis; but if the query be, whether Shell-shock might not
aggravate dementia praecox, it may be stated that =a military board
has decided that dementia praecox may be aggravated by some forms
of military service. There is no reason to suppose that shell-shock
factors might not operate in this way.= Cases 152 and 162 will be of
service in the proof of this contention; and Case 162 seems to be
definitely one in which a latent schizophrenia, showing itself in
one ante-bellum attack, was liberated once more after shell-shock.
Of course, the plan of this book and the method of choice of its
cases precludes any statistical conclusions of great weight from the
relative number of cases found in the different groups; and it might
well happen that psychiatrists would not report cases of an everyday
and commonplace nature which might yet be very frequent. On the whole,
however, it would not appear that dementia praecox is at all a frequent
phenomenon in the war.

=70.= =Nor can the cyclothymias= (manic-depressive psychoses) =be
charged up to war factors= to any important extent.

On account of the somewhat close resemblance between the phenomenon of
manic-depressive psychosis and what we ordinarily feel ourselves--a
logical situation reflecting merely the fact that the phenomena of
over-activity (mania) and of under-activity (depression) are merely
quantitative variations from the normal--it might be supposed that
the war life and its shock and strain would start up the cyclothymias
in some numbers. Why should not a shell explosion start up a mania or
throw a man into a depression? In point of fact the literature somehow
does not agree with this presupposition.

Some years ago in Massachusetts a brief investigation was made of
the assigned causes of the successive attacks in a great number of
cyclothymic (manic-depressive) cases, and it was found that each
successive attack progressively had less of the physical in the
previous history. Something like 45% of all the first attacks had a
pretty obvious cause in the soma, such as a kidney disease, a heart
disease, a puerperal condition and the like, but the second attacks
failed to show even 20% of such obvious somatic causes, and the third
attacks even less than 10%, and so on.

Now war conditions and even the shell explosions themselves have
apparently not set up any such conditions as those of mania or of
depression. Most of the instances of cyclothymia are instances of men
who are cyclothymic before they enter the army. These experiences,
when after the war we can sift them all out, may allow us to form
better ideas as to the etiology of many of the psychoses, and the great
war may thus prove a gigantic experimental reagent which will aid in
solving some of the major problems of mental hygiene.

=71.= =The cyclothymic or manic-depressive group is represented in
strikingly few cases=, seven in number (Cases 163-169). One of the
ideas in the literature concerning the manic-depressive group has
been that it is very possibly remotely allied to Graves’ disease,
a hypothesis upheld by Stransky in Aschaffenburg’s Handbook.
Hyperthyroidism itself has been, of course, a rather striking feature
in the foreground or background of many sick patients in the war.
However, war factors have proved able to bring out very few instances
of cyclothymic (manic-depressive) disease. Amongst our seven cases,
the first (Case 163) was that of a maniacal Alsatian of 59 years, who
volunteered because of his hypomania. Case 165, the case of a German
who pelted French trenches with apples from an appletree in No Man’s
Land, was another case in which the war had little or nothing to do
with the development of the mania. One of fugue (Case 164) was a case
of melancholia and anxiety not closely related with war experience. In
three further cases trench life and war stress may be thought to have
liberated the cyclothymic phenomena. Case 166 was that of a man of
38, previously referred to, who developed arteriosclerosis and whose
depression and hallucinations had followed four months of trench life
devoid of battles or injury. It is possible that this case should be
regarded rather as syphilitic or of some unknown organic origin. At all
events, it is not clear that it could be made to bear a heavy weight
of hypothesis concerning the genesis of cyclothymic psychoses. Case
167, a naval officer who distinguished himself greatly by work on land
in Belgium, was regarded by its reporter as one of manic-depressive
psychosis with the fatigue of war as its base. It might be queried
whether the man’s distinguished work was not due to an early phase
of hypomania, after which the cyclothymic effects began. In Case
168 there was some evidence of the effect of war stress, as certain
hallucinations grew more intense after the bombardment of Dunkirk;
but in point of fact, this man had shown a predisposition and indeed
a period of so-called neurasthenia ante-bellum. It is doubtful,
therefore, whether there is any case here abstracted which can be used
to support the hypothesis that the manic-depressive (cyclothymic) group
of mental diseases has had or is likely to have its genesis in war
stress. The remaining case (Case 169) is one illustrating a method of
treating low blood pressure in depression.

To sum up concerning the cyclothymias: War stress seems to have had
singularly little effect in the production of fresh attacks, and so far
as we are aware, no effect in starting up a manic-depressive diathesis,
unless Case 167,--that of the naval officer who distinguished himself
in land battles,--looks in that direction. It is, of course, to
be conceded that hypomania might readily be overlooked under war
conditions, and that suicidal melancholias, belonging in this group,
might be interpreted as natural war-made depressions. Very possibly,
therefore, this result (running to the effect that the cyclothymic
forms of mental disease are rare in military life) may need revision.

=72.= =Summary of general considerations concerning the nature of the
Shell-shock neuroses (paragraphs 40-71).=

=Having= (_a_) =roughly delimited the Shell-shock neuroses from
syphilis, epilepsy, and somatic disease, we inquired=

(_b_) =What, after all, are functional neuroses? We remained
dissatisfied with a definition by negatives.= But we found that

(_c_) =practically the problem seemed to reduce to telling the organic
apart from the functional= and we found that

(_d_) =in almost all cases we have to raise the hypothesis of the
organic=. Also that

(_e_) =the absence of external injury is no guarantee against the
existence of internal injury=. Also that

(_f_) =cases are frequent enough in which organic and functional
phenomena are combined=. Also that

(_g_) =essentially functional cases may be peritraumatic or
metatraumatic= (in the sense of Charcot’s hysterotraumatism). But

(_h_) =the statistical majority of cases remains essentially
functional=.

(_i_) =We then looked over a series of cases developing incidentally in
the war= and

(_j_) =we compared these with the war cases, the latter arranged
cephalad=.

                               CHART 17

           DIAGNOSTIC ALLIANCES OF THE SHELL-SHOCK NEUROSES

    +---------------+       +----------+    +---------------+
    | SCHIZOPHRENIA |       | SHELL    |    | NEUROSYPHILIS |
    | CYCLOTHYMIA   |<------| SHOCK    |--->| EPILEPSY      |
    | MORONITY      |<------| NEUROSES |--->| SOMATOPATHY   |
    | ALCOHOLISM    |       |          |    |               |
    +---------------+       +----------+    +---------------+

    Note arrow lengths: _Practically_ we find shell-shock neuroses
    very different from certain functional (or but mildly organic)
    disorders and not so different from certain seriously organic
    disorders.

    +---------------+    +----------+       +---------------+
    | SCHIZOPHRENIA |    | SHELL    |       | NEUROSYPHILIS |
    | CYCLOTHYMIA   |<---| SHOCK    |------>| EPILEPSY      |
    | MORONITY      |<---| NEUROSES |------>| SOMATOPATHY   |
    | ALCOHOLISM    |    |          |       |               |
    +---------------+    +----------+       +---------------+

    Note arrow lengths: _Theoretically_, shell-shock neuroses,
    being presumably in large part functional, ought to ally
    themselves more closely with the left-hand group than with the
    right-hand group. But they do not!

    In short, these _functional_ diseases are not so hard to
    distinguish from various other functional diseases as they are
    from certain organic diseases. The most serious diagnostic
    problem is between the war neuroses and organic brain disorders.

                               CHART 18

     LOGICAL PLACE OF THE “REFLEX” DISORDERS (OF BABINSKI-FROMENT)

    e.g. neurosyphilis paretica    |              Hysteria e.g.
    \                              |                         /
     \                             |                        /
      \                            |                       /
       \                           |                      /
        ORGANO-                    |               DYNAMO-
      PSYCHOPATHIC                 |             PSYCHOPATHIC
                                   |
                                   |
                                   |
    -------------------------------+-----------------------------
                                   |
                                   |
                                   |
                                   |
        ORGANO-                    |               DYNAMO-
       NEUROPATHIC                 |              NEUROPATHIC
         /                         |                       \
        /                          |                        \
       /                           |                         \
      /                            |                          \
     /                             |     Babinski’s “reflex”   \
    e.g. neurosyphilis tabetica    |  or physiopathic disorders e.g.

    A frequent error of neurologists has been to identify
    “functional” with “psychic” when it came to a question of the
    classical functional neuroses. The above diagram indicates that
    “functional” contains more than “psychic.” Doubtless much that
    goes under the name “unconscious” belongs in the right lower
    quadrant of this diagram. See discussion in text.

(_k_) We found many war cases showing emphasis, reminiscence, or
repetition of ante-bellum phenomena (weak spots, locus minoris
resistentiae, imitation), but

(_l_) we also found that perfectly sound untainted men could succumb to
Shell-shock neurosis.

(_m_) We found a few purely psychogenic cases without sign or suspicion
of physical shock.

(_n_) We studied the localization (traumatotropic) group.

(_o_) We arrived, with the aid of Babinski, at the necessity of
splitting functional cases into psychopathic and physiopathic.

=73.= =Summary of general considerations: continued.=

We found ourselves looking on the Shell-shock neuroses as, like other
functional neuroses, in a sense mental diseases. Perhaps we would
better say (to get rid of all suspicion of medicolegal “insanity”) that
the Shell-shock neuroses seemed to us in some sense psychopathic. But,
though the Shell-shock neuroses looked psychopathic and were presumably
more functional than organic in nature, it was a curious thing that,
practically speaking, the Shell-shock neuroses proved to be farther
away from the more functional of the psychoses than from certain
organic psychosis.

In particular, we found reliable authors insisting on the _practical_
diagnostic necessity of excluding syphilis, epilepsy, somatic
disease--whereas the nature and causes of the Shell-shock neurosis
seemed _theoretically_ to withdraw them most remotely from that triad
of mainly organic disorders. By the same token, _theoretically_ one
might have supposed these Shell-shock neuroses to draw very near
to those far less organic disorders (schizophrenia, cyclothymia,
feeble-mindedness (_i.e._, the slighter degrees likely to be found in
military service, alcoholism))--yet _practically_ few large diagnostic
problems came to light as between the Shell-shock neuroses and the
tetrad of dynamic or lightly organic diseases above listed.

=74.= Diagrammatically this situation is presented in Chart 17.

But why should the Shell-shock neuroses seem so “organic”? Partly, it
is probable, because the term “organic” is too often used to mean
“subcortical.” In another diagram the truer relations are depicted,
with four classes of phenomena (Chart 18).

(_a_) Organic mental (cortical), _e.g._, general paresis.

(_b_) Functional mental (cortical), _e.g._, hysteria.

(_c_) Organic neural (subcortical), _e.g._, tabes dorsalis.

(_d_) Functional neural (subcortical), _e.g._, “reflex” disorders.


DIAGNOSTIC DIFFERENTIATION PROBLEM

=75.= =Having disposed of the problem of the rougher= DELIMITATION
=of the Shell-shock neuroses, we approach the problem of their finer=
DIFFERENTIATION. =For the sake of the present argument we propose to
regard the Shell-shock neuroses as essentially= DYNAMOPATHIC, _i.e._,
=functional whether in the ordinary mind-born (psychogenic) sense of
classical hysteria or in the modern nerve-born (neurogenic) sense of
Babinski. The problem of this differentiation will accordingly be that
between the dynamopathic and the organopathic.=

In the orderly diagnosis of mental disease, from the standpoint of
the major orders or groups, we ordinarily come at this point to the
focal brain diseases. In analyzing the neuro-psychiatric problem of
a so-called Shell-shocker, it is, of course, our bounden duty to
exclude syphilis. Even though the percentage of syphilitic victims of
Shell-shock is not high, yet these cases promise so much from treatment
that they deserve to get their diagnosis as early as possible, and the
English workers who have worked most in the syphilitic field insist
upon this point.

We next proceed, as above indicated, to the elimination of hypophrenia
with all the various grades of feeble-mindedness. Thirdly, we try to
exclude the various forms of epilepsy; and fourthly, the effects of
alcohol, drugs and poisons.

In ordinary civilian practice, such as that at the Psychopathic
Hospital, the orderly elimination for diagnostic purposes of the great
groups of the syphilitic, hypophrenic (feeble-minded), epileptic and
alcoholic, leaves us with cases in which there either is or is not
important evidence of organic nervous-system disease, such as that
shown in cases with heightened intracranial pressure or in cases with
asymmetry of reflexes and other forms of parareflexia. In military
practice these logical questions of prior elimination of syphilis,
feeble-mindedness, epilepsy, and alcoholism must go a-glimmering at
first, unless their signs are so obvious as to permit diagnosis by
inspection.

=76.= But the nervous and mental cases almost one and all give rise
to =the suspicion= at least of =organic disease=, possibly traumatic
in origin. Even when a man falls to the ground without a scratch
upon his skin, there is some question whether in his fall he has not
sustained some slight intracranial hemorrhage which the lumbar puncture
fluid might show. Add to this that the signs of hysteria are very
often unilateral, and it will readily be conceived how much like an
organic case an hysteric in the casualty clearing station may look.
Rapid decision may be necessary in order to get immediate effects
in psychotherapy a few minutes or hours after the shell explosion,
and one may need to choose between applying a possibly unsuccessful
psychotherapy forthwith and making a thorough neurological examination.
As Babinski has pointed out, making a thorough neurological examination
gives opportunity for all sorts of medical suggestion to be conveyed
to the patient. It would appear that many an hysterical anesthesia has
been given to a patient by the very suggestion of the physician testing
sensation. Here one does not refer to malingering in the conscious and
designed sense of the term, but to the operation of some genuinely
psychopathic, that is to say, hysterical process.

=77.= In the case of head injury, naturally the majority of nerve
phenomena will ordinarily be upon the opposite side of the body to
the side of the head that is injured. The reverse situation holds
for hysterical cases, wherein it would appear that the bursting of a
shell, let us say upon the left side of the body, seems to determine
contractures, paralyses and anesthesias to that same left side of the
body; now and then complicated cases appear which put the neurologist
through his best paces. Such a case is that of a man who was wounded on
the left side of the head and promptly developed a =hemiplegia= on the
same (=left=) side, =with aphasia=. Now aphasia ought to be the result
of a lesion on the left side of the brain in the common run of cases,
whereas left-sided hemiplegia ought to be the result of lesion on the
right side of the brain. In point of fact, the analyst of this case
felt that he was dealing with a direct injury on the left side of the
brain, leading to aphasia, and a lesion by =contrecoup= on the right
side of the brain, leading to a left-sided hemiplegia.

It is not only at the casualty clearing stations and along the lines
of communication that the difficulties in telling Shell-shock in the
neurotic sense from traumatic psychosis and the effects of focal brain
lesions are found, since the literature amply shows that diagnostic
problems remain open for weeks or months in the various institutions of
the interior, to which all the belligerents have been forced to send
their cases.

=78.= A glance at the differential tables that have been developed, for
example, by the French neurologists, will show how fine the diagnosis
betwixt a hysterical and an organic disease may be, especially when
we consider how often there are admixtures of the two. The rule holds
for the vast majority of cases that absolute bullet wounds or shrapnel
wounds do not produce Shell-shock; and the statistical story is so
clear that one might almost think of the wounds as in some sense
protective against shock, that is, against Shell-shock, not against
traumatic or surgical shock. Nevertheless, by some process whose nature
is obscure, the hysteric is apt to pick up some slight wound and, as it
were, surround this wound with hysterical anesthesia, hyperesthesia,
paralysis or contractures.

The chances are, if we should collect all our civilian cases of Railway
Spine and of industrial accident with traumatic neuroses, we should
be able to prove this same strange relation between slight wound in a
particular part of the body and the local determination of hysterical
symptoms to that region. Of course, the determination follows no known
laws of nerve distribution to skin or muscles, and the effect is
apparently a psychopathic or, at all events, a dynamic process without
clear relations to the accepted landmarks.

I do not mean to suggest, that aside from the hurry of war, the
differential diagnoses here are more difficult than those in civilian
practice; but the difficulties are at least as great as those that
have faced the civilian practitioner. What needs emphasis is that just
because we have concluded that the statistical majority of the cases
of so-called Shell-shock belongs in the division of the neuroses,
we should =not feel= too =cock-sure that= a given case of =alleged
Shell-shock= appearing in the war zone or behind it =is necessarily= a
case of =neurosis=.

After the early “period of election” for psychotherapy in the war
zone has passed, there can be no excuse except general war conditions
for not according to every case of alleged Shell-shock a complete
neuropsychiatric examination, having due regard to the ideas of
Babinski concerning medical suggestion of new increments and appendices
to the original hysteria, developed in battle or shortly thereafter.

We have, however, been able to find in the literature good instances of
puzzling diagnosis in which such conditions are in evidence as acute
meningitis of various forms, hydrophobia, tetanus, and the like.

Especially in the diagnosis against Shell-shock hysterias we may need
to think of the abnormal forms of tetanus, to which an entire book in
the _Collection Horizon_ has been devoted. The differential diagnostic
tables here draw up distinctions between local tetanus, involving, let
us say, the contracture of one arm, as against a hysterical monoplegia.

=79.= The focal brain group of psychoses here termed
encephalopsychoses, is illustrated by a comparatively short series of
cases, 16 in number (Cases 103-117). Many more cases of this group are
presented in Section B, On the Nature and Causes of Shell-shock. The
motive here is to show sundry effects of focal brain lesions produced
in the war and not related with shell-shock. Case 103 was the curious
case (see above) of aphasia with hemiplegia--not upon the right side,
but upon the left side. There had been a wound in the left parietal
region, and the aphasia was presumably consequent upon a direct
affection of the left hemisphere. On the other hand, the left-sided
hemiplegia may probably be regarded as due to lesions on the right side
of the brain produced by contrecoup. The case not only has surgical
implications and suggestions of importance, but also it throws some
light on the possibilities in concussion of minor degree. As the
cases in Section B (On the Nature and Causes of Shell-shock) show,
shell-shock, the physical factor, is apt to produce anesthesia and
paralysis or contracture on the side exposed to the shell-shock. The
means by which these symptoms ipsilateral with the shock are produced
is commonly thought to be the “hysterical mechanism,” whatever that
may be. Lhermitte, however, suggests that in some cases such phenomena
might be due to an actual brain jarring with contrecoup effects.
However, it must be granted that Case 103 did not come to autopsy.

=80.= Case 104 might perhaps better be considered in the section
on alcoholism, since a gun-shot wound of the head may be regarded
as having produced intolerance of alcohol in the classical manner,
similar to that described in Case 97, wherein, however, the trauma
was ante-bellum. Peculiar crises associated with cortical blindness,
vertigo, and hallucinations, characterized a case of brain trauma by
bullet (Case 105). Case 106 is that of a Tunisian, who before the war
had had a number of theopathic traits with mystical hallucinations,
but after a gun-shot wound of the occiput developed lilliputian
hallucinations and micromegalopsia.

=81.= Cases 107-112 are cases of infection or probable infection. Cases
107 and 108 are instances of meningococcus meningitis, the second
of which appears to have followed shell-shock (?). Case 107 led to
psychosis with dementia. Case 109 developed a meningitic syndrome,
which followed shell explosion a metre away, the syndrome lasting 14
months. The spinal puncture fluid was several times found to contain
blood. There was apparently no infection of the fluid as in Case
112. Possibly Case 109 should be set down as an unusual example of
shell-shock psychosis, chiefly dependent upon meningeal hemorrhage.

=82.= A syphilitic (Case 110) in which appropriate tests were made
and found positive, showed at autopsy a yellowish abscess or area of
softening in the right hemisphere. The curious point about this case
was that the only neurological phenomenon in the case was the absence
of knee-jerks in the early part of the day; later in the day, they
would appear once more. Possibly Case 111, a case of somewhat doubtful
nature but presumably of organic hemiplegia, ought to be aligned
more with the group of cases illustrating the nature and causes of
Shell-shock. The case was not one with the physical factor shell-shock,
since the phenomena began ten days after a serene convalescence
following an operation for chronic appendicitis. Perhaps the case was
one of organic lesion grafted upon a neurosis.

=83.= Case 112 is the one noted above of infection of the spinal fluid.
It is the only case of infected meningeal hemorrhage observed by
Guillain and Barré in a wide experience. As a rule, these hemorrhages
remain aseptic and have a favorable prognosis. The organism cultivated
from the spinal fluid proved to be the pneumococcus. Case 113 yielded
a somewhat remarkable phenomenon and perhaps would be more logically
considered in relation with the series of cases in Section B that show
the picking up of ante-bellum weak spots (Cases 287-301); for this
subject had had two serious affections of the brain ante-bellum. He had
had a poliomyelitis at five, affecting the left leg, and he had had a
right hemiplegia with aphasia following pneumonia, at 20. He was struck
(but apparently not wounded) by shrapnel on the right shoulder, and
developed athetotic movements of the right hand, as well as a general
weakness of the left leg. In this case, according to Batten, the stress
had been sufficient to bring into prominence symptoms due to an old
cerebral lesion. Whether the mechanism in this case is hysterical is
doubtful.

=84.= That not every case of hemianesthesia is hysterical is suggested
by Case 114, in which the diagnosis of hysteria was actually made; but
the diagnosis was soon rendered doubtful by the fact that there was no
evidence of autosuggestion or heterosuggestion. Other phenomena make a
diagnosis of thalamic hemianesthesia more likely.

=85.= Although Shell-shock is not the subject of this section, yet
a case of syndrome strongly suggesting multiple sclerosis is here
inserted, following shell-shock (Case 115). The co-existence of
hysterical and organic symptoms is illustrated in Case 116, one of
mine explosion, and Case 117, one of injury to back. Case 116 somewhat
resembled another case of Smyly (Case 219).

=86.= =Differential Diagnosis between Organic and Hysteric Hemiplegia.
Babinski, 1900.=

    _Organic Hemiplegia_                  _Hysterical Hemiplegia_

  1. Paralysis unilateral.             1. Paralysis not always
                                          unilateral; especially facial
                                          paralysis, usually bilateral.

  2. Paralysis not symptomatic.,       2. Paralysis sometimes symptomatic;
     _e.g._, in unilateral facial         facial paralysis almost always
     paresis, the paresis occurs also     symptomatic. With complete
     when bilateral synergic movements    unilateral paralysis, the muscles
     are being performed.                 of the paralyzed side may
                                          function normally during the
                                          performance of bilateral synergic
                                          movements.

  3. Paralysis affects voluntary,      3. Voluntary, unconscious, or
     conscious, and unconscious or        sub-conscious movements not
     sub-conscious movements; hence,      disordered. Absence of platysma
     (_a_) platysma sign,[12] (_b_)       sign and combined flexion of
     sign of combined flexion of thigh    thigh and trunk. The active
     and trunk, and (_c_) absence of      balance movements of arm may be
     active balancing arm movements       lacking but there is no
     in walking contrasted with           exaggeration of passive balance
     exaggeration of passive balancing    movements.
     movements (limb inert on sudden
     turn of body).

  4. Tongue usually slightly deviated  4. Tongue sometimes slightly
     to the paralyzed side.               deviated to the paralyzed side;
                                          but sometimes contralateral
                                          deviation.

  5. Hypertonicity of muscles,         5. No hypertonicity of muscles. If
     especially at first. The buccal      facial asymmetry exists, it is
     commissure may be lowered, the       due to spasm. No exaggerated
     eyebrow lowered; there may be        flexion of forearm, and no
     exaggerated flexion of the           pronation sign.
     forearm, and the sign of
     pronation may occur (hand left to
     itself lies in pronation).

  6. Tendon and bone reflexes often    6. No alteration of tendon or bone
     disturbed at the beginning,          reflexes. No trepidation of the
     either absent, weakened, or          foot.
     exaggerated (almost always
     exaggerated.) In many cases,
     there is epileptoid trepidation
     of the foot.

  7. Skin reflexes usually disordered.  7. No disturbance of skin reflexes.
     Abdominal and cremasteric reflexes,   Abdominal and cremasteric
     especially at first, weakened or      reflexes normal. Babinski toe
     abolished. On stimulation of sole,    reflex and fan sign absent.
     toes, and especially the great toe,   Defense reflexes not
     are extended on the metatarsals.      exaggerated.
     Babinski toe reflex. Extension of
     great toe often associated with
     abduction of other toes (fan sign).
     Sometimes exaggeration of reflexes
     of defence.

  8. Contracture characteristic and      8. The contracture can be
     non-reproducible by voluntary          reproduced by voluntary
     contractions. The hand-grip            contractions.
     yields a sensation of elastic
     resistance, automatically
     accentuated on passive
     extension of the hand.

  9. Evolution of diseased regular       9. Evolution of disease
     contracture follows flaccidity.        capricious. Paralysis may
     When regression of disorder            remain indefinitely flaccid
     occurs, it is progressive.             or may be spastic from the
                                            beginning. Spastic phenomena
                                            may sometimes be associated
     Paralysis not subject to ups           (particularly in the face)
     and downs (motor defect fixed).        with characteristic phenomena.

                                            The disorder may get better and
                                            worse alternately several
                                            times, alter rapidly in
                                            intensity, and present
                                            transitory remissions which may
                                            last even but a few moments
                                            (motor defect variable).

    [12] More energetic contraction of platysma on healthy side
    when mouth is opened or when head is flexed against resistance.

=87.= =Differential between Reflex (Physiopathic) Contracture and
Paralysis, and Hysterical Contracture and Paralysis. Babinski, 1917.=

               _Reflex_                         _Hysterical_

   1. Paralysis usually limited but      1. Paralysis usually extensive
      severe and obstinate even when        but superficial and transient
      methodically treated.                 if treated.

   2. In the hypertonic forms attitude   2. The hysterical contracture as
      of the limb does not correspond       a rule resembles a natural
      to any natural attitude.              attitude fixed.

   3. Amyotrophy marked and of rapid     3. Amyotrophy, as a rule, absent,
      development.                          even when the paralysis is of
                                            long standing. If existent, it
                                            is not marked.

   4. Vasomotor and thermic disorder     4. There may be thermo-asymmetry
      often very marked, accompanied by     but it is slight. There are no
      an often very pronounced reduction    very characteristic vasomotor
      in amplitude of oscillations          disorders nor modifications in
      measured by oscillometer.             amplitude of oscillations.

   5. Sometimes very marked              5. No sharply defined
      hyperidrosis.                         hyperidrosis.

   6. Tendon reflexes often              6. No modifications of tendon
      exaggerated.                          reflexes.

   7. Hypotonia sometimes very well      7. Hypotonia absent.
      marked, and in arm paralysis
      _main ballante_.

   8. Mechanical over excitability of    8. Over-excitability of muscles
      muscles, often accompanied by         absent.
      slow response (?).

   9. Fibrotendinous retractions of      9. No retractions even if
      rapid development except in the       paralysis is of long
      rare completely flaccid forms.        duration.

  10. Trophic disorders of bone,        10. No trophic disorders.
      decalcification of the hairs
      and of the phanères.

=88.= The section on Shell-shock diagnosis contains 102 cases (Cases
371-472). These cases differ in no respect from those of Section B
except that many of them are more puzzling and dubious and have been
presented by their reporters more from the standpoint of diagnosis
than from that of etiology or therapeutics. In general arrangement,
the cases roughly correspond to those of Section B. First are four
cases illustrating the value of =lumbar puncture= data (Cases 371-374).
There follow cases with either a mixture of =organic and functional
symptoms=, or such a constellation of symptoms as might readily lead
to erroneous diagnosis (Cases 375-381). =Retention= and =incontinence=
of urine after shell-shock are illustrated in Cases 382-384. =Crural
monoplegia=, =monocontractures=, and other affections of one leg
are shown in Cases 385-392; but these monocrural cases are in many
respects peculiar or even unique as compared with the monocrural cases
of Section B. Peculiar paraplegias or spasms affecting =both legs=
are found in the series 393-395. Then follow (Cases 396-400) other
cases of doubtful spinal cord lesion or shock, including several with
=dysbasia=. =Camptocormia=, =astasia-abasia= and =abdominothoracic
contracture= are found respectively in 401, 402, and 403. Affections of
=one arm= follow (Cases 404-409). An assortment of peculiar cases in
which the differentiation between =hysteria and structural disease= is
in question, is found in Cases 410-415. =Peripheral nerve injuries= of
a sort which might be confused with Shell-shock phenomena, including
one of light =tetanus=, are considered in Cases 416-419. A variety
of cases bearing upon the question of the =reflex or physiopathic
disorders of Babinski= is found in the series of Cases 420-432.
Peculiar =eye phenomena= are presented by Cases 433-438; and cases
of =otological= interest are 439 and 440. =Epileptoid=, =obsessive=,
=fugue=, and =amnestic phenomena= follow in Cases 441-450; 451 and 452
are cases of =soldier’s heart=. The =simulation question= is presented
in a series of 20 cases (Cases 453-472).


GENERAL NATURE OF SHELL-SHOCK

=89.= We are now ready to consider in how far Shell-shock[13] is a
distinctive disease. The physical event, shell-shock[13] we have seen
at work in most of the major groups of mental disease and in some
groups of nervous disease. Shell-shock, the physical event, has started
up a “Shell-shock” paresis, a “Shell-shock” epilepsy, a “Shell-shock”
Graves’ disease, a “Shell-shock” dementia praecox, wherein the term
“Shell-shock” is merely a more specific term than the term “traumatic.”
The physical event, shell-shock, has in special ways also changed the
responses of the feeble-minded, the alcoholic, the cyclothymic, and the
psychopathic person of whatever ill-defined sort may get into military
service.

    [13] I capitalize Shell-shock here (as elsewhere) to indicate
    the name of a supposed disease entity and leave shell-shock
    without an initial capital to indicate the physical event.

The physical event, shell-shock, has likewise caused focal irritative
and destructive brain disease, spinal cord disease, peripheral nerve
disease; and many well-recognized species of the so-called “organic”
diseases of the nervous system have been produced. Shell-shock
“organic” diseases have proved as difficult to tell from all sorts of
Shell-shock “functional” diseases as ever have been the organic and
functional analogues of these diseases in peace practice.

But, besides (_a_) sharing in the cause of mental and nervous disease
(in the sense of “Shell-shock” general paresis and “Shell-shock” tabes,
wherein at least one other factor, _viz._ the spirochete, is known to
be at work) and (_b_) producing mental and nervous disease by killing
or weakening or sensitizing neurones in the classical manner of the
“focal” lesion, the physical event, Shell-shock, (_c_) appears able to
bring out the subtler diseases and dispositions of mind which we term
psychoneuroses, that is, hysteria, neurasthenia, psychasthenia. Just
as we have for years spoken of “traumatic” psychoneuroses, so we may
now speak of “Shell-shock” psychoneuroses--nor should anyone believe
we cheat ourselves with the idea that the adjective “Shell-shock”
has helped us more _re_ genesis than the adjective “traumatic.”
“Shell-shock hysteria” and “traumatic hysteria” are on precisely the
same--slippery--footing in the matter of their origin. The physics and
chemistry of the psychoneuroses remain in Egyptian darkness.

The physical event, shell-shock, then, as the common man might say,
affects body, brain, and mind in a great number of familiar ways; and
these familiar ways remain as plain or as blind as the neuropathology
and the psychopathology of today leave them. If thunderstorms and
earthquakes got suddenly more frequent, we should have numbers of
“lightning neuroses” and “earthquake hysterias,” neither of which would
render the physics and chemistry of the psychoneuroses immediately a
whit clearer.

When the common man speaks of some one as suffering from lightning
stroke or earthquake, he is entitled to be met halfway by his hearer,
who readily understands that the victim is suffering some sort of
transient or permanent effects of the stroke or quake. In a like common
sense should the term shell-shock be taken. Stroke, quake, or shock,
each physical event is recognized as a factor in the situation. An
event has become a factor. A condition for which the noun “shell-shock”
was descriptive, in the present tense of some event, has passed into
history; and the adjective “shell-shock” is now explanatory of the past
cause, or one of the past causes, of a new situation. Shell-shock, the
physical event, takes part in a great number of pathological events
and as such lapses from noun to adjective.

But what are these pathological events, _viz._, the conditions of
disease, that supervene? So far, in our consideration of psychoses
incidental in the war, we have found Shell-shock _varieties_, perhaps,
of mental disease; again, possibly a few Shell-shock _species_,
using both these terms, variety and species, in a quasi botanical or
zoölogical sense. But in either instance we do not rise, under the
ordinary principles of nomenclature, beyond the adjective: Is there
any evidence that shell-shock, the physical happening, has issued in a
pathological event of greater dignity, namely, a _genus of disease_?
Can shell-shock rise to the dignity of a proper noun, Shell-shock,
so that we might think of _e.g._, a new genus of the psychoneuroses,
something coördinate with hysteria, neurasthenia, psychasthenia? None,
I believe, has the hardihood to propose a new genus of mental or
nervous disease for Shell-shock regarded as a pathological event. _A
fortiori_, it is unheard-of to think of Shell-shock, the pathological
event, as representing a new _order_ of such events, coördinate with
the psychoneuroses or the epilepsies, for example.

Shell-shock, the pathological event, we conclude, is a variety or a
species, hardly a genus or an order of mental or nervous diseases.
If we can keep in mind the obvious distinction between shell-shock,
the physical event, and Shell-shock, the pathological event, we shall
save ourselves much trouble. And if we can apply the ordinary criteria
for the differentiation of the great groups (or orders) and the
lesser groups (or genera) of mental and nervous disease to the given
concrete case, we shall not go far wrong therapeutically in any case of
so-called Shell-shock. For Shell-shock, the pathological event, becomes
a humble variety or species of disease whose therapeutic indications
are in larger part those of higher and comparatively well-recognized
genera of disease, _e.g._, hysteria, neurasthenia, psychasthenia.

A shock is not a smash, a crush, a breach. A shock literally shakes.
The shaken thing stays, for a time at least. Shaken up or down, the
victim of shock is not at first thought of as done for. The spirit of
the language is against the thought of shock as destruction or even as
permanent irritation. Shock ought to be a “functional” rather than an
“organic” thing, as medicine bandies these terms about. Shell-shock or
Surgical Shock, it is all one to the logic of shock, which is thought
of as a physical or chemical disturbance of mechanisms and arrangements
that are, or ought to be readjustable. The one character which the late
Professor Royce told me (in conversation) he could find in the term
“functional” was the idea “reversible.” Shock is or ought to be, as a
pathological event, reversible.

If this thought is in the backs of our minds as we think of
Shell-shock, it can readily be seen why the “organic,” that is,
non-reversible diseases, do not take kindly to the term Shell-shock.
Shell-shock, the pathological event, prefers to be an item in the
pathology of function. Can we further specify? The pathology of
function, neuropsychically taken, considers such great groups as the
psychoneuroses; (so far as we know) the cyclothymias; some of the
symptomatic psychoses; a portion of the alcohol and drug group; some
of the epilepsies; perhaps the dementia præcox group; not to mention
various unresolved psychopathias. The psychoneuroses are the group most
innocent of every “organic” taint: the machinery is assumed to be most
normal in them and presumably the effects of disorder most reversible.

Shall we not therefore accept the psychoneuroses as the group in which
to place those pathological happenings called Shell-shock? It will
do no harm to make this choice if we do it humbly in the spirit of
acknowledgment that we know next to nothing about the psychoneuroses.
The psychoneuroses should fall on their knees to Shell-shock rather
than that Shell-shock make obeisance to the psychoneuroses. For what is
a psychoneurosis? It is a functional disease of the nervous system in
which the mind plays an important part--it is also probably much else.
But the “much else” is as likely to be found in Shell-shock as anywhere
else during these particular years.

Thus, rehearsing in a broad way =the case arrangement of Section B=,
we find, first, autopsied cases and cases with lumbar puncture data;
then cases with prominent admixture of organic phenomena; a few cases
to illustrate the victims’ own impressions of their disease; the long
toe to top, or “cephalad” series (crural monoplegias and paraplegias,
campto-cormias, astasia-abasias, brachial monoplegias, brachial
paraplegias, deafmutism, blindness); the series to illustrate the idea
of reflex or physiopathic disorders; the series of delayed Shell-shock
phenomena; the series to show the picking out by Shell-shock of
ante-bellum weak spots and tendencies in the organism; cases touching
the hereditary question; peculiar and unique cases; examples of
Shell-shock equivalents; and cases of a psychopathic rather than local
hystero-traumatic trend.

=90.= At the outset of Section B (Shell-shock: Nature and Causes), we
face the question of the possibly organic nature of Shell-shock. It is
safe to say that the vast majority of cases of Shell-shock do not die
of Shell-shock, and the collection of material from true Shell-shock
cases that are killed by accident or intercurrent disease has proved a
matter of great difficulty under military conditions. Of course, it is
possible to answer the question _à priori_, by agreeing that any case
with structural lesion of whatever sort, is by the same token not a
case of Shell-shock.

=91.= Apparently the most informatory case yet presented is that
of Mott (Case 197). In this case, death came in 24 hours, and the
immediate cause of death was doubtless a small hemorrhage of the
spinal bulb. There was a congestion of veins in the bulb, as well as a
congestion of the pia mater over all other parts of the brain. Nor was
the bulbar hemorrhage unique, for there were a number of superficial
punctate hemorrhages. In short, the brain was not even grossly normal,
such as one might desire in a case of true Shell-shock as conceived
by _à priori_ workers. Yet, according to Mott, there are microscopic
changes of an intimate nature that lie nearer to the microscopic
possibilities in true Shell-shock. For example, in the bulb itself
there was a distinct and photographable change of nerve cells: =the
vago-accessorius nucleus had cells in a state of chromatolysis=. The
internal alterations of these cells, with dissolution of chromatic
material, may possibly indeed have been the direct cause of death or
an indicator of its direct cause. Here again, to accord full justice
to Mott’s contention, we are dealing perhaps more with a phenomenon of
the cause of death than with a Shell-shock phenomenon. According to
Mott, the Shell-shock symptoms themselves are due to capillary anemia
and to nerve cell changes such as he found in various regions. These
nerve cell lesions were of the nature of chromatolysis and identical
with those of the vago-accessorius nucleus. In this connection, one
thinks of the ideas of Crile concerning exhaustion and its effect upon
certain nerve cells and other cells, and indeed the whole conception
runs back to the early years of discussion of the meaning of chromatin
deposits in nerve cells, and to the work on fatigue of such cells.
It may well be that Mott’s suggestion is sound, and that changes of
the order of chromatolysis are what subtend some, if not most, of the
phenomena of Shell-shock. On account of the myriad interconnections of
neurones and the remote effects upon normal neurones of disturbances
of a microchemical or microphysical nature in a few neurones, it
would not do to throw out of court forthwith such a contention as
that of Mott by triumphantly pointing to the miracle cures of certain
Shell-shock phenomena; for it will not necessarily be the chromatolytic
(or otherwise microchemically or physically altered) cells that will
be directly responsible for the symptoms in question. Cells whose
activity is but temporarily in abeyance (perhaps by phenomena akin to
diaschisis) might be reached from an unusual source in the process
of “miracle cure,” whereupon the newly opened paths of energy might
conceivably remain open. Nevertheless, it cannot be denied that there
are considerable stretches of speculation in the thread of this
hypothesis.

=92.= Particularly important is the question, how frequently such
hemorrhages as those found by Mott in Case 197 occur. Cases are given
in the text which show such hemorrhages.

Rather often quoted in this relation is Case 201, a case of Sencert,
in which a shell exploded one metre away from a soldier and injured
him so that he died that night through the bursting of the pleura
of both lungs within a thoracic cage which was quite intact. This
sort of finding reminds one of cases in which the inner partitions
of houses are burst by explosion when the outer walls remain intact.
In particular, one thinks of the physical changes within an aneroid
barometer, which have been shown to come about when something is
exploded near by. If such an event may happen as the bursting of the
lungs within an otherwise intact body, so also is there evidence that
a similar event occurs in the nervous system. Clinical evidence of
this is obtained in the hemorrhage and pleocytosis of spinal fluid
obtained early in the clinical examination of certain cases. In fact,
in Case 205 (one of Souques), there is a pleocytosis of the fluid
as late as a month after shell-shock. When there is no pleocytosis
or hemorrhage, there may be a hypertension of the fluid,--a finding
sometimes attributed to Dejerine (see, for example, Case 207, of
Leriche). It might be inquired whether the fall sustained by the
patient as a result of the shell explosion could not be responsible for
the hemorrhage, and this may indeed be the fact in certain instances.
Babinski has offered in Case 209, an instance in which hematomyelia
(with later partial recovery) was produced in a subject who was lying
prone in the performance of machine-gun duty (the phenomena in this
case were well described by the victim himself, a veterinary student
who was six months a captive in Germany). Doubtless, it would not be
difficult to produce a complete series of cases with and without trauma
to the tissues investing the nervous system, with definite clinical or
autopsy evidence of organic lesions of the nervous system, whether by
mechanical impact, by the concussion (windage) of the air, or even by
the effects of muscular contractions.

=93.= A case of Chavigny’s (Case 198), in which there was an extremely
careful autopsy, showed a strongly blood-stained cerebrospinal fluid;
in fact, there was an intradural hemorrhage, though of minor degree and
possibly not the cause of death; and throughout the brain substance
there were slight hemorrhagic points. But there was no sign whatever
of fracture of the cranial vault or base. Another case of similar
meningeal hemorrhage but sharply localized, was Case 199, an instance
of minor explosion in which neither skin nor muscles, bone or viscera
showed any lesion; and the death, which occurred in seven days, seemed
hardly explicable on the basis of hemorrhage itself. In fact, this case
would require the sort of microscopic examination performed by Mott in
Case 197 for a proof of the cause of death, which was thought by the
reporters themselves (Roussy and Boisseau) to be within the field of
histology.

=94.= Case 200 seems to bring proof that there may be areas of gross
softening within the spinal cord produced by the concussion of the
cord from shell-burst, although there had been no fracture of the
spine itself and no penetration of splinters of shell or of bone into
the spinal canal or the substance of the cord itself. The argument
here is that the tissues that lie between the agent of violence and
the interior of the spinal cord are affected _en bloc_ by the impact,
the resultant gross or molar lesions being several millimetres or
centimetres from the point reached by the impinging body or force.
How complicated such a situation might be, we may recall from a case
previously studied, namely, Case 103 (Lhermitte), wherein a missile
struck the left side of the skull and produced lesions beneath its
point of impact, but at the same time apparently caused a _contre-coup_
effect upon the opposite hemisphere. That particular case did not come
to autopsy, but Lhermitte’s explanation of its queer association of
aphasia with ipsilateral hemiplegia seems sound enough. In fine, what
with the mechanical trauma to which many victims of shell explosion
are subject, what with the findings in sundry autopsies, and what with
the determination of hemorrhage in the spinal fluid early after the
shock, it might be conceived that the majority of cases of Shell-shock
are actually cases of mechanical injury to the brain or spinal cord in
which hemorrhage or laceration and overriding of neuronic tissues would
be found. Nor would such a hypothesis be _prima facie_ absurd with the
evidence afforded by certain cases of Shell-shock having an admixture
of reflex phenomena and other symptoms proved by the older neurologists
to be beyond peradventure organic. (Compare, for example, such a case
as that of Case 210, with herpes zoster and segmentary symptoms.) It
should be remembered, however, that Mott in the case cited above (Case
197) sharply distinguishes between the hemorrhages (especially the
bulbar hemorrhage which caused death) and the nerve cell chromatolysis
which he regarded as possibly at the basis of Shell-shock symptoms.
It is decidedly doubtful whether the hypothesis of microscopic or
larger hemorrhages, or of local areas of destruction of neurones will
suffice for the explanation of true Shell-shock. This is not to say
that in the diagnosis of true Shell-shock (that is, roughly speaking,
the psychoneurosis), we shall not need to concede and consider in
every case the possibility of =traumatic focal brain disease=. This
will always need =to be faithfully excluded= in all cases unless the
initial set-up of symptoms is so suggestive of immediately curable
psychoneurosis that without further ado miracle-therapy is undertaken
and executed. But in virtually all the slower cases, an exclusion of
organic brain and cord disease is undertaken. Admixtures of organic and
focal phenomena are quite in the order of everyday occurrence.

=95.= Especially good instances of this co-existence of functional
and organic symptoms are found in ear cases; and it may be suspected
that when, after the war, all these data can be suitably gathered and
compared, it will be from the field of otology that some of the most
fruitful hypotheses will be developed. In the cases of Shell-shock
deafness, mechanical peripheral factors are admixed with central
factors in phenomena admitting in some ways more exact diagnosis than
in other fields. We may await the correlation of these data by some
worker, equally skilled in otology and neurology, with the profoundest
interest. Analogous results may be hoped from a correlation of
neurological and ophthalmological conceptions.

=96.= Suffice it to say that the differentiation of organic and
functional phenomena has long been possible on the basis of what we
know concerning various reflexes (_e.g._, the Babinski reflex and
its congeners); and the net result of this work is that the majority
of Shell-shock cases,--that is, cases in which the physical factor
shell-shock has entered,--are probably not cases in which a coarse
organic disease could be proved to exist, or assumed with any color
of likelihood to exist. Even limiting ourselves to cases in which the
physical factor shell-shock or some sort of impact with or without
an external wound occurred, we shall find cases enough of a truly
functional nature, as indicated by their reflexes, to render it quite
impossible to assert that they are in the classical sense “organic”
cases. Putting these cases with the physical shell-shock factors
together with the other large series of cases in which precisely
similar symptoms occur without the presence of the physical shell-shock
factor, we shall find ourselves convinced that classical Shell-shock
phenomena are by and large what is called functional. We shall arrive
at the hypothesis that they are cases of hysteria or other form of
psychoneurosis, entitled to the diagnosis of traumatic hysteria (or
hysterotraumatism, in the sense of Charcot), or not, according to
whether the physical factor shell-shock was in evidence. What now
underlies the concept functional, as we use it in Charcot’s sense of
hysterotraumatism, or in the more modern phrase traumatic hysteria?
Do we perhaps mean some microchemical or microphysical change of a
reversible nature, similar to that described by Mott, _e.g._, in Case
197? It is not possible to answer this question at this time.

=97.= But if we give up the hypothesis of organic disease of the
nervous system (that is, the hypothesis of coarse lesions, small or
large, conceived to be the direct effect of mechanical impact), can we
incriminate any other factor? Chemical factors from the gas of bursting
shells may be thought of; yet in abundant cases there is no evidence
that these have been in play. They and a variety of other special
causes may be found working in a few instances but have nothing to do
with the moot question.

=98.= Upon giving up the organic hypothesis, the modern functionalist
is very apt to run directly into the embrace of hysteria. If a thing
is not physical, it must be psychical in its genesis, so runs the
argument. What, after all, is a neurosis? We mean ordinarily by
neurosis, something functional rather than structural. We often mean
something psychical rather than peripheral. Accordingly, as we have
seen, many writers rush to the hypothesis that Shell-shock effects,
except in a few unusual instances of organic disease, are functional;
and not only are they functional but psychic, and maintained by some of
the so-called “mechanisms” which abound in modern speculative writing.

=99.= Case 253, a case of Tinel, may serve to illustrate this point.
Tinel’s patient was not subject to shell-shock at all, but was wounded
in the arm. Three weeks later, he was able to flex his forearm only
by means of the supinator longus. It was found that the biceps was
soft and flaccid, though the electrical reactions of the biceps were
normal. Now, since flexion of the forearm is normally produced by a
synergic contraction of the biceps and supinator longus, the situation
in Tinel’s case was striking in that the functions of the biceps and
supinator longus had been separated out by a process which could not be
hysterica. The hypothesis is that in hysteria it has always been found
impossible to split the synergic action of these two muscles. What has
happened? In Tinel’s picturesque phrase, the biceps muscle has been
=stupefied= by a process which involved no destruction of a nerve trunk
or any important nerve elements. This process of stupefaction passed
away with a few weeks’ massage and rhythmic faradism. But what is this
process of stupefaction, as Tinel calls it? No definite answer can be
given. But is not the process analogous to what may happen in a variety
of cases of shell explosion in which, for one reason or another, sundry
neurones are, as it were, stupefied, stunned, anesthetized, or thrown
out of gear by some internal physico-chemical readjustment of unknown
nature? Perhaps that readjustment, though in Tinel’s case it probably
took place within the tissues of the arm itself, is analogous to the
chromatolytic process in nerve-cell bodies suspected by Mott to be at
the bottom of certain Shell-shock symptoms as in Case 197.

=100.= Are there, then, phenomena of peripheral nerve shock analogous
to the phenomena of spinal cord and brain shock which we find in so
many cases? But if so, it is clearly unnecessary, and indeed injurious
for us to conceive that cases proved not to be organic must necessarily
be hysterical. Several authors have called a halt upon this undue
extension of the concept of hysteria to include all the non-organic
phenomena. Take, for example, the case of the Victoria Cross winner
(Case 529), reported by Eder, in which a contracture was shown by
hypnosis to be a representation of the patient’s clutch upon his
bayonet (he had been at Gallipoli and was wounded in fourteen places
during a bayonet fight with Turks). It would not be possible--in fact,
it would seem almost impolite--to refuse to entertain the hypothesis of
a kind of symbolism in the bayonet-clutch contracture of Eder’s case;
but it would, on the contrary, be far from exact to consider all cases
of contracture to be even probably or possibly symbolic in the manner
of the bayonet-clutch. There are, many workers feel, many functional
phenomena that are non-hysterical, and as it were infra-hysterical in
the sense that the “mechanisms” (to use that over-worked term) are
in neurones below the level of complexity required by hysteria. This
theoretical possibility (that the functional should be divided into
the psychical and the infrapsychical) has been given a new status by
the work of Babinski and his associates. That work seems to show that
the older doctrines of Charcot concerning the existence of “reflex”
disorders, are perfectly sound.

=101.= Babinski has been able to bring into the light of observation
the morbid operation of certain of these reflex arcs. Even in cases
where in the waking life the central nervous system is able to
overpower the reflex arcs in question and permit the limb or limbs to
work reasonably well and smoothly, the process of chloroform anesthesia
will quickly bring out an odd and unsuspected interior situation. The
chloroform suspends the operation of numerous neurones, including those
that have to do with the downflow of cerebral inhibitions, those silent
streams of impulse that serve to keep the knee-jerks, for example,
in leash. Now at a time when all the other muscles of the body are
relaxed, the withdrawal of the cerebral inhibitions by chloroform
anesthesia may cause a phenomenon to appear in certain reflex arcs
that argues an excess of activity; thus in the leg, for example, an
ankle-clonus, or a patella-clonus, or a degree of contracture, may be
brought about early in chloroform anesthesia, though there had been
little or no suspicion of such a tendency in the waking life. The
cerebral inhibitions in the waking life have been enough to dampen the
ardor of the reflex arc in question. It must be remarked that these
cases of reflex, or, as Babinski termed them, _physiopathic disorders_,
as a rule occur in cases locally wounded. It is the locally wounded
limb that develops functional excess of contained reflex arcs. Does
this occur by a process of neuritis, or by some other unknown process?
Whatever the answer to this question, Babinski and his associates
appear to have shown the existence of a group of physiopathic or reflex
disorders; disorders below the level of the psyche and below the
theatre of operations of hysteria.

=102.= Practically speaking, also, it is important not to consider
every functional situation hysterical, since the non-hysterical
functional changes may be extremely obstinate to treatment. Both
physician and patient suffer if the patient is treated along
psychotherapeutic lines for hysterical symptoms, some of which turn out
on investigation to be functional enough but non-psychic. The peculiar
configuration of symptoms shown in cases with the physical shell-shock
or its equivalent, is perhaps dependent upon what neurones are locally
affected. If there has been good evidence of near-by explosion or of
wound, it will be especially important to learn just what parts of the
nervous system and just what synergic neurones and other structures
were affected. Whether the process within these neurones be one
analogous to the dissolution of chromatin, or whether the process is
more like one of narcosis, or narcosis and stupefaction, or whether the
process is more like that of a stun, or like the plight of the nerves
in a foot for a long time “asleep,” it may be impossible to say; but it
is entirely unnecessary to soar directly to the higher mental process,
unnecessary in short, to assume a hysterical dissociation when the
dissociation may be far lower down in the nervous system.


THE TREATMENT OF SHELL-SHOCK NEUROSES

=103.= We have pictured the practical situation in which the neuroses
of the war find themselves--a situation bristling with diagnostic
difficulties. The great proposition deducible therefrom is,

=The diagnostic problem in Shell-shock is the diagnostic problem of
neuropsychiatry at large.=

The neuroses of war have this in common with the neuroses of
peace--that they need to be distinguished from all other nervous and
mental diseases. One cannot be a specialist in Shell-shock unless one
is a neuropsychiatric specialist; even the neuropsychiatrist has much
to learn from the internist, the orthopedist, the neurosurgeon, as well
as from the psychologist.

=But however wide the diagnostic field for Shell-shock, the therapeutic
field is wider still.= For the neuropsychiatric reconstructionist has
to face the peculiarities of the military status of his ward, the
difficulties of demobilization into civilian life (a canal system
with very precise technic for the opening and closing of locks), the
choice and timing of the proper measures of bedside occupation, of
occupation therapy in a broader sense, of prevocational and vocational
training--the whole complicated by the character changes that may have
set in to bowl over all one’s preconceptions. The nub of the matter,
after the era of the _manière forte_, the brusque psychotherapy, the
rough jarring of the man back into approximate normality is, perhaps,
this potentiality of subtle character changes defying possibly
anybody’s analysis, but stimulating us all to our best endeavor,
whether we are physicians, psychologists, occupation-workers, social
workers, or nurses. Now that all sorts of reconstruction programs
are in the air, each claiming its share, or more than its share,
of attention, let us not forget that no one can stake out in any
small plot the measures of refitting, readjustment, readaptation,
rehabilitation--all these terms with slightly differing denotation have
been used--especially when we take into account that not only must
the patient be refitted to his entourage, but also not seldom the
entourage to its returned Shell-shocker.

=104.= It is proper to place these general considerations first
because =the slow, patient, prosaic measures of reëducation are apt
to be forgotten in our enthusiasm for the lightning-like cures of
the hypnotic, the psychoelectric, the pseudo-operative, and other
psychotherapeutic forms=. Psychotherapy in all its forms has come into
its own in Shell-shock. Miracles or their equivalents are daily wrought
by men who are not prophets. Lourdes and Christian Science have their
unassuming rivals. Let us remember, however, that even Lourdes and
Christian Science never solved 100% of the problems placed before them,
even though the votaries have the best will in the world to be cured.
If the will itself is disordered, what can be done save investigate?
And the _mauvaise volonté_ is by no means absent from some of our
prospective patients; witness one man, a Frenchman, who so resented
being cured by _torpillage_, _i.e._, by the electric brush, that he
carried his case against Clovis Vincent, who cured him of his hysteria,
clear to the Academy! And, even after we have cured our cases by these
modern miracles, let us not be too proud of ourselves! One soldier
sent back to Australia, hysterically mute for months, got his voice
back after killing a snake--a peculiar instance of occupation-therapy,
not enumerated in courses on reconstruction. And remember the man who
jumped the wall and got drunk, breaking back into the hospital to
show his doctor how his refractory voice had at last come back. Thus
there are cures and cures (even a newspaper cure of mutism by a moving
picture vision of the antics of Charlie Chaplin), and spontaneous
non-medical cures as well as medical ones, and slow cures due to _vis
medicatrix_, as well as to shrewd reëducation measures.

=105.= I shall not attempt to cover systematically the topic of
Shell-shock therapy in this epicrisis. The reader must go through the
treated cases, especially in Section D but _passim_ elsewhere, if he is
to obtain a proper conception of all the methods so far employed--and
at the end he cannot know the ultimate outcome of the cases. Patrons
of the miracle cures and the _manière forte_ are having their day: on
the whole, the law of =sudden onset, sudden ending= has much to say for
itself in the hysterical (pithiatic) group. Forebodings of relapse in
these =torpedoed= cases may indeed have some foundation: but figures
are yet lacking, and relapses may be as expectantly predicted in the
=slow-onset, slow-cure= group. =The decision must be post-bellum.= Nor
must the fact that a few absolutely normal subjects have succumbed _de
novo_ to Shell-shock blind us to the fact that, statistically speaking,
most cases are _ab ovo_ psychopaths in whom relapses, recurrences, or
new instances of neurosis may be confidently expected. For these _ab
ovo_ psychopaths, what can suffice but (_a_) removal of the disease
by the _vis medicatrix naturae_; or (_b_) reëducation, intellectual
or (_c_) moral (as the case may be); or else (_d_) some plan of
environmental shielding from new occasions of disease?

=106.= I shall content myself with a brief survey (insisting that
the details be read of at least the leading cases in each treatment
subgroup) of the cases offered in Section =D= (Shell-shock: Treatment
and Results), consisting of 117 cases (Cases 473-589). The cases are
in general arranged with the =spontaneous and quasi-natural cures= at
the outset,--a series of 11 cases (Cases 473-483). The remainder of
the section deals with cures under medical conditions, although many
cases naturally show an interplay of non-medical factors in the cure or
persistence of one or more symptoms.

A few cases illustrative of the =physical value of hydrotherapy=,
=mechanical therapy=, and =drugs= are given in a short series (Cases
484-489). A treatment of hysterical contractures by =induced fatigue=
is dealt with in Cases 489-493; and the occasional value of =surgery=
is shown by Case 494.

The simpler methods of =persuasion and explanation= follow in a series
of 19 cases (Cases 495-513).

=Pseudo-operations= and =suggestive operative manipulation= of avail in
the treatment of certain local hysterical phenomena are considered in a
series of eight cases (Cases 514-521). The comparatively long =hypnotic
series= follows: 27 cases (Cases 522-548). The above-mentioned cures
by pseudo-operation and by hypnosis may be classified with those that
follow, _i.e._, mainly rapid cures by =psychoelectric= methods and by
=suggestion on emergence from anesthesia= (Cases 549-574), as modern
miracles. These cases of modern miracle are followed by a briefer set
of =reëducative cases= (Cases 575-589).

Throughout the treatment section are scattered instances in which, not
a cure, but merely a modification or even a persistence of symptoms was
the outcome. It is useful to bear in mind, while reading cases in the
etiological and diagnostic sections, these main divisions of treatment
into what might be called (1) spontaneous, (2) rapid (or “miraculous”)
and (3) slow or reëducative.

=107.= It is beyond the scope of this book to deal systematically with
the hospital and administrative side of these questions. Especially
the zone question is of practical importance, that is, the question of
arrangements at the front, on evacuation lines, and in the interior.
Roussy and Lhermitte have particularly discussed these matters.

After thirty months’ experience in the psychiatric centers of two
armies, Damaye suggested an organization of psychiatric centers in two
parts,--First, a service draining patients =from the firing line=,
rapidly give them first care and evacuate them, =in charge of special
attendants=, to: Second, a psychiatric or neurological =center in the
communication zone= (_étapes_) without danger of bombardment and at a
distance from the guns. The more serious cases will then be evacuated,
thirdly, into the interior from these centers along communication
lines. But most will have gotten well at the front.

=108.= By orthopedists and mechanotherapeutists too much stress may
indeed be laid on non-psychiatric measures, as Duprat hints. Yet
perhaps neuropsychiatrists may need as much coaching in the opposite
direction. One must remember the non-psychopathic fraction of these
Shell-shock disorders and their need of diathermy (Babinski). Duprat
says that the centers for physiotherapy cannot effectively do the work
of all Shell-shock therapy, as the physiotherapists have their aims
fixed on nerves and muscles rather than the mind. Each case requiring
psychotherapy ought to be studied in an =experimental psychological
laboratory= from a number of points of view such as mechano-motor
capacity, the sensibility, emotional and intellectual sides, memory,
impulses and the like. Testing apparatus should be available
together with dynamometers, sphygmometers, chronoscopes, ergographs,
pneumographs, cardiographs and recording apparatus.

                               CHART 19

               PSYCHOELECTRIC AND REËDUCATIVE TREATMENT

    PHASE   I. PERSUASIVE TALK IN CONSULTING ROOM

    PHASE  II. ISOLATION, REST IN BED, MILK DIET (a few days)

    PHASE III. FARADIZATION

    PHASE  IV. REËDUCATION (Physiotherapy and Psychotherapy)

    PHASE   V. AFTER-CARE

       Curing a psychoneuropath means victory in a moral battle!

                                         After Roussy and Lhermitte

                               CHART 20

                  TREATMENT FOR INVETERATE HYSTERICS

    PHASE   I. “TORPILLAGE” AND INTENSIVE REËDUCATION

    PHASE  II. FIXATION OF PROGRESS BY EXERCISES

    PHASE III. PROLONGED SPECIAL TRAINING

                                               After Clovis Vincent

Specialists for consultation should be available, including
ophthalmologists, otologists, laryngologists and electrical
specialists. The tests over, the patient should be examined as it
were, in a free state and his habits and character noted. Hypnosis may
be tried but it should not be prolonged. Psychic contagion is to be
avoided especially in the case of subjects with epileptoid crises.

It would be well to establish for the cases regarded as susceptible to
psychotherapy, =reëducation centers= like those for the re-adaptation
of the tuberculous. The improved tuberculous are sent to health centers
under the Ministry of the Interior for three months at the maximum and
emerge much better able to support the exigencies of life. According
to Duprat, there ought to be =psychotherapy centers= which should not
in any sense recall asylums for the insane. Set in the country but
not far from the city, managed by the psychological physicians and
“_médecins psychologues, plus éducateurs que médecins_.” The personnel
should consist of students going into psychiatry and of teachers whose
pedagogical practice ought to enable them to second the efforts of the
psychiatrists. In this way we might avoid the perpetuation of some of
the psychopathies of war.

=109.= Possibly “putting forward the best foot” may yield a wrong
impression of the proportion of what I have termed “miracle cures.”
Other devices of a slower nature are mentioned throughout the book.
Perhaps much depends on the temperament of the psychotherapeutist,
as _e.g._, Laignel-Lavastine has remarked about the method of
psychotherapy by means of conversation: that =one might easily remain
in a honeymoon state in military psychotherapy=. When hundreds and
thousands of functional nervous cases pass through one’s hands it is
necessary to remember that behind the conversation there stands the
imposing finger of material force.

Compare the work of Clovis Vincent, Yealland, Kaufmann.

=110.= On the other hand, Rows points out that shock is a term that
does not explain at all adequately the great variety of mental
illnesses occurring in the soldiers at the front. The term is popularly
used for cases which recover quickly, but in the majority of cases
there is a residuum after the shock has disappeared. Accordingly Rows’
work has dealt chiefly with underlying causes, conditions, and factors.
Here we may consider

    (_a_) The =war strain= before breakdown;

    (_b_) =Special causes= of shock, such as death of comrades near
          by, near-by shell explosions and blowing up of trenches;

    (_c_) =Fatigue and exhaustion= with lowered capacity of
          resistance.

    The men themselves find that they have

    (_d_) undergone a =change of character=, having become
          irascible, unable to sustain interest and attention;
          solitary and morose, and less capable of self-control.
          Anxiety, worry and a state of morbid expectancy set in.
          Everyday trifles are exaggerated.

    But below these cases are still deeper ones, such as

    (_e_) revival of =horrible memories and terrifying dreams=
          of war scenes, together with memories of incidents of
          past life.

    (Rows attributes to Dejerine the idea that the cause of all
    cases of hysteria and neurasthenia must be sought in antecedent
    emotion.)

Emotion compels attention, and to such a degree in some cases that
the memories and attendant fears and anxieties cannot be expelled.
Hallucinations and delusions may then develop. The patient is largely
incapable of reasoning about his status; he lacks “insight into the
nature and mode of origin of his mental illness. This insight can be
provided by explaining to him in plain language the mechanism of simple
mental processes, by enabling him to understand that every incident is
accompanied by its own special emotional state, and that this emotional
state can be re-awakened by the revival of the incident in memory.” The
patient and the physician now “begin to realize that they have some
ground in common.… The mystery of the illness will be swept away and
the physician will be able to … show him how he can educate himself
to regain that which was lost.” “The patient can be induced to face
the trouble.” “The excessive emotional tone will thus be stripped away
and the patient will thus become able to appreciate the real value of
the incident.” “The reëducation must vary with each case in order to
overcome the difficulties connected with the specific cause which has
been discovered.”

Rows’ work has been done at the Red Cross Hospital at Maghull, and
several of the Maghull cases have been reported in Elliot Smith and
T. H. Pear’s book on Shell-shock. A somewhat similar point of view
has been maintained by Wm. Brown, who has suggested the neat term
_autognosis_ for psychoanalysis. W. A. Turner speaks of the Maghull
point of view as one of modified psychoanalysis.

=111.= Or again a species of combination of the _manière forte_ and the
_manière douce_ (operations, shall we say with William James, of the
“tough-minded” and the “tender-minded” respectively?) may be used as in
the formula

SYMPATHY + FIRMNESS (MOTT).

=112.= More special devices, suggesting faintly the methods of animal
training, may be used, as described in the following account of a new
=isolation and psychotherapeutic service= established in May, 1915,
at the =Salpêtrière= for soldiers with functional nervous diseases.
The basic idea has long been held by Dejerine,--the avoidance of
heterosuggestion by other patients, imitation, ill effects of visits
from members of the family. The functional additions that come from
near-by organic patients are among the disadvantages of the ordinary
treatment. The isolation service of the neurological center is composed
of 34 beds, arranged in two halls, with three extra rooms. Each bed is
isolated. The régime in one of the rooms is more rigorous than in the
other, and =it is an advance for a patient to be moved from the first
to the second room=. The patient on wakening has no right to leave his
box or communicate with his neighbors. He leaves only to be treated
by hydrotherapy or electrotherapy. He takes his meals in isolation,
receives no calls, and has no leave to go out. The physician sees the
patient twice a day and carries on psychotherapy and motor reëducation,
as well as special treatments.

Women nurses care for the patients. A system of control and of
=progressive rewards= has been installed, being a sort of metric
evaluation of the process of cure. As the cure proceeds the patient’s
lot is progressively mitigated, or if he gets worse the regime is
clamped down. Suppose a man a victim of paralysis of leg--the height to
which he can lift his leg is measured in centimeters daily as well as
the time during which he can hold the leg in air; or, the progress of
an ankle, or of the forearm or the arm in a case of arm contracture,
is measured. The grade obtained by our =scholar in psychotherapy= is
inscribed upon a slate. Finally, walks, concerts, visits and eventually
permission to go out into the town are granted.

=113.= =Can Shell-shock neuroses be prevented=, other than by stopping
or modifying the war or by weeding out Shell-shock candidates as
they volunteer or are drafted? Morton Prince offers points of some
suggestive value. The very various proportions of neurosis observed in
different units and arms of the service suggest that various degrees
of preparedness may have played a part. Bernheim says =suggestion= is
an =idea accepted=. Aside from a possible increase of simulation, much
might depend on what idea administered really got accepted! Morton
Prince’s plan is that the prevention must be based upon the education
of the mind. This therapeutic education should be based, however,
on a preliminary systematic study by a board of specialists in the
psychoneuroses of (_a_) the mental attitude of minds generally toward
shell fire, and (_b_) clinical varieties of this “shock” neurosis as it
occurs in trench warfare, (_c_) its frequency and disabling incidence,
and (_d_) the state of mind previous to the trauma of those suffering
from it.

On the basis of the findings of such a study, first, the regimental
surgeon through lectures and clinical demonstrations would be
instructed systematically in the symptoms and pathology of the disease
and the methods of psychotherapy for its prevention.

Second, soldiers, including officers, could then, in units of say 100,
in turn be instructed in the nature of the disease through lectures by
regimental surgeons. Shell-shock, they should be told, is a form of
hysteria caused by mental factors. The work of the instruction should
be done in France in the atmosphere of the war, wherein would be formed
an attitude of healthy mental preparedness instead of an attitude of
fear and mystery. Has mental hygiene this great scope? =Is morale
merely education?=

=114.= =What after all, is Morale?= We hope to learn a little about it
from this war for use hereafter, when we can say with the Florentine

    _e quindi uscimmo a riveder le stelle_

    And thence we issued out again to see the stars

                          Inferno, Canto XXXIV, 139.




BIBLIOGRAPHY


These references were collected in the main by Sergeant Norman Fenton
both before and after his entering the army, in connection with
preparations for the work of one of the Neuropsychiatric Training
Schools (that at Boston), established by the Division of Neurology
and Psychiatry of the Surgeon-General’s Office, U. S. Army. The
work, through the year 1917, at least, is not a mere _vernis de
bibliographe_, but is based on a first-hand search through journals
available in the Boston Medical Library and the New York Academy of
Medicine (to whose officers thanks are due for very special privileges
accorded). After Sergeant Fenton’s departure for service in the war
neurosis hospital, 117, American E. F., France, the work was finished
by the writer in considerable haste by skimming the current indexes
and gathering the more prominent titles for 1918 (some for 1919).
The titles, be it noted, go beyond the scope of the case-material in
the body of the book and cover also a variety of reconstructional,
reëducational, clinical-neurological, neurosurgical, and other topics
bearing indirectly on neuropsychiatry. These auxiliary subjects are by
no means completely covered, but it was thought the titles might help
other inquirers. Under the war conditions numerous errors have no doubt
crept into the references, which errors we hope will not, by reason of
the short space of time covered by the bibliography, prove particularly
misleading. The auxiliary topics can be referred to in the Index under
page-numbers after the word “Bib.”

E. E. S.


    =Abadie.= La neuro-psychiatrie d’urgence aux armées. Presse
    Méd., Par., 1915, v. 23, p. 46.

    =Abrahams, Adolphe.= A case of hysterical paraplegia. Lancet,
    Lond., 1915, v. ii, p. 178.

    =Abrahams, A.= “Soldier’s Heart.” Lancet, Lond., 1917, i, 442.

    =Absence of neuroses in war.= N. York M. J., 1916, v. 103, p.
    1178.

    =Ackerley, R.= Treatment by physical methods of mental
    disabilities induced by the war. Proc. Roy. Soc. Med., Lond.,
    1917-1918, v. 10 (sect. Balneol.), pp. 37-38.

    =Aconi, A.= Le nevrosi di cuore e la guerra. Riforma med.,
    Napoli, 1916, v. 32, pp. 501-505.

    =Addinsell, A. W.= Head injuries in war. Brit. Med. Jour.,
    1916, ii, 99.

    =Adler, H. M.= The broader psychiatry and the war. Mental Hyg.,
    Concord, N. H., 1917, v. 1, pp. 364-370.

    =Adrian, E. D. and Yealland, L. R.= The treatment of some
    common war neuroses. Lancet, Lond., 1917, i, 667.

    =Adrian and Yealland.= The treatment of some common war
    neuroses. Lancet, Lond., 1917, i, pp. 867-872.

    =After care of nerve injuries.= Rev. of War Surg. & Med., 1918,
    i, no. 3, 49.

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    =Babinski, J. and Froment, J.= Service de neurologie militarisé
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    =Baumel, J.= La ponction lombaire dans les commotions nerveuses
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    =Beaton, T.= Some Observations on Mental Conditions among a
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    =Bellin et Vernet.= Sur une forme nouvelle de syndrome bulbaire
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    =Benisty-Athanassio.= Clinical Forms of Nerve Lesions. Military
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    =Benisty-Athanassio.= Traitement et restoration de lésions des
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    =Benon, R.= Au sujet des névroses traumatiques, Réunion de la
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    Riv. sper. di freniat., Reggio-Emilia, 1916, v. 42, pp. 131-172.

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    =Cooper, P. R.= (Discussion of Milligan’s paper.) Brit. M. J.,
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    =Cooper, J. W. A.= Use of alcohol on the battlefield and
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    1916, ii, 201.

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    =Core, Donald E.= “Instinct-distortion,” or “war-neurosis.”
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    =Cornet.= L’auto-mutilation. Rev. gén. de clin. et de thérap.,
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    =Cottet, J.= Syndrome d’aéro-paresthésie a frigore et gelures
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    =Craig, C. B.= Injuries to the peripheral nerves produced by
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    =Craig, Maurice.= Psychological medicine. 1917, 3rd ed.,
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    =Crile, G. W.= The Kinetic Drive. W. B. Saunders, 1916.

    =Crile, G. W.= A mechanistic view of war and peace. Macmillan,
    1916.

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    =Crile, G. W.= The Fallacy of the German State Philosophy.
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    =Crinon, J.= Les éclopés psychiques. (Méd. légale.) Caducée,
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    =Crouzon, O.= Cécité temporaire provoquée par l’éclatement
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    =Crouzon, O.= Les pseudo-maux de Pott au conseil de révision.
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    =Crouzon, O.= De la valeur de l’hypotension artérielle comme
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    d’hôp. de Par., 1915, v. 39, pp. 234-237.

    =Cruchet, R. Calmettes et Bertrand.= Épilepsie Jacksonienne
    grave. Trépanation et application de sac herniaire. Cessation
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    =Cruchet, R. Calmettes et Bertrand.= Fracture du crâne
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    muscles and the interpretation of the results with reference to
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    =Curschmann.= Bemerkungen zur Behandlung hysterischer
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    =D’Abundo, G.= Alterazioni nel sistema nervoso centrale
    consecutive a particolari commozioni traumatiche. Riv. ital. di
    neuropat., Catania, 1916, v. 9, pp. 145-171.

    =D’Abundo, G.= Considerazioni cliniche sui traumi di guerra a
    capo. Riv. ital. di neuropat. psichiatr., ed elettroter., 1917,
    v. 10, 357-76.

    =D’Abundo, G.= Reparto neuropatologico militarizzato della
    clinica delle malattie nervose e mentale della R. Universita
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    22-24.

    =Dacco, E.= Autolesioni cutanee nei militari. Gior. ital. d.
    mal. ven., Milano, 1917, lii, 340, 370.

    =Dal Collo, M. E.= Contributo casuistico alle dermatosi
    simulate di guerra. Quaderni di med. leg., Milano, 1917, i,
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    neuropsychiatrie, d’armée. Presse méd., Par., 1916, v. 24, p.
    24.

    =Damaye, H.= Étude sur les affections mentales et
    neuropathiques occasionnées par les commotions de la guerre.
    Progrès méd., Par., 1917, 3. s., xxxii, 441-443.

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    =Damaye, H.= Considérations cliniques sur les commotions de la
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    =Damaye, H.= Aperçu général sur les fonctions d’un service
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    (appareillage, rééducation professionelle, placement). Arch. de
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    =Davidenkoff, S. N.= (Acute psychoses in time of war.)
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    =Davidenkoff, S. N.= Acute traumatic psychoses;
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    embedded in the internal popliteal nerve: illustrating the
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    dans certains cas de paralysies fonctionnelles, accompagnées
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    1914-15, v. 22^1, pp. 521-529.

    =Dejerine, J.= Deux cas de paralysie fonctionnelle d’origine
    émotive observés chez les militaires. Rev. neurol., Par.,
    1914-15, v. 22^2, pp. 421-424.

    =Dejerine et Gascuel.= Tachycardie d’origine émotive
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    et la psychothérapie des militaires atteints de troubles
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    Travaux des centres neurologiques. Rev. neurol., Par., 1915, p.
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    Rev. neurol., Par., 1914-15, v. 22^2, p. 388.

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    projectiles de guerre. Les différents syndrômes cliniques et
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    =Dejerine et Mouzon.= Un nouveau type de syndrôme sensitif
    cortical dans un cas de monoplégie corticale dissociée. Rev.
    neurol., Par., 1914-15, v. 22^2, pp. 1265-1273.

    =Dejerine et Mouzon.= Le diagnostic de l’interruption complète
    des gros troncs nerveux de membres. Presse méd., Par., 1916, v.
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    =Dejerine, M. and Mme. and Mouzon.= Troubles trophiques
    articulaires analogues à ceux du rhumatisme subaigu et semblant
    consécutif à un tiraillement des racines des plexus brachiaux
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    =Dejerine et Schwartz.= Déformations articulaires analogues
    à celles du rhumatisme chronique, avec troubles trophiques,
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    neuropat. (Psichiat. ed elettro.) Catania, 1917, v. 10, pp.
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    Par., 1916, v. 2, pp. 292-300.

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    rééducation intensive d’après Cl. Vincent. J. de radiol. et
    d’électrol., Par., 1917, v. 2, pp. 531-532.

    =Delherm and Py.= De l’importance de bien différencier les
    manifestations organiques et les manifestations psychiques
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    =Delinquent children and the war.= Brit. M. J., Lond., 1917, i,
    p. 231.

    =Délire raisonnant d’invention.= Ann. méd.-psychol., Par.,
    1917, v. 73, pp. 589-594.

    =De Lisi, L.= Ricerche sperimentali sulle alterazioni nervose
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    v. 73, p. 397.

    =DeMartel, T.= Blessures du crâne. Collection Horizon, Masson
    et Cie, Paris, 1917.

    =De Massary, E., et Du Souich, P.= Syndrôme choréiforme
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    1917, v. 24, pp. 219-221.

    =De Massary, E., et Tockmann.= Un cas de paludisme
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    =Deny, G.= La neuropsychopathologie française pendant une année
    de guerre (août 1914-août 1915). Encéphale, Par., 1914-15, ii,
    pp. 153-174.

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    =Desplates, R., and Buquet, A.= Oblitération des artères
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    =Detecting the pretense of deafness=; tests adopted in France
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    =Devaux et Logue.= Les délires guerriers dans la fièvre
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    =Devaux et Logue.= Les anxieux. 1917, Paris, Masson et Cie.,
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    =Die behauptete Zunahme geistiger Erkrankungen= bei Beginn des
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    =Di Pietro, S.= Pneumotorace curativo o pneumotorace practicato
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    1914-15, v. 8, (sect. laryngol.), pp. 117-120.

    =Discussion on Shell Shock.= Lancet, Lond., 1916, i, p. 306.

    =Discussion on the treatment by physical methods= of mental
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    1917-18, v. 10 (sect. Balneol.), pp. 1-44.

    =Discussion sur les troubles nerveux dits fonctionnels=
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    =Disordered action= of the heart among soldiers. Jour. Lab. and
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    =Disqué.= Behandlung der Kriegsneurosen durch Hypnose,
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    recherches oscillo-métriques pratiquées dans 100 cas de mains
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    =Donath, J.= Schwere Polyneuritis rheumatica der Plexus
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    auditive, lecture sur les lèvres, orthophonie. Rev. scient.,
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    =Drug Habit and Mobilization in France.= Lancet, Lond., 1915,
    i, p. 161.

    =Dub.= Heilung psychogenen Taubheit und Stummheit. Deutsche
    med. Wchnschr., Berl. u. Leipz., 1916, No. 52, pp. 1601-1602.

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    =Duco, A. and Blum, E.= Guide pratique du médecin dans les
    expertises médico-légales militaires. Collection Horizon,
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    =Ducoste.= Les contractures dans les lésions nerveuses
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    p. 435.

    =Ducroquet.= L’ankylose tibio-tarsienne et les troubles
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    =Ducroquet.= Les troubles fonctionnels dans les raideurs et
    les ankyloses douloureuses de l’articulation tibio-tarsienne.
    Presse méd., Par., 1917, v. 25, pp. 597-599.

    =Dufour, Henri.= De l’origine infectieuse de certaines
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    nutrition décelée par l’examen du sang. Presse méd., Par.,
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    =Dumas, R.= Libération des nerfs et recupération fonctionnelle.
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    =Dumas, G. et Aimé, H.= Les troubles mentaux et nerveux dans
    les armées Austro-Allemandes. J. de psychol. norm. et path.,
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    =Dumolard, Rebierre et Quellien.= Réflexes tendineux variables.
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    septic materials used therefor. Pub. Health Rep., Wash., 1917,
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    =Dupouy, Roger.= Notes statistiques et cliniques sur les
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    les expertises en matière d’accidents du travail dont seront
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    =Grasset.= Les névroses et psychonévroses de guerre; conduite à
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    =Guerre et les éclopés psychiques.= Ann. d’Hyg., Par., 1917, v.
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    physique en groupe. Méthode de gymnastique rééducative pour les
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    symptômes méningés consécutive à l’éclatement d’un projectile
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    =Guillain, G.= Sur un cas de mutisme consécutif à l’éclatement
    d’un projectile. Presse Méd., Par., 1915, v. 23, p. 182.

    =Guillain, G.= Un cas de tremblement pseudo-parkinsonien
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    =Guillain, G.= Sur un état de stupeur avec catatonie,
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    =Guillain, G.= Les névrites irradiantes et les contractures
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    =Guillain, G.= Hémiplegie organique consécutive à un éclatement
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    =Guillain, G.= Un syndrôme consécutif à l’éclatement des gros
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    =Guillain et Barré.= Hémorragie méningée consécutive à une
    commotion par éclatement d’obus sans plaie extérieure.
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    dans les commotions par éclatement de gros projectiles sans
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    =Guillain et Barré.= Troubles pyramidaux organiques consécutifs
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    =Guillain et Barré.= Soc. méd. d’hôp. Par., 1916, 21 janvier.

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    =Guillain et Barré.= Les contractures ischémiques. Réunion Méd.
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    =Guillain et Barré.= Forme clinique de la névrite ascendante.
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    =Guillain and Barré.= Deux cas d’astasie-abasie avec troubles
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    =Guillain and Barré.= Apoplexie tardive consécutive à une
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    =Guillain et Barré.= Hémiplégies par blessures de guerre.
    Diagnostic topographique du siège des lésions. Presse méd.,
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    =Guillain et Barré.= Syndrôme d’avellis bilatéral,
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    =Guillain et Barré.= Deux cas d’hémiplégie organique
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    Wien. klin. Wchnschr., 1914, v. 27, pp. 1590-1593.

    =Hadfield, J. A.= Influence of hypnotic suggestion on
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    =Heilig and Sick, P.= Uber Schussverletzungen des Gehirns.
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    =Henderson, Yandell and Seibert, E. G.= Organization and
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    =Hertz, A. F.= (See also Hurst.) Paresis and involuntary
    movements following commotion produced by the bursting of a
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    =Hertz, A. F.= Concussion Blindness. Lancet, 1916, i, p. 15.

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    =Hertz, A. F. and Ormond, A. W.= The treatment of concussion
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    =Hesnard, A.= Un nouvel élément de la réaction de
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    =Hesnard, A.= Un cas d’hémiplégie
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    =Hesnard, A.= Un cas de psychose post-onirique chez un aliéné
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    =Lumsden, T.= Shell Shock. (A letter.) Lancet, Lond., 1917, i,
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    =Mairet et Piéron.= De quelques problèmes posés par la
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    =Mairet et Piéron.= Le syndrôme émotionnel. Sa différenciation
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    =Mairet, A. and Piéron, H.= Le syndrôme commotionnel. _Ibid._,
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    =Mann, L.= Zur Frage der traumatischen Neurosen. Wien. klin.
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    =Mann, Lillienstein, etc.= Discussion; Neurosen nach
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    =Mannell, J. D.= Reëducation in walking. Hospital, Lon., 1917,
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    =Marage, M.= Classement des soldats sourds d’àprès leur degré
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    =Marage.= Traitement de la surdité par commotion. Paris méd.,
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    =Marie, P.= La conduite à tenir vis-à-vis des blessés du crâne.
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    =Marie, P.= Tétanos tardif localisé à type abdominothoracique.
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    =Marie and Benisty.= Individualité clinique des nerfs
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    =Marie and Benisty.= Une forme douloureuse des lésions de nerf
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    =Marie, P. et Chatelin.= Un cas d’hématomyélie par éclatement
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    =Marie, P., Chatelin et Patrikios.= Paralysie générale
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    =Marie, P., Dejerine, Ballet, G., Thomas, A., Dupré, Babinski,
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    =Marie, P. et Foix.= Sur une forme spéciale de parésie
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    =Marie et Foix.= Les syncinésies des hémiplégiques étude
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    =Marie et Foix.= Influence du froid et des troubles vasomoteurs
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    =Marie et Foix.= Indications opératoires fournies par l’examen
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    =Marie et Meige.= Appareils pour blessés nerveux. Académie de
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    =Marie, Meige, et Gosset.= Les localisations motrices dans les
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    =Marie, P. et Mlle. G. Lévy.= Un cas d’hémiplégie organique par
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    =Marie, P., Meige, H., et Béhague, P.= Necessité d’un examen
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    =Mathieu, Albert.= Cause psychique de vomissements excessifs
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    =Meige, H.= Réformes, incapacités, gratifications dans les
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    =Meige, H.= Torticolis convulsif survenu chez un blessé du
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    =Meige, H.= Tremblement, tressaillement, trémophobie
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    =Meige, H.= Les tremblements consécutifs aux explosions
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    =Meige, H.= Sur les accidents nerveux déterminés par la
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    =Meige, H.= Appareil pour redresser les griffes cubitales
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    vasculaires associées aux lésions des nerfs périphériques dans
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    =Meige et Benisty.= Les formes douloureuses des blessures des
    nerfs. Soc. de Neurol., July 1, 1915.

    =Meige et Benisty.= Les signes cliniques des lésions de
    l’appareil sympathique et de l’appareil vasculaire dans les
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    =Meige, H., Benisty, A., et Lévy, G.= Impotence de tous les
    mouvements de la main et des doigts, avec intégrité des
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    =Melocchi, F.= Importanza dei centri fisiatrici di rieducazione
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    =Mental and nervous cases in the war.= Alb. Med. Ann., 1917,
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    =Mental disabilities for war service.= Lancet, Lond., 1916, v.
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    =Mentality (fortitude) of Wounded.= Brit. M. J., Lond., 1915,
    i. p. 980.

    =Menzel.= Mobilisierung in ursächlichem Zusammenhange stehenden
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    =Mériel.= Deux cas de tétanos partiel. Soc. chir., 2 Feb., 1916.

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    =Meyer, E.= Beitrag zur Kenntnis des Einflusses kriegerischer
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    =Meyer, E.= Zwei Soldaten mit psychogenen Störungen. Berl.
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    =Meyer, E.= Krankheitsanlagen und Krankheitsursachen im Gebiete
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    =Military mental cases.= Med. officer, Lond., 1915, v. 14, p.
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    =Military Orthopedic Surgery.= No. 4, Medical Manual War
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    =Military psychiatry.= Bos. M. and S. J., 1918, clxxviii, 98.

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    =Milligan, W.= Treatment of Shell Shock. Brit. M. J., Lond.,
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    =Moll, A.= Psychopathologische Erfahrungen im Kriege. Aerzt.
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    =Morchen.= Traumatische Neurosen und Kriegsgefangene. München.
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    =Morhardt, P. E.= Cure de soleil et chirurgie de guerre. Paris
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    =Moricand, I.= Note sur un cas de paralysie radiale bilatérale
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    =Morcelli, Arturo.= (Psychiatry of War.) Boll. d. r. Accad.
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    =Morselli, A.= Sui fenomeni fisio-patologici da emozione
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    =Morselli, A.= Sugli stati confusionali psichici da guerra.
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    =Mott, F. W.= The microscopic examination of the brains of two
    men dead of commotio cerebri (shell shock) without visible
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    1917, v. 63, pp. 467-488.

    =Mott, F. W.= 1. On war psychoneurosis. 2. The psychology of
    soldiers’ dreams. Lancet, Lond., 1918, i, pp. 169-177.

    =Mott, F. W.= Punctiform hemorrhages of the brain in gas
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    =Mott, F. W.= The Chadwick Lectures on mental hygiene and shell
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    =Mott, F. W.= War psychoneurosis. Lancet, Lon., 1918, i, 127,
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    =Mougeot, A. and Duverger.= Bradycardie et réflexe
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    =Mouriquand.= Sur quelques maladies simulées. Vomissements
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    =Myers, Charles S.= Shell shock. Three cases of loss of memory,
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    =Myers, Charles S.= Shell shock. An account of certain cases
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    =Myers, Charles S.= Shell shock. Certain disorders of
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    =Nageotte, J.= Le processus de la cicatrisation des nerfs. Rev.
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    =Nash, E. H.= Education of the left hand of disabled sailors
    and soldiers. Lancet, Lond., 1917, v. 1, p. 964.

    =Natalelli and Roger, H.= Erythèmes de la face provoqués pour
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    =Naville, F.= Le traitement et la guérison des psychonévroses
    de guerre invétérés à l’hôpital Saint-André de Salins.
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    =Necessité de créer des établissements spéciaux= destinés aux
    invalides nerveux. Rev. neurol. Par., 1916, v. 23, pp. 593-594.

    =Necessité des services de psychiatrie et de médecine légale
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    =Necessité de traiter les plicatures vertébrales
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    =Negro, C.= Annotazione di neurologia di guerra. Gior. d. r.
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    =Neiding, M. N.= (Nervous phenomena accompanying poisoning by
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    =Neilson, W. A.= The Training School of Psychiatric Social Work
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    =Nepper et Vallée.= Recherches comparatives sur les impotences
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    =Nervöse Disposition.= Med. Cor. Bl. d. Württemb. ärztl.
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    =Nervous and mental disease among soldiers.= N. Y. Med. Jour.,
    1917, cvi, 1043.

    =Nervous temperament in war.= Brit. Med. Jour., 1918, i, 649.

    =Netter, F.= L’épilepsie généralisée consécutive aux
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    =Neurasthenia and shell shock.= Lancet, Lond., 1916, i, p. 627.

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    =Notes on hydrological treatment for wounded soldiers and
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    =Rouge, C.= Influence de la guerre actuelle: (1) Sur le
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    =Roussy, G.= Discussion de la conduite à tenir vis-à-vis des
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    =Roussy, G.= Un cas de tumeur de lobe frontal pris cliniquement
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    =Roussy, G.= Des complications pleuro-pulmonaires comme facteur
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    =Rusca, Franchino.= Experimentelle Untersuchungen über die
    traumatischen Druckwirkung der Explosionen. Deutsche Ztschr. f.
    Chir., 1914-15, v. 132, pp. 315-374.

    =Russel, Colin K.= A study of certain psychogenetic conditions
    among soldiers. Canad. Med. Ass. J., Montreal, 1917, v. 7, No.
    8, pp. 704-720.

    =Ryan, E.= A case of shell shock. Canad. Prac. and Rev.,
    Toronto, 1916, v. 41, pp. 507-510. Also Canad. Med. Ass. J.,
    Montreal, 1915, v. 6, pp. 1095-1099.

    =S. (C.)= Le service d’isolement et de psychothérapie à la
    Salpêtrière pour le traitement des militaires atteints de
    troubles fonctionnels du système nerveux. J. de méd. et de
    chir. prat., 1916, lxxxvii, 90-94.

    =S. (C.)= Les blessures indirectes du système nerveux
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    prat., Par., 1916, lxxxvii, 436.

    =Saaler, B.= Ueber nervöse und psychische Krankheiten in ihren
    Beziehungen zum Kriegsdienst. Berl. klin. Wchnschr., 1916,
    liii, 1389.

    =Sabrazis.= Simulation de méningite cérébro-spinale par les
    accidents nerveux du 1914, dans deux cas guérison. Gaz. hebd.
    d. sc. med. de Bordeaux, 1917, v. 38, pp. 134-135.

    =Sainsbury, H.= Treatment of neuritis, with special reference
    to sciatica. Lancet, Lon., 1917, i, 911.

    =Salmon, Thomas W.= Care and treatment of mental diseases of
    war neuroses (“shell shock”) in the British Army. Nat. Com.
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    =Salmon, T. W.= Outline of American plans for dealing with war
    neuroses. War Med., 1918, ii, 34.

    =Salmon, Thomas W.= The care and treatment of mental diseases
    and war neuroses (“shell shock”) in the British Army. Ment.
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    =Salmon, Thomas W.= The use of institutions for the insane as
    military hospitals. Ment. Hyg., Concord, N. H., 1917, v. 7, pp.
    806-812.

    =Salmon, Thomas W.= Recommendations for the treatment of mental
    and nervous diseases in the United States Army. Psychiat.
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    =Samuel.= Neurologische Beobachtungen bei den Truppen. Berl.
    klin. Wchnschr. 1915, v. 52^1, pp. 140-141.

    =Sandberg.= Zwei Fälle von traumatischer Hysterie nach
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    =Sandoz, F.= Le mécanothérapie des raideurs articulaires
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    =Sänger.= Ueber die durch den Krieg bedingten Folgezustände im
    Nervensystem. Deutsche med. Wchnschr., Berl. u. Leipz., 1915,
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    =Sänger and Cimbal.= Nervöse Erkrankungen im Kriege. Deutsche
    med. Wchnschr., Leipz. u. Berl., 1915, v. 41, p. 902; also
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    v. 62^1, p. 230.

    =Sarbó, A.= Ueber die durch Granat- und Schrapnell-explosionen
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    =Sarbó, A. v.= Durch Schrapnel- und Granatexplosion
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    =Savage, George H.= Mental disabilities for war service. J.
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    =Schlayer.= Vorschläge zur Versorgung der funktionellen
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    =Schlendler, L.= Schädelverletzungen. Bruns’ kriegschir. Hefte
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    =Schlesinger, H.= Fall von hochgradiger retrograder Amnesie
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    =Schlesinger, H.= Hochgradige retrograde Amnesie nach
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    =Schlesinger, H.= Epilepsie und Anfall Temperaturerhöhungen.
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    =Schmidt, G. B.= Chirurgische Behandlung der Kriegsverletzungen
    peripherischer Nerven. Deutsche med. Wchnschr., Berl. u.
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    =Schmidt, W.= Die psychischen und nervösen Folgezustände nach
    Granatexplosionen und Minenverschüttungen. Ztschr. f. d. ges.
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    =Schneider, E.= Zur Klinik und Prognose der Kriegsneurosen.
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    =Scholtz, W.= Funktionelle Sprachlähmung im Felde. Med. Klin.,
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    =Schröder, P.= Traumatische Psychosen. Monatschr. f. Psychiat.
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    =Schüller, A.= Pulsus paradoxus respiratorius. Klin. therap.
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    =Schüller, A.= Hypertrichose bei Ischiadicusläsionen. Wiener
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    =Schultz, J. H.= Einige Bemerkungen über Feindschaftsgefühle im
    Felde. Neurol. Centralbl., Leipz., 1915, v. 34, pp. 373-378.

    =Schultz, J. H.= Wege und Ziele der Psychotherapie. Therap.
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    =Schultz, J. H.= Fünf neurologisch bemerkungswerte Hirnschüsse.
    Monatschr. f. Psychiat. u. Neurol., 1916, v. 39, No. 6, p. 319.

    =Schultz, J. H. and Meyer, Robert.= Zur klinischen Analyse der
    Granatschockwirkung. Med. Klin., Berl. u. Wien, 1916, v. 12,
    pp. 230-233.

    =Schultze, Otto.= Ueber die Kaufmanns’sche Behandlung
    hysterischen Bewegungsstörungen. Münch. med. Wchnschr., 1916,
    No. 38, pp. 1349-1353.

    =Schuster.= Kriegsneurologische Demonstrationen. Neurol.
    Centralbl., Leipz., 1915, v. 34, pp. 1914-1916.

    =Schuster.= Crampusneurose. Neurol. Centralbl., Leipz., 1915,
    v. 34, p. 72.

    =Schuster.= Entstehen der traumatischen Neurosen oder
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    =Schuster.= Kriegsneurologische Demonstrationen. Berl. klin.
    Wchnschr., 1916, No. 1, pp. 24-25.

    =Schuster, Bonhoeffer, Oppenheim.= Diskussion--Zerebellare
    Symptomen-Komplexe nach Kriegsverletzungen. Neurol. Centralbl.,
    Leipz., 1915, v. 34, pp. 664-666.

    =Schuster.= Der Mechanismus der hysterischen Skoliose. Neurol.
    Centralbl., Leipz., 37, Nr. 18, 1918.

    =Sebileau, Pierre.= Monoplégie du membre inférieur, conséquence
    d’un coup de feu de la cuisse sans blessure apparente de
    l’appareil d’innervation. Bull. et mém. Soc. de chir. de Par.,
    1914-15, v. 40, pp. 1175-1177.

    =Seelert, H.= Ueber Neurosen nach Unfällen mit besonderer
    Berücksichtigung von Erfahrungen im Kriege. Monatschr. f.
    Psychiat. u. Neurol., Berl., 195, v. 38, pp. 328-340.

    =Seelert, H.= Differentialdiagnose der Hysterie und des
    progressiven Torsionspasmus. Arch. f. Psychiat., Berl., 1918,
    v. 56, pp. 684-688.

    =Seeuwen, H. J.= Heart and active service. Lancet, Lon., 1916,
    ii, 432.

    =Seeuwen, H. J.= Treatment of the wounded by means of
    electricity. Arch. of Radiol. and Electrotherap., 1917, xxii,
    136.

    =Segaloff, T. E.= Contribution à l’étude des lésions organiques
    et fonctionnelles dans les contusions par éclatements d’obus.
    Psychiatrie contemporaine russe, 1015; Revue Neurol. 1914-15,
    II, p. 1081-1082.

    =Segaloff, T. E.= Nature of contusions caused by artillery
    fire. Morbus decompressionis. Sovrem. Psikhiat., Mosk., 1915,
    ix, 103, 263, 405.

    =Segaloff, T. E.= (de Moscou.) Contribution à la connaissance
    de la nature des contusions par les obus actuels. Psychiatrie
    contemp. russe, 1915.

    =Self-mutilation by soldiers.= Brit. M. J., Lond., 1915, i, p.
    899.

    =Sencert, L.= Rupture des deux poumons par le “vent du boulet.”
    Bull. et mém. Soc. de chir. de Par., 1915, v. 41, pp. 79-82.

    =Sensory phenomena in head injuries.= Brit. M. J., Lond., 1915,
    i, p. 738.

    =Seppilli, G.= Guerra e psicopatie. Gazz. med. d. Marche,
    Ancona, 1915, v. 23, No. 6, p. 3.

    =Seppilli, G.= I disturbi mentali nei militari in rapporto alla
    guerra. Riv. ital. di neuropat. etc., Catania, 1917, v. 10, pp.
    105-114; also pp. 137-141.

    =Sereysky, M. J.= (A contribution to the problem of poisoning
    by German asphyxiating gas: Their influence in the nervous
    psychic condition of the asphyxiated.) Russk. Vrach., Petrogr.,
    1917, v. 16, p. 401.

    =Sérieux, P. et Laignel-Lavastine.= Sur utilité de mesures
    spéciales pour les anormaux psychiques constitutionnels en
    temps de guerre. Bull. méd., Par., 1917, v. 31, pp. 11-12.

    =Serog.= Zwei Fälle von krankhafter Selbstbesichtigung der
    Simulation. Med. Klin., Berl., 1916, xii, 1100-1102.

    =Serre, Biron and Brette.= Tentative de fraude au moyen de
    l’ovoalbumine (simulation de l’albuminurie). Arch. de méd. et
    pharm. mil., Par., 1917, lxviii, 935-939.

    =Service d’isolement et de psychothérapie à la Salpêtrière=
    pour le traitement des militaires atteints de troubles
    fonctionnels du système nerveux. J. de méd. et chir. prat.,
    Par., 1916, v. 87, pp. 90-94.

    =Sforza, N.= Le sindromi nervose di commozione da scoppio de
    granata. Med. nuova, Roma, 1916, v. 7, pp. 6-10.

    =Sgobbo, F. P.= La röntgenologia causa di turbamento psichico
    nei militari, ed utile mezzo per la diagnosi di alcuni male
    simulati. Radiol. med., Torino, 1916, v. 3, pp. 313-317.

    =Shaikevich, M. O.= (Neuro-mental disease in time of war and
    its prevention.) Sibirsk. Vrach., Tomsk, 1915, v. 2, pp. 35-39.

    =Shairp, L. V.= The reëducation of disabled soldiers. Am. J.
    Care Cripples, N. Y., 1917, v. 4, pp. 201-211.

    =Shangengberg, E.= (War injuries affecting the voice and
    speech.) Hygiea, Stockholm, 1917, v. 79, p. 49.

    =Sheehan, R.= Malingering in mental disease. U. S. Nav. M.
    Bull., Wash., 1916, x, 646-653.

    =Shell explosions and the special senses.= Lancet, Lond., 1915,
    i, p. 663.

    =Shell shock and neurasthenia.= Lancet, Lond., 1916, i, p. 627.

    =Shell shock.= Am. med., Burlington, Vt., 1917, v. 23, pp.
    606-607.

    =Shell shock among troops.= Bos. M. and S. J., 1918, clxxviii,
    133.

    =Shell shock patients in air raids.= Brit. M. J., Lond., 1918,
    i, p. 90.

    =Shufflebotham, Frank.= The effects of military training upon
    lead workers. Brit. M. J., Lond., 1915, i, p. 672.

    =Shumkoff, G. E.= (Number of the insane in the war.) Psikhiat.
    Gaz., Petrogr., 1915, v. 2, pp. 363-366.

    =Shumkoff, G. E.= (Rapid psychiatric aid in the war.) Psikhiat.
    Gaz., Petrograd, 1916, v. 3, pp. 281-288.

    =Shuttleworth, G.= War and insanity. J. Ment. Sc., Lond., 1916,
    v. 62.

    =Sicard, J. A.= Blessures de guerre. Traitement de certaines
    algies et acrocontractures rebelles par l’alcoolisation
    nerveuse locale. Soc. méd. des Hôpitaux, 17 decembre 1915.

    =Sicard.= Simulateurs de création et simulateurs de fixation.
    Simulateurs sourds-muets. Paris méd., 1915, v. 17 (Part. méd.),
    pp. 423-428.

    =Sicard.= Traitement de la névrite douloureuse du médian
    par l’alcoolisation tronculaire sus-lésionnelle. Soc. Méd.
    de Hôp., July 9, 1915; Traitement de certaines algies et
    acrocontractures rebelles par l’alcoolisation nerveuse locale.
    Ibid., Dec. 17, 1915.

    =Sicard.= Traitement des névrites douloureuses de guerre
    causalgies par l’alcoolisation nerveuse locale. Presse méd.,
    juin, 1916.

    =Sicard.= Examen du liquide céphalo-rachidien au cours des
    commotions par “vent d’explosif.” Paris méd., 1915, v. 17, p.
    556.

    =Sicard.= Plicatures vertébrales par “vent d’obus.” Spondyloses
    et attitudes vertébrales antalgiques. Examen du liquide
    céphalo-rachidien. Soc. méd. des Hôpitaux, 9 juillet, 1915.

    =Sicard.= Spondylites par obusite ou vent d’obus. Attitudes
    vertébrales antalgiques. Bull. et mém. Soc. méd. d. hôp. de
    Paris, 1915, v. 39, p. 582.

    =Sicard.= À propos du procès-verbal et de la communication
    de MM. Souques, Mégévand et Donet sur l’examen du liquide
    céphalo-rachidien (séance du 29 octobre, 1915) au cours des
    commotions par vent d’explosif. Bull. et mém. Soc. méd. d. hôp.
    de Par., 1915, x. s. xxxix, 1034.

    =Sicard.= L’alcoolisation tronculaire au cours des acromyonties
    rebelles du membre supérieur. Paris méd., 1916, v. 19, 509-512.

    =Sicard.= Discussion de la conduite à tenir vis-à-vis des
    blessures du crâne--par P. Marie. Rev. Neurol. Paris, 1916, v.
    29, p. 462.

    =Sicard et Cantaloube.= Les oedèmes de striction. Soc. méd. des
    Hôpitaux, 26 mai 1916.

    =Sicard et Cantaloube.= Les réflexes musculaires du pied et de
    la main (myo-diagnostic mécanique). Presse méd., Par., 1916, v.
    24, pp. 145-147.

    =Sicard et Cantaloube.= Réflexes musculaires pédo-dorsaux. Leur
    valeur diagnostique et pronostique. Soc. de Neurol. 3 février
    1916.

    =Sicard, J. A., Roger, H. and Rimbaud, L.= Syncinésie d’effort;
    réactions syncinétiques par choc du liquide rachidien sur le
    faisceau pyramidal dégéneré. Ibid., 1917, 3. s, xli, 619-622.

    =Siciliano.= Les tropho-névroses traumatiques. Rivista critica
    di clinica medica, Nos. 19, 20 et 21.

    =Signorelli e Buscaino.= Bradicardia e riflesso oculo-cardiaco
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    =Siege, Max.= Typhuspsychosen im Felde. Neurol. Centralbl.,
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    =Silberstein, Adolf.= Kriegsenvalidenfürsorge und staatliche
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    =Silberstein.= The Royal Orthopedic Reserve Hospital at
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    188-191.

    =Silex, P.= Neue Wege in der Kriegsblindfürsorge. 2 Aufl.,
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    =Silver, D.= The function of orthopedic surgery in the present
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    =Similarity of War Neuroses to Accident Neuroses.= Brit. M. J.,
    Lond., 1915, i, p. 1072.

    =Simple method of detecting simulated deafness.= Lancet, Lond.,
    1917, ii, 369.

    =Singer, Kurt.= Wesen und Bedeutung der Kriegspsychosen. Berl.
    klin. Wchnschr., 1915, v. 52, pp. 177-180.

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    =Small, C. P.= Equilibrium tests for aviation recruits. Jour.
    A. M. A., 1917, lxix, 1078.

    =Smirkoff, D.= Deux cas graves de névrose traumatique par
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    Rev. neurol., Par., 1917, v. 24, p. 477.

    =Smith, G. E.= Shock and the soldier. Lancet, Lond., 1916, i,
    pp. 813-817, and pp. 853-857.

    =Smith, G. E. and Pear, T. H.= Shell shock and its lessons.
    Nature, Lond., 1917, v. 100, pp. 64-66.

    =Smith, G. E. and Pear, T. H.= Shell shock and its lessons.
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    =Smith, Percy.= War and insanity. J. Ment. Sc., Lond., 1916, v.
    62, pp. 815-817.

    =Smith, Percy.= Civilian mental disease in wartime. Proc. Roy.
    Soc. Med., Lond., 1916, v. 10, pp. 1-20.

    =Smyly, C. P.= Shell shock. Dublin, J. M. Sc., 1917, v. 142,
    pp. 247-256.

    =Sogenannten funktionellen Nervenerkrankungen der
    Kriegsteilnehmer.= Jahresb. f. ärztl. Fortbild, München, 1915,
    v. 6, pp. 26-27.

    =Soldats aveugles masseurs.= Caducée, Par., 1917, v. 11, p. 12.

    =Soldat mendiant.= Ann. méd. psychol., Par., 1914-1915, v. 6,
    p. 527.

    =Sollier, P.= Discussion de la conduite à tenir vis-à-vis des
    blessures du crâne--par P. Marie. Rev. neurol., Par., 1916, v.
    29, pp. 63-64. Also p. 473.

    =Sollier.= Sur les accidents nerveux déterminés par la
    déflagration de fortes charges d’explosifs. Rev. neurol., Par.,
    1916, v. 29, pp. 575-576.

    =Sollier.= Troubles trophiques osseux dans un cas d’hémiplégie
    hystérique. Lyon méd., 1916, v. 125, pp. 20-21.

    =Sollier.= Impotence fonctionnelle d’origine nerveuse chez les
    blessés de guerre. Bull. Acad. de méd., Par., 1914, v. 72, pp.
    346-347.

    =Sollier.= Trois cas d’hémiplégie hystérique consécutive à des
    lésions craniocérébrales. Lyon méd., 1915, v. 124, p. 334.

    =Sollier.= La neurologie de guerre: Décisions prises aux trois
    réunions des chefs des centres neurologiques. Lyon méd., 1916,
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    =Sollier.= Un cas de canitie par commotion et émotion. Lyon
    méd., 1916, v. 125, p. 329.

    =Sollier.= Persistance des troubles fonctionnelles pendant le
    sommeil. Rev. neurol., Par., 1914-15, v. 22^2, p. 1240.

    =Sollier.= Sur l’abolition du réflexe cutané plantaire dans les
    paralysies ou contractures fonctionnelles. Rev. neurol., Par.,
    1914-15, v. 22^2, pp. 1280-1283.

    =Sollier.= Du diagnostic clinique de l’exagération et de la
    persévérance des troubles nerveux fonctionnelles. Presse méd.,
    Par., 1915, v. 23, pp. 505-507.

    =Sollier.= Statistique des cas de névrose dus à la guerre.
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    =Sollier.= Diagnostic des contractures hystéro-traumatiques et
    des rétractions. Lyon méd., 1917, v. 126, pp. 93-96.

    =Sollier.= Mécanothérapie et rééducation motrice au point de
    vue psycho-physiologique et moral. Paris méd., 1917, No. 38,
    pp. 246-249.

    =Sollier et Chartier.= La commotion par explosifs et ses
    conséquences sur le système nerveux. Paris méd., 1915, v. 17,
    pp. 406-414.

    =Sollier and Jousset, Xavier.= Névrites nitro-phénolées. Lyon
    méd., 1917, v. 126, pp. 187-192.

    =Somen, H.= La pratique du massage. Paris méd., 1915, v. 17,
    pp. 97-103.

    =Somen, H.= Memento de mécanothérapie. Paris, 1916, J. B.
    Ballière et fils, 96 p., 8^o.

    =Sommer, R.= Krieg und Seelenleben--Einfluss des Krieges auf
    das normale Seelenleben. Wien. med. Wchnschr., 1915, No. 40, p.
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    =Soulié, A.= Les nerfs. In Poirier, tome iii, fasc. 3.

    =Souttar, H. S.= Some points in nerve injuries. Brit. M. J.,
    Lond., 1917, ii, pp. 817-820.

    =Soukhanoff, S. A.= De la conviction délirante d’être
    prisonnier de guerre; contribution à l’étude des troubles
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    =Soukhanoff, S. A.= Des psychonévroses traumatiques de
    guerre. Assemblée scientifique des médecins de l’hôpital
    de Notre-Dame-des-Affligés pour les alienés et de l’asile
    Novoznamenskaia, à Petrograd, avril 1915.

    =Soukhanoff, S. A.= Psychopathy in time of war. Russk. Vrach.,
    Petrogr., 1915, xiv, 800-804.

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    =Zange, Johannes.= Die organischen Schädigungen des nervösen
    Ohrapparates im Kriege. Deutsche med. Wchnschr., Berl. u.
    Leipz., 1915, v. 41^2, p. 994.

    =Zangger.= Welche medizinischen Erfahrungen bei Katastrophen
    können im heutiger Kriege verwertet werden? Cor. Bl. f.
    Schweiz. Aerzte, 1915, v. 45, pp. 190-191.

    =Zangger, H.= Zur Frage der traumatischen Neurose. Zentralbl.
    f. Gewerbehyg., Berl., 1916, v. 4, p. 10; pp. 25-32.

    =Zanietowski, J.= Die moderne Elektromedizin in der
    Kriegstherapie. Wien. klin. Wchnschr., 1915, v. 28, p. 805, p.
    810, p. 838.

    =Zimmern, A.= Quels enseignements nous fournit la réaction de
    dégénérescence dans les blessures des nerfs. Presse méd., April
    15, 1915.

    =Zimmern, A. et Logre, B.= Sur le réflexe galvano-psychique.
    Rev. neurol., Par., 1917, v. 24, pp. 565-567; also Jour. de
    Radiol. et d’Electrol., v. 2, No. 10, 1917, juillet-août, p.
    610.

    =Zimmern, A. et Logre, B.= Sur le réflexe galvano-psychique.
    Presse méd., Par., 1917, v. 25, p. 414.

    =Zimmern et Perol.= Electrodiagnostie de guerre. Collection
    Horizon, Masson et Cie, 1917.

    =Zoroastroff, A. V.= (Malingering with a view to avoiding
    military service). Voyenno-Med. J., Petrogr., 1915, v. 243, pp.
    473-475.

    =Zuccari, G.= Alcuni casi di psicosi da guerra. Riv. di
    psicol., Bologna, 1916, v. 12, pp. 129-140.

    =Zunahme geistiger Erkrankungen=, Die behauptete, bei Beginn
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    167-170.




INDEX


  Abderhalden test, 219.

  Abdominothoracic tetanus, =Case= =403=.

  Aboulia, 719.

  Abrahams, 639, 640, 769, =Case= =236=.

  Accommodation paresis, 612.

  Acrocontracture, =Cases= =235=, =428=, =486=, =489=, =529=
     (bayonet clutch), =530=.

  Acroparalysis, =Cases= =250=, =428=.

  Acroparesthesia, 845, =Case= =132=.

  Acoumeter, 809.

  Addison’s disease, 239.

  Adiadochokinesis, 301.

  Adrenalin, 229, 239, 689.

  Adrian and Yealland, 674, 702, 797, =Cases= =563=, =564=.

  Ageusia, 375.

  Agoraphobia, 260, 763.

  Agraphia, =Cases= =220=.

  Aimé, 672, 689.

  Albumin in spinal fluid, 280.

  Albuminuria, question of hysterical, 535.

  Alcoholism (see Pharmacopsychoses, dipsomania), 58, 113-130, 459, 589,
     668, 768, 800, 874, =Cases= =86-97=, BIB., 907, 910, 912, 964.

  Alcoholism, experimental, 118.

  Alexia, 161.

  Alquier, 196.

  Amaurosis (see Ophthalmology).

  Amblyopia, 374, 609-610. BIB., 959.

  Amentia, 360.

  Amnesia, 303, 392, 435, 441, 444, 453, 462, 467, 477, 487, 488, 492,
     499, 634 (recurrent), 635, 676, 734, 739, 757, 828. BIB., 932,
     955, 958, 968.

  Amnesia, in malaria, =Case= =129=. BIB., 923.

  Amyotrophy, 719, 761.

  Analgesia, 252, 253, 483, 567.

  Anaphylaxis, 114, 329, 414, 464.

  Anemia, capillary, 265.

  Aneroid, 275.

  Anesthesia, 253, 262, 277, 292, 320, 452, 483, 498, 538, 544, 568, 575,
     577, 685, 744, 771, 783, 800, 824, 827, 872. BIB., 918, 961.

  Anesthesia, corneal, in normal persons, 610.

  Anesthesia _en lunettes_, 610.

  Anesthesia, reëducation of, 568.

  Anesthesia, sexual parts, 531, 533.

  Ankle-jerk, 585. BIB., 906, 916.

  Ankylosis, BIB., 925.

  Anonymous, =Case= =481=.

  Anorexia, BIB., 975.

  Anosmia, 301, 580.

  Antagonist muscles, 353, 355, 545.

  Antagonist muscles in contraction, 350.

  Antalgic reaction, 525.

  Anterior horn cell shock, 526.

  Antebellum experiences repeated in shell-shock hysteria, 876, =Cases=
     =286-301=, =397=, =532=, =537=, =576=.

  Antityphoid inoculation, 842, =Cases= =65=, =180=, =303=.

  Anuria, 535.

  Anxiety neurosis, 110, 260, 457. BIB., 910, 924, 925, 927, 963.

  Aphasia, 159-161, 874, =Case= =103=, BIB., 910, 928, 929, 950, 961, 981.

  Aphasia, hysterical, non-existent, 454, 766.

  Aphonia, 370, 725, 727, 816. BIB., 931, 932, 940, 953, 957, 959, 963,
     975, 978, 980.

  Apoplexy, BIB., 936.

  Apraxia, BIB., 928, 936.

  Aprosexia, 487, 632, 637.

  Argyll-Robertson sign inverted (Sollier), 612

  Arinstein, 716, 746. =Cases= =212=, =249=, =551=, =554=, =555=, =588=.

  Arnoux, 270.

  Armstrong-Jones, 526.

  Arrangement of cases (see Shell-shock, general arrangement of cases).

  Arteriosclerosis, 225, 866. BIB., 919.

  Arthritics, 231.

  Arthritis, 325.

  Association-experiment, BIB., 927.

  Association of hysterical and other symptoms (see _passim_), 522, 523,
     especially 530-534.

  Association of hysteric, reflex, and organic conditions, 605.

  Astasia-abasia, 282, 312, 362, =Cases= =246=, =247=, =348=, =402=, =512=,
     =533=, =569=, =576=. BIB., 934, 973.

  Asymmetry of reflexes, chloroform, 594.

  Athanassio-Benisty, 540, 556.

  Athetosis, 876, =Case= =113=.

  “Atmosphere of cure,” 728.

  Atrocities, 860, =Cases= =94=, =95=.

  Atrophy, “reflex,” 545.

  Aura, 98, 626.

  Autobiographical statements of soldiers, =Cases= =121=, =209=, =216=,
     =217=, =226=, =227=, =341=, =344=, =361=, =364=, =463=, =527=,
     =528=, =575=.

  Autocritique, 63.

  Autofixity, 369.

  Autognosis, 702, 859, 901.

  Autokratow, 9, 469.

  Automatism, 431, 734.

  Autopsies, =Cases= =110=, =118=, =133=, =197=, =198=, =199=, =200=,
     =201=.

  Auto-suggestion, frontispiece, 95, 98, 109, 153, 395, 498, 543, 577,
     674, 738, 748.

  Aviation (see also Otology), 275, 489, 823. BIB., 907, 930, 938, 945,
     959, 960, 964, 970, 973.


  Babinski, 157, 395, 401, 454, 456, 469, 481, 491, 498, 535, 543, 544,
    554, 563, 566, 568, 569, 576, 578, 603, 604, 605, 643, 647, 671, 723,
    746, 748, 788, 819, 833, 848, 856, 857, 871, 874, 877, 878, 891, 896,
    =Cases= =871=, =877=, =878=, =891=, =896=.

  Babinski reflex, 280.

  Babinski-Weil test, 621.

  Babinski and Froment, 389, 390, 585, 607, 608, 695, 696, 717, 719, 742,
    787, =Cases= =274=, =275=, =276=, =422-426=.

  Babonneix and Célos, =Case= =145=.

  Babonneix and David, =Cases= =16=, =17=, =30=.

  “Bait” for hysteria, 544.

  Baldwin, 374.

  Ballard, 675, 689, 736, 840, =Cases= =82-84=.

  Ballet, 465, 554, 643, =Cases= =267=, =396=, =407=.

  Ballet and de Fursac, 404, 472, 675.

  Barany, 624. BIB., 907, 909.

  Barat, =Case= =75=.

  Batten, =Cases= =113=, =222=, =227=, =589=.

  Battle hypnosis, 638.

  Beaton, 9, =Case= =5=.

  Bechterew, 342.

  Beck, =Case= =439=.

  “Bends,” 275.

  Benisty, 331.

  Bennati, 414, =Cases= =186=, =221=, =320=, =336=.

  Benon, 633.

  “Bent-back” (see Camptocormia).

  Bérard, 118, 696.

  Bergonié, 790.

  Bernheim, 95, 740, 902.

  “Big belly” (see Pregnancy, hysterical).

  Bilateral symptoms, 362.

  Binswanger, =Cases= =179=, =217=, =220=, =229=, =233=, =239=, =309=,
    =327=, =368=, =483=, =505=, =549=, =575=, =576=, =577=, =579=, =587=.

  Biological principles and neuroses, BIB. 915.

  Birdlike movements, 487, 632, 637.

  Birnbaum, 222.

  Bispham, 644.

  Bladder, 276, 284, 294.

  Blässig, =Case= =264=.

  Blepharospasm, =Case= =211=. BIB. 931.

  Blepharospasm, 372, 374.

  Blin, =Case= =131=.

  Blindness, =Cases= =29=, =208-272=, =296=, =297=, =433=, =517=, =521=,
    =537=, =538=. BIB., 915, 921, 928, 935, 943, 952, 958, 974, 976.

  Blindness, cortical, =Case= =105=.

  Block (see Inhibition).

  Blood, buffer salts, 640.

  Blood pressure high, 497. BIB. 232.

  Blood pressure low, 225, 228, 231, 239, 260, 690, 851. BIB. 232.

  Blum, 661.

  Bolshevist, 249.

  Bonhoeffer, 31, 82, 83, 222, 700, =Cases= =54=, =55=, =57=, =65=, =58=,
    =70=, =71=, =76=, =147=, =155=, =158=, =340=.

  Bonnet’s sign, 452.

  Boschi, 704, 716.

  Boucherot, 36, =Cases= =6=, =18=, =86=, =149=, =163=.

  Bouquet, =Case= =419=.

  Bourgeois and Sourdille, 620, 623, 809.

  Brachial plexus palsy, 353, 566, 611.

  Brachial symptoms (see Monoplegia).

  Brain abscess, =Case= =110=.

  “Brain fag,” 104.

  Brain injury, 67, 265, 270. BIB. 915.

  Brain tumor. BIB. 919 (third ventricle).

  Brasch, 41, 689.

  Bravery, psychopathic, 859, =Case= =36=.

  Briand, =Case= =1=, =40=, =43=, =99=, =100=, =101=, =102=.

  Briand and Haury, =Cases= =98=, =467=.

  Briand and Kalt, =Case= =461=.

  Briand and Philippe, 683, =Case= =578=.

  Broca, 160-161.

  Bronchopneumonia, 845.

  Brown, 412, 470, 901, =Case= =496=.

  Brown-Séquard, 89, 528, 555, 843.

  Bruce, 716, 724, 769, =Cases= =521=, =553=.

  Bulbar syndrome, BIB. 910.

  Burial, 334, 349, 373, 393, 396, 405, 419, 435, 457, 499, 512, 573, 682,
    696, 698, 768, 779, 796, 814, 819.

  Bury, 228.

  Buscaino and Coppola, 205, =Cases= =34=, =188=, =189=, =190=, =370=.

  Butenko, 222.

  Buzzard, 668 (chart), 791, =Cases= =380=, =381=, =513=.


  Caisson disease, 275.

  Campbell, A. W., 669.

  Campbell, H., 373, 704.

  Camptocormia, 525, 529, =Cases= =242-245=, =322=, =385=, =401=, =572=,
    =584=. BIB. 938, 950, 951, 956, 965, 972.

  Canities, =Cases= =211=, =212=, =540=. BIB. 943, 971, 974.

  Cargill, =Case= =418=.

  Carlill, =Case= =130=.

  Carlill, Fildes, Baker, =Case= =2=.

  Cassirer, =Case= =398=.

  Catalepsy, local, 544, 551, 552. BIB. 916 (post mortem), 942.

  Catatonia, 485. BIB. 928.

  Catiemophrenosis, 479.

  Cauda equina, 533, 540.

  Causes (see Shell-shock, nature and causes).

  Cellulitis, 764.

  Celluloid obturators, 813.

  Central gyrus lesions, 160.

  Cephalad arrangement of Shell-shock cases, 852.

  Cephalea, 490.

  Cerebellar symptoms, =Cases= =375=, =398=.

  Cerebellum, 268, 296, 300.

  Cerebrospinal fluid (see Spinal fluid).

  Cerumen, 813.

  Cestex, 366.

  Chaplin, Charlie, 672, 894.

  Character (see also Psychology). BIB. 921.

  Charcot, 348, 454, 531, 544, 545, 569, 572, 618, 719, especially 744 and
    833, 848, 867, 891.

  Charon and Halberstadt, =Case= =318=.

  Charpentier, 608, 696.

  Chartier, =Case= =257=.

  Chavigny, 115, 223, 275, 460, 487, 568, 637, 656, 680, 723, 738, 740,
    886, =Cases= =198=, =400=, =446=.

  Chemical warfare, 321, 574, 799, 889, =Cases= =215=, =216=, =232=, =284=,
    =314=, =318=, =360=, =367=, =452=, =586=. BIB. 956, 962, 969, 980.

  Children (delinquent and the War). BIB. 923, 943.

  Chloroform (Babinski’s experiments), 380, 388, 545, 554, especially
    592-597, 608.

  Chorea, 421, =Cases= =14=, =224=, =300=. BIB. 924, 933.

  Chromatolysis of nerve-cells, 265, 884, 885.

  _Cintrage_ (see Camptocormia).

  Civilians, psychiatry of, BIB. 915, 924, 952, 953, 965, 981, 982.

  Clarke, =Cases= =67=, =394=.

  Clarke, Michell, 701.

  Claude, 693, 979, =Cases= =560=, =561=, =573=.

  Claude, Dide, and Lejonne, 509, =Case= =331=.

  Claude and Lhermitte, 275, =Cases= =120=, =200=, =214=, =375=.

  Claude, Lhermitte, Vigouroux, =Case= =159=.

  Claustrophobia, =Case= =182=. BIB. 964.

  Clavus hystericus, 349.

  Claw foot, 698.

  Clunet, 456.

  Colchicum, 239.

  Colin and Lautier, 260, =Cases= =32=, =195=.

  Colin, Lautier, Magnac, 46.

  Collie, =Cases= =458=, =472=.

  _Commotio cerebri_ (see also Brain), 134, 260, 366, 490, 524, 699, 888.

  _Commotio spinalis_, 335, 528-534.

  Compensation (see also Simulation), 14, 28, 482, 666, 837, =Cases= =3=,
    =7=, =8=, =22=. BIB. 910, 911, 912.

  Concussion deafness, 364.

  Conditioned reflex, 445, 467, 495, 530, 613, 622.

  Confusion, 483, 484, 487, 492, 509, 637. BIB. 916, 925, 948, 954, 963.

  Consiglio, 36, =Cases= =63=, =150=, =180=, =191=, =367=.

  Constriction edema (see also Edema), 569.

  Contracture, 282, 318, 525, 529, 545, 569, =Cases= =489-493= (Treatment
    by induced fatigue) and _passim_. BIB. 921, 926, 933, 939, 944, 947,
    956, 962, 963, 971, 972.

  _Contrecoup_, 873, 887, =Case= =103=.

  Conversion-hysteria, 405, 823.

  Convulsions, 706, 759, 762, 820 (see Hysteria, Epilepsy). BIB. 941.

  Convulsions after inoculation, =Cases= =63=, =65=.

  Corpse-contacts, 262, 375, 467, 476, 491, 716 (no redeeming feature).

  Cortical blindness, =Case= =105=.

  Cottet, =Case= =132=.

  Coughing, 425.

  Courtois-Suffit and Giroux, 164.

  Crabtree, 759.

  Craig, 644, 716.

  _Crampusneurose_, 409, 588. BIB. 968.

  Cranial nerves, 378.

  Crile, 269.

  Criminality (see also Medico-legal, Simulation, etc.). BIB. 920, 921.

  Crises (see Emotional crises), 548.

  Crouzon, 373, 851, =Cases= =177=, =433=.

  Crutch-paralysis, 324, 605, 833.

  Cyclothymoses (Manic-Depressive group), 865-867, =Cases= =163-169=.


  D.A.H. (see Soldiers’ heart).

  Damaye, 153, 896.

  Dawson, =Case= =552=.

  Deaf-mutism, 362, 405, 767, 815, =Cases= =497-499=, =514=, =515=, =517=,
    =552=, =557=, =558=, =580=, =585=, =588=. BIB. 911, 914, 937.

  Deafmutism, cure, 672, 681, 721, 734, 775, 776, 781. BIB. 925, 946, 948,
    950, 960, 965.

  Deafness, 813, 888, =Cases= =259-267=, =514=, =515=, =522=. (See also
    Otology), BIB. 913, 915, 916, 917, 924, 927, 932, 933, 937, 942, 945,
    954, 962, 974, 979.

  Death, delusion, 405.

  DeBrun, =Case= =129=.

  Decubitus, 285, 527, 533.

  DeFursac, =Case= =302=.

  Dejerine, 528, 538, 648, 740, 819, 886, 900, 901, =Cases= =288=, =289=,
    =412=.

  Dejerine and Gascuel, =Case= =143=.

  De la Motte, =Cases= =152=, =234=.

  Delherm, =Cases= =431=, =432=.

  Deliria (see also Oniric), 488. BIB. 919, 924, 925, 929, 942, 971.

  Delirium, oniric (see Oniric delirium).

  Delusions, influenced by war, 214, 702, 863.

  DeMassary and Du Sonich, =Case= =14=.

  Dementia praecox (see Schizophrenoses), 861, =Cases= =147-162=. BIB. 935,
    939, 957, 958.

  Denechau and Matrais, 479.

  Dentistry (see teeth).

  Depressions (see also Cyclothymoses), 714.

  Dercum’s disease, 846, =Case= =141=. BIB. 936.

  Dermatology, 331, 358, 361, 362, 535 (see also Hypertrichosis). BIB.
    914, 921, 922.

  Desertion, =Cases= =1=, =12=, =45=, =52=, =56=, =58=, =88=, =90=, =92=,
    =149=, =150=. BIB. 923, 924.

  Determination of symptoms to parts of body, 459, 359, 360, 362.

  Diabetes mellitus, 846, =Case= =140=.

  Diagnosis, delimitation, 834-847.

  _Diagnosis per exclusionem in ordine_, 847, 871.

  Diagnosis, Shell-shock, differentiation, 871-880. BIB. 923.

  Diagnosis: Shell-shock, 2, 3, =Cases= =371-422= and _passim_. BIB. 942.

  Diathermia, 166, 607, 896.

  Dichroism, spinal fluid, 283.

  Dide, 456.

  Dietotherapy, 476, 674, 675, 701.

  Dieulafoy, 373, 609.

  Diphtheria, 845, =Cases= =127=, =128=. BIB. 931, 953, 962.

  Diplegia, facial, BIB. 909, 958.

  Diplopia, monocular, 427, 613, 827.

  Dipsomania, BIB. 917.

  Disciplinary (see Medicolegal).

  Disgust (see also Corpse-contacts), 262, 375, 467, 476, 491, 519, 855.

  Dissociation of personality, =Case= =369=.

  Dissociation of sensations, 570.

  “Doll’s head” anesthesia, 744.

  Donath, =Cases= =20=, =306=, =362=.

  Dubois, 716, 740, 819.

  Dreams, hunger and thirst, 475.

  Dreams, smell, 476.

  Dreams (see also Oniric delirium), 470, 477, 503, 582, 713, 716, 728,
    732, 756. BIB. 947, 955.

  Dromomania (see also Fugue), =Case= =191=.

  Duco and Blum, =Case= =22=.

  Dumas, 637.

  Dumesnil, =Cases= =167=, =168=, =185=.

  Dumolard, Rebierre, Quellien, =Case= =110=.

  Dupouy, =Cases= =161=, =300=, =377=.

  Duprat, 896, 899, =Cases= =51=, =346=, =442=, =443=.

  Dupré, 437, 459.

  Duprés and Rist, =Case= =292=.

  Duret and Michel, 273.

  Duvernay, 554, =Case= =486=.

  Dynamopathic, 856, 871.

  Dysarthria, 159, 356.

  Dysbasia (see _passim_), 560, =Cases= =248=, =278=; _especially_
    =397-400=; =537=, =547=, =560=, =561=. BIB. 941.

  Dysentery, 586, 705.

  Dysentery, psychosis, =Case= =122=.

  Dyskinesia, 633.

  Dysmnesia, 637.


  Ear, injuries of (see also Otology), BIB. 929, 932, 937, 940, 943, 948,
    949, 955, 957, 962, 981.

  “Earthquake hysterias,” 881.

  Ecmnesia, 438.

  Eczema, 429.

  Edema, hysterical, 535, 569, 646, 663. BIB. 909, 942, 943.

  Eder, 702, 740, 750, 891, =Cases= =178=, =296=, =359=, =529=, =544=.

  Edinger, 414.

  “Effectives,” military, 56, 161.

  Elective exaggeration of reflexes, 380 (see Physiopathic).

  Electrotherapy (see also Treatment, psychoelectric), BIB. 916.

  Elliot, =Cases= =210=, =237=.

  Embolism (see Fat, Gas).

  Emotion, 266, 348, 413, 539, 559, 582, 589, 635, 679, 701, 706, 713, 735,
    (B group, emotional, Myers), 808, 900. BIB. 909, 919, 920, 923, 926,
    939, 941, 944, 947, 948, 954, 955, 958, 963, 964, 965, 968, 976, 978.

  Emotion and epilepsy, 97, 413, =Cases= =85=, =302=.

  Emotional crises, 453, 455.

  Emotional factors absent, =Case= =239=.

  Emotional shock, =Cases= =334-339=, =343=. BIB. 928.

  Encephalitis (alcoholic?), 459.

  Encephalopsychoses (focal brain group of mental diseases), 490, =Cases=
    =103-121=.

  Enterospasm, BIB. 928.

  Enuresis, 70, 252, =Cases= =51=, =61=. BIB. 964, 967.

  Epilepsy, see Epileptoses.

  Epilepsy, “affect,” 97.

  Epilepsy, Brown-Séquard’s, =Case= =69=. BIB. 947.

  Epilepsy, hysterical, treatment of, 628. BIB. 938.

  Epilepsy and inoculation (see Convulsions).

  Epilepsy, Jacksonian, 158, =Cases= =66=, =105=, =441= (hysterical), =547=
    (same). BIB. 916, 922, 925, 938, 944, 965.

  Epilepsy, _larvata_, 73, =Case= =81=.

  Epilepsy, late, 93.

  Epilepsy, pleural, 187.

  Epilepsy, “reactive,” 70, 102, =Cases= =57=, =70=, =76=. BIB. 933.

  Epileptic equivalents, 112, 488, 490.

  Epileptoses (Epileptic Group), 675, 699, 839-843, =Cases= =53-85=. BIB.
    905, 910, 911, 937, 938, 939, 945, 947, 956, 961, 968, 972, 973, 975,
    977.

  Equilibrium-tests (see Otology).

  Erb’s palsy, 598.

  Ereutophobia, 432.

  Erichsen, 544.

  Erythromelalgia, BIB. 916.

  Eschars, 285.

  Eschbach and Lacaze, =Case= =108=.

  Espionage, 126, 201.

  _États commotionnels_, 832.

  _États émotionnels_, 832.

  _États seconds_, 72, 108, 530.

  Etiology (see Shell-shock, Nature and causes).

  Ether _versus_ chloroform, 769.

  “Excommunication” by inhibition, 369, 403.

  Exhaustion, 102, 228, 469, 482, 689, 699.

  Experimental work, 294.

  Explosive diathesis, 700.

  Explosives, high, 115, 266, 294, 295.

  Exposure, 519, =Case= =239=.

  Eye (see also Ophthalmology), BIB. 932, 934, 940, 941, 962, 964.

  Eye, functional cases, =Cases= =432-437=.


  Facial paralysis, 530.

  Facial spasm, =Case= =306=.

  Facies, deafmutism, 815.

  Faradism (see Treatment, Shell-shock neuroses, Psychoelectric).

  Farrar, =Case= =8=.

  Fat embolism, 24.

  Fatigue, 225, 231, 375, 448, 469, 498, 502, 557, 639, 689, 708, 855, 900.
    BIB. 907, 924, 929, 931, 937, 941, 943, 948, 964, 975.

  Fatigue, induced (see Treatment).

  Fauntleroy, 275.

  Fear, 64, 223, 258, 338, 375, 404, 425, 440, 441, 451, 466, 519, 675,
    855. BIB. 907, 958.

  Fearnsides, 12.

  Feeblemindedness, 857, =Cases= =35-52=.

  Feebleminded, of use in army, 48, =Cases= =35=, =37=, =41=.

  Feiling, 750, 775, =Case= =369=.

  Ferrand, 390, =Case= =567=.

  Finger-prints, BIB. 916.

  First name extraordinary, =Case= =48=.

  Fluorescein test, 372.

  Focal brain lesions with mental disease, =Cases= =103-121= (see also
    under Encephalopsychoses).

  Foix, 159.

  Formulae of Shell-shock, 4, 5, chart 2 (page 6), chart 3 (page 7).

  Forster, 348, 349.

  Forsyth, 702, =Cases= =286=, =297=.

  Foucault, 405, 561.

  Fractures, BIB. 906.

  Fraser, 364.

  Freud, 39, 702, 716.

  Friedmann, 843, =Case= =77=.

  Friedreich’s disease, 551.

  Froment (see also Babinski and Froment), =Case= =203=.

  _Fugue à deux_, 235.

  Fugue, alcoholic, 841, =Case= =88=.

  Fugue, catatonic, 202, =Case= =149=.

  Fugue, emotional, =Cases= =43=, =52=, =75=.

  Fugue, epileptic, 72, 841, =Cases= =58=, =61=, =62=, =75=. BIB. 977.

  Fugue, hysterical, 850, =Cases= =171=, =173=, =368=, =444=.

  Fugue, melancholic, =Case= =164=.

  Fugue, obsessive, =Case= =445=.

  Fugue and oniric delirium, 471, 569. BIB. 914, 917, 948.

  Furloughs, 685. BIB. 919.


  Gaillard, =Case= =137=.

  Gait disorder (see Astasia-abasia, Dysbasia).

  Gallavardin, 641.

  Galvanism, (see Treatment, Shell-shock, Neurosis, Psychoelectric).

  Ganser symptom, 212, 213.

  Garel, 723, =Case= =581=.

  Gas embolism, 270.

  Gassing (see Chemical warfare).

  Gastroenterology (see Stomach).

  Gastropaths, 400.

  Gaucher and Klein, =Case= =313=.

  Gault’s cochleopalpebral reflex, 624.

  Gaupp, =Cases= =226=, =259=, =317=, =334=, =353=, =359=, =449=, =469=.

  Gayet, 26.

  General paresis, 9, 18, 223, =Cases= =2=, =6=, =9=, =12=, =15=. BIB. 924,
    946, 947, 949, 953, 958.

  Genito-urinary, 260.

  Genito-urinary disorder, see Urology.

  Geriopsychoses (senile-senescent group), 200, 225, 262.

  Gerver, 31, =Cases= =157=, =166=, =255=, =257=, =258=, =347=, =350=,
    =351=, =352=.

  Giles, =Cases= =466=, =474=.

  Gilles de la Tourette, 18.

  Ginestous, =Case= =268=.

  Gleboff, 644, 663.

  Glueck, 667.

  Glycosuria, BIB. 919.

  Goldstein, 723, 728.

  Gonorrhœa, 41, 260, 261.

  Gordon sign, 157.

  Gosset, 624.

  Gougerot and Charpentier, =Cases= =428=, =429=, =430=.

  Gradenigo, =Cases= =465=, =557=.

  Grandclaude, 486.

  Grant, Dundas, 683, 738, 809.

  Grasset, 405, 501, 522, 523, 638, 724.

  Gray hair (see Canities).

  Green, =Case= =169=.

  Greenlees, =Case= =269=.

  Grenier de Cardenal, Legrand, Benoit, =Case= =118=.

  Grünbaum, =Case= =532=.

  Guillain, 281, 421, 746, =Case= =372=.

  Guillain and Barré, =Cases= =31=, =112=, =382=, =384=, =402=.

  Gunshot head wounds, see especially under Encephalopsychoses.


  Hahn, 222.

  Hair (see Canities, Hypertrichosis).

  Hallucinations. BIB. 944, 948.

  Hallucinations, auditory, 367, 371, 431, 484, 493. BIB. 913.

  Hallucinations, experimental, 460.

  Hallucinations, Lilliputian, =Case= =106=.

  Hallucinations, pain and temperature, 452.

  Hallucinations, smell, 478.

  Hallucinations, tetanus, 164.

  Hallucinations, visual, 485, =Case= =159=.

  Harris, 404, =Case= =565=.

  Harwood, =Case= =436=.

  Haury, =Cases= =46=, =154=.

  Head, Henry, 641.

  Headache, 255, 258, 524, 525, 526.

  Head injury (see also cases under Encephalopsychoses wounds), BIB. 905,
    906, 907, 912, 913.

  Head sensations, 321, 490.

  Heart, neurosis, 35, 400, 477, 689, 764 (see also Soldiers’ heart,
    Precordial sensations). BIB. 909, 914, 927, 929, 930, 931, 934, 936,
    937, 945, 950, 951, 959, 968, 969, 974, 975, 976, 977.

  Heat stroke, 447.

  Hecht, 838.

  Heilbronner’s sign, 157.

  Heitz, =Case= =134=.

  Heliotherapy, BIB. 954.

  Helmet, BIB. 916.

  Hemeralopia (see night-blindness).

  Hematology (see Blood).

  Hematomyelia, 277, 284, 286, 555, 570.

  Hemeralopia, BIB. 907, 914, 927, 929.

  Hemiageusia, 476.

  Hemianosmia, 476.

  Hemianesthesia, 876, =Cases= =114=, =218=, =255=, =376=, =380=, =554=.
    BIB. 958.

  Hemianopsia, 428, 616. BIB. 930, 931, 953, 974, 977.

  Hemicontracture, 529.

  Hemichorea, 411.

  Hemiplegia, 282, 293, 302, 874, especially, 877, =Cases= =255=, =256=,
    =281=, =291=, =292=, =372=, =408=, =412=, =551=, =554=. BIB. 926, 931,
    934, 936, 943, 945, 946, 949, 953, 958, 959, 960, 964, 966, 971, 977.

  Hemiplegia, organic, minor signs of, 157. BIB. 925, 933, 950.

  Hemorrhages of brain, 265, 270. BIB. 955.

  Hemorrhage, bladder, =Case= =202=.

  Hemorrhages, meningeal, 270, 271, 372. BIB. 933.

  Hemorrhages, naso-pharyngeal. BIB. 921.

  Hemorrhages of skin, 358, 362.

  Hemorrhage, spinal, 888, =Cases= =202=, =372=.

  Henderson, =Case= =183=.

  Heredity, 289, 401, 418, 419, 668, 812.

  Heredity and acquired soil absent in Shell-shock, 348, 349, 401, 418,
    419.

  Herpes, 288.

  Hesnard, 212.

  Heterosuggestion--frontispiece, 109, 153, 395, 674, 676, 767, 777, 794,
    901.

  Hewat, =Cases= =53=, =299=, =571=.

  Hippus, 87.

  Hirschfeld, =Case= =484=.

  Histology, 265, 271, 272.

  Hollande and Marchand, =Case= =141=.

  Homosexuality, 257.

  “Honeymoon” psychotherapy, 899.

  Hoover’s sign, 157.

  Horse (in the unconscious), =Case= =359=.

  Hospital organization, 896. BIB. 907.

  Hoven, =Cases= =156=, =183=, =333=.

  Howland, 748.

  Hunger dreams, 475.

  Hunter, John, 608.

  Hurst, 91, 736, =Cases= =4=, =15=, =24=, =25=, =64=, =72=, =78=, =80=,
    =238=, =378=, =399=, =501=, =514=, =527=, =538=, =543=, =548=.

  Hydrophobia, =Case= =118=.

  Hydrotherapy (see Treatment), BIB. 905, 906, 911, 929, 936.

  Hyperalbuminosis (see Spinal fluid), =Cases= =371=, =373=.

  Hyperalgesia, 288, 299, 579, 583. BIB. 951.

  Hyperacusis, 367.

  Hyperboulia, 859.

  Hyperesthesia, 267, 700, =Cases= =221=, =223=, =262=, =383=. BIB. 960.

  Hyperreflexia, hysterical, 535.

  Hypersensitive phase (see Anaphylaxis).

  Hypertension, spinal fluid, 282, 283.

  Hyperthyroidism, 361, 639, 640, 760, 844, 846, 866, =Cases= =142-145=,
    =315=, =326=, =497=. BIB. 939, 965.

  Hypertonus (see _passim_), 543, 545.

  Hypertrichosis, 89, 567.

  Hypnotism in blind, 377.

  Hypnotism, 96, 282, 509, 532, 554, 702, 729 (blind), 731 (deaf), 743
    (not in French army), =Cases= =142=, =174=, =361=, =369=. BIB. 934,
    951, 953, 955, 957, 964, 967.

  Hypnotism, spontaneous, 504-508.

  Hypochondria, 231, 260.

  Hypophrenoses (Feeble-mindednesses), =Cases= =35-52=, =236=. BIB. 920,
    935, 940, 941, 942, 957, 962, 977.

  Hypotonia, 350, 592.

  Hysteria, 69, 152, 165, 211, 213, 253, =Cases= =67=, =68=, =123=, =128=,
    =137=. BIB. 917, 924, 930, 932, 940, 942, 943, 944, 945, 952, 956, 957,
    965, 973, 974, 975, 978, 979, 982.

  Hysterical symptoms in sleep, 554.

  Hysterical and organic symptoms, =Cases= =116=, =117=, =134=, =214=,
    =219=, =230=, =231=, =399=, =495=. BIB. 924, 928, 933, 981.

  Hystero-emotive factors, 456, 509.

  Hystero-organic association, 605, 799.

  Hystero-reflex association, 605.

  Hystero-traumatism, 531, 544, 545, 560, 568, 571, 799. BIB. 918, 933.


  Imaginary symptoms, 833.

  Imboden, 288, 693, 793.

  Incontinence of urine (see Urology), =Cases= =384=, =401=, =500=, =577=.

  Indemnity-neurosis, 348.

  Industrial medicine, 854, 873.

  Infection (see also Somatopsychoses), 488, 509, 875.

  Inferno, _passim_.

  Inhibition, 355, 356, 369, 653, 891.

  Inoculation and convulsions (see Convulsions).

  Insomnia, 299. BIB. 945.

  Insular sclerosis (see Multiple Sclerosis).

  Intermediolateral tract shock, 526.

  Iron cross and psychopathy, 863, =Case= =158=.

  Iron cross and psychotherapy, =Case= =479=.

  Instinct (see Emotion, Psychology, etc.), BIB. 921, 934, 978.

  Insubordination, 77, =Cases= =47=, =59=, =60=, =63=, =93=.

  Isolation, see Treatment.


  Jacquet’s biokinetic treatment, 646.

  James, 632, 901.

  Jeanselme and Huet, 538, =Case= =441=.

  Jelly-fish not shocked, 858.

  Joint-disease, 539, 545, 562, 569, 608, 744, 789.

  Jolly, =Cases= =176=, =349=.

  Joltrain, =Case= =245=.

  Jones, 692, =Case= =476=.

  Joubert, =Case= =374=.

  Jousset, 609.

  Jumping-jack, =Case= =555=.

  Jung, 240.

  Juquelier, =Case= =58=.

  Juquelier and Quellien, 97, =Case= =81=.


  Kaplan, 700.

  Karplus, 348, =Cases= =27=, =140=.

  Kastan, 860, =Cases= =11=, =12=, =13=, =44=, =45=, =47=, =49=, =89=,
    =90=, =91=, =92=, =93=, =94=, =95=, =96=, =97=, =104=, =148=, =151=.

  Kaufmann’s Treatment (see Treatment, Shell-shock Neuroses,
    Psychoelectric), 723, 750, 753, 786, 791, 792, 793, 900. BIB. 940, 945,
    962, 968.

  Khoroshko, 227.

  Kidner, 803.

  King, Edgar, 210.

  Klippel and Weil, 528.

  Knee-jerks, loss of (matutinal), =Case= =110=.

  Kocher, 343.

  Korsakow syndrome, in malaria, =Case= =130=. BIB. 916, 930.

  Kyphosis, 340.


  Labilizing factors, 329.

  Labyrinth disease, 366, 623, =Case= =211=. BIB. 955, 966.

  _La Carotte_, 660.

  Laehr, 689.

  Laignel-Lavastine, 14, 570, 796, 899.

  Laignel-Lavastine and Ballet, =Cases= =38=, =438=.

  Laignel-Lavastine and Courbon, 560, =Cases= =29=, =106=, =170=, =194=,
    =314=.

  Laignel-Lavastine and Fay, =Case= =74=.

  Lannois and Chavanne, 657.

  Laryngology, 576, 683, 721, 723, 726, 727, 766, 823 (see also Treatment,
    Shell-shock neuroses, pseudo-operations). BIB. 909, 912.

  Lasègue, 452, 483.

  Lattes, 257.

  Lattes and Goria, =Cases= =196=, =266=, =295=, =319=, =321=, =322=,
    =323=.

  Lautier, 36, =Cases= =42=, =48=, =56=.

  Lebar, 569, =Cases= =211=, =456=.

  Lépine, 18, 27, 30, 72, 73, 75, 81, 82, 91, 112, 113, 120, 126, 155, 202,
    231, 260, 458, 473, 490, 638, 860.

  Lereboullet and Mouzon, =Case= =105=.

  Lèri, 498, 696, 723, =Cases= =114=, =228=, =393=.

  Lèri, Froment and Mahar, =Case= =411=.

  Lèri and Roger, =Cases= =252=, =468=.

  Leriche, 886, =Cases= =66=, =206=, =207=.

  Lévy, 331.

  Lewandowski, 348, 674, 724.

  Lewitus, =Case= =471=.

  Lhermitte, 157, 874, 887, =Case= =103=.

  Liébault, 726, =Cases= =261=, =447=, =580=, =585=.

  “Lightning neuroses,” 881.

  Lilliputian hallucinations, =Case= =106=.

  Lipomatosis, 846, =Case= =141=.

  Lloyd Morgan, 374.

  Localizing sense, 557.

  Localization of hysterical symptoms (see _passim_) 529, 855, 872, 873.

  _Locus minoris resistentiae_, Shell-shock hysteria, 36, 854, 876, =Cases=
    =286-301=, =409-414=.

  Loewy, =Cases= =87=, =122=, =310=.

  Logre, =Cases= =21=, =62=, =88=, =164=, =235=.

  Long, =Case= =10=.

  Lortat-Jacob and Sézary, =Case= =316=.

  Lumbar puncture (see Spinal fluid and Treatment).

  Lumière and Astier, =Case= =119=.

  Lumsden, 645.

  Lungs, 846.

  Lust, 228.

  Lymphatics, BIB. 906.

  Lymphocytosis of spinal fluid (see Spinal fluid and Meningitis).


  MacCurdy, 683, =Cases= =193=, =232=, =293=, =307=, =332=, =355=, =415=,
    =451=, =452=, =586=.

  MacMahon, 738, =Cases= =582=, =583=.

  MacKenzie, 641.

  _Main d’accoucheur_, 593.

  _Main figée_, 593.

  _Main succulent_, 186.

  Mairet, 401.

  Mairet and Durante, 294.

  Mairet and Piéron, 92, =Cases= =28=, =69=, =448=, =450=.

  Mairet, Piéron, Bouzansky, 134, =Case= =330=.

  Maitland, 225.

  Maixandeau, =Case= =107=.

  Malaria, 845, =Cases= =129-131=. BIB. 923, 926, 961.

  Malingering (see Simulation, Medicolegal, etc.), 514, 554, 642, 643, 707,
    717, =Cases= =453-472=. BIB. 920, 927, 931, 936, 938, 940, 948, 950,
    955, 958, 969, 974, 975, 976, 982.

  Mallet, 487, =Cases= =354=, =444=, =445=.

  Mania, =Cases= =163=, =165=, =187=, =188=, =350=, =351=.

  Manic-depressive psychoses (Cyclothymoses), =Cases= =163-169=.

  Manic-depressive (also see Cyclothymia), =Case= =16=.

  _Manière forte_, 189, 893, 895, 901.

  Mann, 718, 793, 797, =Cases= =240=, =265=, =356=.

  Mannkopf-Thomayer test, 415.

  Marage, 809, 813.

  Marchand, =Cases= =127=, =128=.

  Marie, 14, 159, 342, 648, 796, =Cases= =403=, =470=.

  Marie, Chatelin, Patrikios, =Case= =9=.

  Marie-Foix sign, 157.

  Marie and Lévy, =Case= =213=.

  Marie, Meige, Béhagne, =Case= =401=.

  Marionette movements, 350.

  Marriage, H. J., =Case= =260=.

  Martial misfit, 415, 668.

  Martinet, 231.

  Massage, 353, 529, 566. BIB. 918, 940, 959, 961, 971.

  Mathieu, 796.

  Maurice, 231.

  _Mauvaise volonté_, 717, 812, 894, =Case= =228=.

  McDougall, 374.

  McDowell, =Cases= =495=, =500=.

  McWalter, 391.

  “Mechanisms,” 890, 891.

  Mechanotherapy (see also Treatment), BIB. 914.

  Medicolegal, 509 (see also Desertion, Fugue, Epilepsy, Simulation,
    etc.), 837, 838, 841, 862, 864, =Cases= =1=, =3=, =11=. BIB. 914, 917,
    920, 925, 926, 932, 935, 938, 940, 941, 942, 943, 944, 952, 953, 956,
    960, 961, 973, 977.

  Medicolegal period in general paresis, 18.

  Meige, 331, 432, 465, 696, 746, =Cases= =224=, =308=, =413=.

  Meiopragia, 592.

  Melancholia, =Cases= =164=, =166=, =168=, =169=.

  Memory (see Amnesia, Hypnosis, etc.).

  Mendel-Bechterew’s sign, 157.

  Mendelssohn, =Cases= =111=, =208=.

  Ménière’s disease, 623.

  Meninges (see also Hemorrhage), BIB. 912 (cysts).

  Meningitis, 875, =Case= =109=. BIB. 927, 930, 967.

  Meningitis (Meningococcus). =Cases= =107=, =108=. BIB. 906.

  Meningitis (pneumococcus), =Case= =112=.

  Mental disease (in war), 926, 936, 937, 963, 966, 967, 975, 980,
    981, 982.

  Mental hygiene, BIB. 955.

  Mental symptoms, BIB. 917.

  Mériel, 548.

  Merklen, =Cases= =125=, =126=.

  Metatraumatic hysteria, 329.

  Meyer, 50, 208, 222.

  Meynert, 62, 226.

  Micawber, 674.

  Micromegalopsia, =Case= =106=.

  Micro-organic changes, 572.

  Milian, 501, 638, =Cases= =171=, =364=, =365=, =366=.

  Military psychiatry (see War and Psychiatry).

  Milligan and Westmacott, 365.

  Milligan, 775.

  Mills, =Cases= =454=, =459=, =517=.

  Mine-explosion, 492.

  “Miracle” cures (see Treatment, Shell-shock, rapid _versus_ slow, and
    _passim_, 885).

  Mitchell, Weir, 821.

  Mobilization, neuropsychiatry of, BIB. 908, 929.

  Molecular changes, 572.

  Monier-Vinard, 388.

  Monoplegia, 282, 317, 318, 323, 539, 591 (diagnostic table), 595, 596,
    605, 874, =Cases (crural)=, =229-234=, =286=, =287=, =385=, =386=,
    =388=, =410=, =428=, =534=, =575=, =577=, =Cases (brachial)=,
    =249-254=, =281=, =404=, =405=, =409=, =421=, =426=, =427=, =429=,
    =430=, =563=, =564=, =571=, =573=. BIB. 954.

  Montembault, 222.

  Moore, 641, 644.

  Morale, 9, 257, 903.

  Mörchen, 228.

  Morestin, =Case= =516=.

  Morphinism, =Cases= =99-102=.

  Morselli, 222, 226, 645.

  Mott, 158, 228, 476, 643, 689, 704, 719, 728, 775, 797, 813, 884, 885,
    887, 888, 901, =Cases= =85=, =197=, =262=, =328=, =341=, =344=, =414=,
    =473=.

  Muck, 726.

  Multiple sclerosis, 309, 422, 530, 580, 876, =Case= =115=.

  Musculospiral nerve, 540.

  Musical alexia, 775.

  Mutism, 282, 454, =Cases= =185=, =219=, =226=, =227=, =283=, =330=,
    =356=, =365=, =447=, =473=, =475=, =476=, =480=, =516=, =520=, =526=,
    =528=, =531=, =544=, =550=, =555=, =556=, =559=, =578=, =586=.
    BIB. 916, 924, 927, 931, 932, 933, 946, 954, 964.

  Mutism, classification (Myers), 369.

  Mutism, treatment, 674 and _passim_. BIB. 915, 927, 976.

  Myelitis (see Spinal cord lesions).

  Myers, 355, 568, 579, 740, 750, =Cases= =174=, =223=, =263=, =272=,
    =287=, =329=, =360=, =361=, =395=, =453=, =463=, =464=, =523=, =524=,
    =525=, =538=.

  Myokymia, 361.

  Myopathy, question of Shell-shock, 574.


  Narcolepsy, 487, 843, =Case= =77=.

  Narcosis (see Treatment, Narcosis).

  Naval Service, BIB. 910, 929, 965.

  Neiding, =Case= =215=.

  Neisser, 838.

  Néri’s sign, 452.

  Nerve concussion, 354.

  Nerve leaks, BIB. 910.

  Nerve lesions, peripheral (see also Neuritis), BIB. 905, 909, 910, 916,
    918, 920, 921, 925, 926, 928, 933, 934, 935, 936, 937, 938, 939, 941,
    945, 947, 948, 949, 950, 951, 953, 955, 956, 957, 958, 959, 960, 963,
    965, 967, 968, 970, 971, 972, 973, 975, 976, 977 (large nerve trunks),
    923 (median), 914, 923 (electrical methods of diagnosis), 922.

  Nerve sutures, 916, 926.

  Nerves (and the War), 915, 953, 956.

  Nervous system, 922, 923, 925, 928, 933, 938, 940, 944, 945, 958, 959,
    962, 963, 967, 971, 972, 973, 975, 978.

  Nervous temperament, 956.

  Neurasthenia, 231, 578, 639, 718, =Cases= =143=, =175=, =176=, =177=,
    =179=, =284=, =340=, =349=, =416=, =420=, =545=. BIB. 914, 915, 916,
    920, 925, 930, 950, 957, 964, 969, 975, 980.

  Neuritis, 89, 574, 583, 598, 843, 846, =Cases= =127=, =128=, =130=,
    =131=, =132=, =135=, =387=, =417=, =418=, =512=, =540=. BIB. 907.

  Neuropsychiatry, BIB. 915, 922, 924, 926, 947, 951, 952, 955, 960, 963,
    969, 976, 980.

  Neurological centers, BIB. 918, 923, 941, 956, 961, 966, 971, 972, 981.

  Neurologists in war, BIB. 914.

  Neurology (see War and neurology).

  Neuropotential, 268.

  Neurosis, definition, 831-834, 889. BIB. 926, 938, 939, 946, 947,
    952, 957.

  Neurosyphilis, =Cases= =1-34=, =53=, =110=. BIB. 916, 972.

  Neurosyphilis and exhaustion, 31.

  Neurosyphilis and trauma, 838.

  Night-blindness, BIB. 907, 911, 942, 959, 975, 979, 980.

  Nitrophenol, =Case= =434=.

  Nitrous oxide anesthesia, 769.

  Noise, 308.

  Nonne, 282, 348, 716, 718, 736, 748, =Cases= =248=, =479=, =530=, =531=,
    =533=, =535=, =536=.

  Nose, see Rhinology.

  Nosophobia, =Case= =261=.

  Nostalgia, 440. BIB. 927.

  Nystagmus, 432, 489, 557. BIB. 952, 956, 975.


  Obsessions, 229, 466, 631.

  Obturators, aural, 813.

  Obtusion, 487, especially, 637.

  Occipital lesions, 159, 217.

  Officers’ susceptibility to Shell-shock, 735, 744, 857.

  Old age, 200, 225, 262.

  O’Malley, =Cases= =515=, =518=.

  Oniric delirium, 405, 437, 456, 477, 478, 628, =Cases= =50=, =81=, =295=,
    =314=, =319=, =321=, =331=, =333=, =444=, =477=, =579=.

  Oniric delirium, treatment by prearranged emotional shock, 461.

  Ontological fallacy, 833.

  Ophthalmology (see Vision, etc.), =Cases= =268-272=, =433-438=. BIB. 906,
    907, 910, 911, 916, 918, 930, 931, 938, 941, 944, 954, 955, 970.

  Ophthalmoplegia, =Case= =19=.

  Ophthalmoplegia externa, 613.

  Oppenheim, 157, 348, 361, 401, 747, 749, =Cases= =146=, =256=, =311=,
    =326=, =376=, =379=, =405=, =420=, =427=.

  Organic neurology (see Encephalopsychoses, Trauma, and _passim_),
    158-161, 489. BIB. 914.

  Organo-hysterical association, 605. BIB. 916.

  Organopathic, 856, 871.

  Orientation-sense (see Otology).

  Ormond, 653, =Case= =537=.

  Ormond and Hurst, 729.

  Orthopedics, 356, 692. BIB. 906, 910, 915, 927, 931, 939, 947, 950, 953,
    957, 963, 970.

  Otology (see Ear, Labyrinth, Vestibular, Deafness, Mutism, Aviation),
    888, =Cases= =259-287=, =370=, =414=, =439=, =440=, =497-499=, =562=,
    =578=, =579=, =588=. BIB. 907, 913, 916 (Equilibrium, Orientation),
    919, 925, 962.

  Over-reaction, 307.

  Over the top, 481, 699.

  Overwork, 11.


  Pachantoni, =Case= =273=.

  Pactet and Bonhomme, =Case= =52=.

  Pain, see Antalgic hallucinations.

  Panic (see Psychology, Emotion, etc.), BIB. 922.

  Paranoia, =Case= =185=. BIB. 960.

  Paraphernalia, 785 (see Atmosphere of cure).

  Paralyses (see also Hemiplegia, Monoplegia, Paraplegia, etc.), (P.
    Brachialis), BIB. 919, 943; (traumatic), 923, 927, 933; (facial), 955;
    (functional), 977.

  Paraplegia, 282, 284, 541, 769, =Cases= =236-241=, =279=, =288=, =374=,
    =379=, =387=, =393=, =394=, =421=, =479=, =511=, =536=, =555=, =568=,
    =572=. BIB. 919, 923, 926, 927, 929, 930, 935, 938, 939, 947, 949, 950,
    952, 956, 966.

  Paratyphoid fever, psychosis, 845, =Cases= =125=, =126=. BIB. 952.

  Paresthesia, 357, 359.

  Parinaud, 618.

  Paris, 84.

  Parkinson, =Cases= =138=, =139=. BIB. 933, 958.

  Parkinson’s disease, 422.

  Parsons, 653, =Case= =270=.

  Pastine, 693.

  Pathological intoxication, =Cases= =86=, =87=, =90=, =96=.

  Pathological lying, =Case= =183=.

  Paulian, 576, =Case= =385=.

  Pearson, 373.

  Pellacani, =Case= =59=, =60=, =187=.

  Pemberton, =Case= =271=.

  Penhallow, 769.

  “Pensionitis,” 666.

  Pensions (see Medicolegal), BIB. 914.

  Periorganic hysterical symptoms (see _passim_), 529-534, 544, 548
    (tetanic), 563, 569, 849, 873.

  Personality disorder (see also _passim_ and Psychopathoses), 493, 512.
    BIB. 927.

  Persuasion, 96. BIB. 927.

  Petrol-injection, =Case= =98=.

  Pharmacopsychoses (Alcohol, Drug, and Poison group), =Cases= =86-102=.
    BIB. 925.

  Phillipson, 364.

  Phobia (see Psychoneuroses, Psychasthenia), 627, 628.

  Phobias, 464.

  Phocas and Gutmann, 846, =Case= =136=.

  Photophobia, 372, 511.

  Physiopathic decalcification, =Case= =429=.

  Physiopathic disorder, 380, 521, 543, 544, 554, 585 (diagnostic table),
    =Cases= =274-281=, =421-428=; 591 (diagnostic table), 878, 892.
    BIB. 932, 953, 954, 956, 964, 966, 977, 978.

  Physiopathic electrodiagnostics, 608.

  Physiopathic disorder, cure, 387, 607, 671. BIB. 928.

  Physiotherapy, 821, 896, 897. BIB. 914, 918, 920, 926, 929, 931, 935,
    939, 948, 950, 951, 957, 960, 967, 975, 978.

  Pick, =Case= =33=.

  _Pied figé_, 330.

  Pitres and Marchand, 837, =Cases= =23=, =109=, =115=, =218=.

  Pitres and Régis, 423.

  Pituitrin, 228, 690.

  Plantar reflex, question of absence, 537, 538, 575. BIB. 923.

  Pleocytosis (see Spinal fluid).

  Pleura, hemorrhage, =Case= =201=.

  Pleura, reflex disorder, 186, 846.

  _Plicature_ (see Camptocormia).

  Plumbism, 584.

  Pneumonia, =Case= =133=.

  Podiapolsky, 740, =Cases= =539=, =540=.

  Podmanizky, 693.

  Poliencephalitis, 26.

  Poliomyelitis, 574, 598.

  Polyneuritis neurasthenica (Mann), 718. BIB. 925, 957.

  Poliomyelitis, residuals, =Case= =113=.

  Pollakisuria, 347

  “Poor dears!”, 719.

  Popliteal nerve, 354, 540, 600.

  Post-diphtheritic symptoms, =Case= =127=.

  Post mortem (see Autopsies).

  Post-oniric suggestion, 477, 628.

  Potain, 239.

  Pott’s disease, 343.

  Precordial sensations, 477, 526.

  Predisposition, 401 (see also frontispiece).

  Prefrontal lesions, 159.

  Pregnancy, hysterical, 387, =Case= =348=. BIB. 966.

  Prestige, 819.

  Prevention of Shell-shock, 3, 902.

  Prince, Morton, 902.

  Prisoners, 228, 303. BIB. 913.

  Proctor, 769, =Cases= =480=, =556=.

  Pruvost, =Cases= =35=, =36=, =37=, =39=, =41=.

  Pseudodementia, BIB. 910.

  Pseudologia phantastica, =Case= =183=.

  Pseudocoxalgia, 323, 341, 819.

  Pseudohallucinations, 430.

  Pseudo multiple sclerosis, 155.

  Pseudoparesis, =Case= =26=.

  Pseudoptosis of Charcot and Parinaud, 618.

  Pseudotabes, =Case= =23=.

  Psoitis, 525.

  Psoriasis, =Case= =313=. BIB. 930.

  Psychasthenia, =Cases= =170=, =178=, =194=, =342=, =347=. BIB. 910, 921,
    929, 942, 975, 980.

  Psychiatric social work, BIB. 917, 938, 956, 972.

  Psychiatrists in war, BIB. 914, 927, 950.

  Psychiatry in war (see War and psychiatry).

  Psychoanalysis, 361, 497, 582, 675, 677, 702, 712-716 (rationalization),
    851, 901 (autognosis). BIB. 926, 937, 979.

  Psychoelectric treatment, 285, 313.

  Psychogenesis, 69, 83, 332, 337, 348, 351, 497, 744, 855, 871. BIB. 919.

  Psychological laboratory, 896.

  Psychology, _passim_, also BIB. 907, 911, 924, 925, 928, 931, 932, 934,
    936, 937, 938, 941, 943, 946, 947, 952, 955, 956, 959, 960, 962, 963,
    964, 968, 971, 873, 876, 982.

  Psychoneuroses, =Cases= =170-182=. BIB. 926.

  Psychoneuroses of war, Charts 11 and 12, pages 522 and 523, 760, 761,
    799. BIB. 932, 940, 941, 943, 955, 956, 959, 960, 961, 965, 966, 972,
    973, 976, 978, 981.

  Psychopathic constitution, =Case= =147=.

  Psychopathic hospitals, 3, 680, 871.

  Psychopathic inferiority, =Case= =186=.

  Psychopathology of War, BIB. 917, 922, 926, 954, 971, 972.

  Psychopathoses (Psychopathias), =Cases= =183-196=. BIB. 935, 948, 957,
    960, 962, 969, 977, 980.

  Psychoses, 2-262, Chart 1 (page 2). BIB. 915, 918, 922 (acute), 926
    (post-shell-shock), 927 (Dysglandular), 927, 928, 934, 936, 940,
    (vesical) 943, 952, 955, 957, 958, 962, 965, 968, 972, 973, 975, 976,
    978, 979, 980, 982 (see also Mental diseases [in war]).

  Psychoses, treatment, BIB. 918.

  Psychotherapy (see Treatment);
    also chart 16 (page 673).

  Psychotic symptoms in hysterical cases, 327.

  Puerilism, =Case= =318=. BIB. 912, 917, 941.

  Pulmonary phenomena, 846.

  Pupils in Shell-shock, 526. BIB. 933.

  Purser, =Case= =475=.


  Quadriplegia, 528, 530, 551, 573.

  Quincke’s disease, 646, 665.


  Rabies, 844, =Case= =118=.

  Radial paralysis, 350, 351.

  Radicular symptoms, =Case= =134=.

  Railway spine, 5, 348, 544, 831, 873.

  Raimiste, 528.

  Ranjard, 809.

  Rationalization (Rivers), =Cases= =506-510= (see also Treatment:
    Shell-shock neuroses), 237, 859.

  Ravaut, 275, 281, =Cases= =202=, =373=, =408=, =488=.

  Raynaud, 569.

  Reaction-psychosis, 304.

  Reactive idealization, 468.

  _Realsuggestionen_, 799, 803.

  Reconstruction, 831, 859, 893 (see Treatment, Shell-shock neuroses,
    Mechanotherapy, Reëducation, etc., etc., and _passim_). BIB. 908.

  Recovery (see Shell-shock).

  Recruits, possible elimination of defective (see also Hypophrenoses),
    835, 858, =Cases= =42=, =44=, =49=, =91=. BIB. 906.

  Rectal incontinence, 807.

  Recurrence, =Cases= =286-301=.

  Reëducation (see Treatment, Shell-shock neuroses, Reëducation), also BIB.
    906, 914, 915, 916, 918, 920, 922, 923, 925, 926, 927, 928, 930, 931,
    933, 935, 937, 938, 940, 942, 943, 948, 949, 950, 951, 952, 954, 956,
    957, 961, 962, 963, 964, 969, 971, 978.

  Reëducation, respiratory, 808, 814-818.

  Reeve, 793, =Cases= =489=, =490=, =491=, =492=, =493=.

  “Reflex” disorder (see Physiopathic).

  Reflexes, BIB. 919, 925, 934, 939, 953, 970, 971, 977, 978.

  Refrigeration, 424, 590.

  Régis, 62, 72, 233, 461, 478, 509, 631, 637, 638, 680, 850.

  Relapse (see also “Reminiscence” process in shell-shock), 403, 404, 457,
    463, 495, 675.

  Religiosity, 256.

  “Reminiscence” process in Shell-shock hysteria, =Cases= =286-301=, =314=.

  Responsibility (see Desertion, Fugue, Insubordination,
    Pharmacopsychoses), 72, 100, 117, 171.

  Responsibility a psychogenic factor, 458.

  Retention of urine (see also Urology), =Cases= =111=, =382=, =383=, =539=
    (_Hypnotism_).

  Retrobulbar neuritis, 609, =Case= =434=.

  Retrocentral lesions, 160.

  Rhinology, 262, 321, 375, 476, 511, 665. BIB. 955.

  Riggall, =Case= =541=.

  Rivers, 476, =Cases= =506-510=.

  Rombergism, Shell-shock, 620.

  Romner, =Case= =406=.

  Rontgenology (see X-Ray).

  Rosanoff-Saloff, Mme., 340.

  Roselle and Oberthur, 456.

  Rossolimo’s sign, 157.

  Rothacker, =Case= =144=.

  Rouge, =Cases= =153=, =162=.

  Roussy, 281, 696, =Cases= =133=, =279=, =387=, =460=, =497=, =498=,
    =499=, =502=.

  Roussy and Boisseau, 275, 362, 404, 689, 743, 797, 815, 887, =Cases=
    =199=, =440=.

  Roussy, Boisseau, Cornil, =Case= =348=.

  Roussy and Lhermitte, 466, 471, 476, 487, 509, 525, 560, 563, 578, 637,
    701, 726, 738, 743, 787, 807, 896, =Cases= =230=, =235=, =243=, =244=,
    =246=, =247=, =250=, =291=, =572=, =584=.

  Routier, =Case= =409=.

  Rows, 471, 478, 900, =Cases= =301=, =335=, =342=, =343=.

  Russca, 295.

  Russel, 404, 650, 740, 775, 781, =Cases= =79=, =241=, =503=, =504=.


  Saaler, 208.

  Salmon, 804.

  Sargent and Holmes, 158.

  Sartorius muscle, 553.

  Savage, 48, 83, 404.

  Schäfer’s sign, 151.

  Schizophrenia and typhoid fever, =Case= =124=.

  Schizophrenoses (Dementia præcox group), 202, 223, 861-865, 864
    (medicolegal), =Cases= =124=, =147-162=. BIB. 913.

  Scholz, =Case= =550=.

  Schultz, 726.

  Schultzer, =Case= =570=.

  Schuster, 343, 349, =Cases= =19=, =234=, =298=.

  Sciatica, =Cases= =10=, =565=.

  Scotoma, 98, 374.

  Sebileau, =Case= =388=.

  Secretory disorder, 387.

  Séguin and Rouma, 809.

  Self-inflicted injury, =Cases= =153=, =187=, =193=. BIB. 917, 921, 922,
    926, 961, 969.

  Sencert, 885, =Case= =201=.

  Senility (see Geriopsychoses), 200, 225, 262.

  Sensibility (see Dermatology, Ophthalmology, etc.). BIB. 923, 946, 955,
    962, 969, 978, 980.

  Serbians, 102, 225, 228.

  Sereysky, 297.

  Serology (see Syphilopsychoses, also under Spinal fluid).

  Sexual continence, 459.

  Sex sensations, 259.

  Shell-shock: animal experimentation, 294, 295.

  “Shell-shock,” the term, 5.

  Shell-shock and _croix de guerre_, 430, 675.

  Shell-shock: Diagnosis, =Cases= =371-472= and _passim_. BIB. 915, 922,
    941.

  Shell-shock: Nature and Causes, =Cases= =197-370= and _passim_. BIB. 917,
    918, 920, 926, 927, 928, 935, 937, 942, 958, 967, 977, 981.

  Shell-shock: Treatment and results, =Cases= =473-589= (and see special
    headings under Treatment, Shell-shock). BIB. 967.

  “Shell-shock” diseases, 880.

  Shell-shock and epilepsy (Ballard’s Theory), =Cases= =82-84=.

  Shell-shock and traumatic neurosis, =Case= =248=.

  Shell-shock equivalent, 850.

  Shell-shock, general arrangement of cases, 852 _et seq._, 879-880, 883,
    894 _et seq._

  Shell-shock, nature in general, 847, 867, 880-892. BIB. 926, 931, 932,
    934, 946, 950, 952, 953, 954, 955, 961, 962, 965, 967, 968, 971, 974.

  Shell-shock: organic hypotheses, 526, =Cases= =197-222=. BIB. 927.

  Shell-shock, relapse, 391.

  Shell-shock, repeated, 299.

  Shell-shock (spelled with capital letter) _versus_ shell-shock (spelled
    lower case), 880.

  Shell-shock, symptoms delayed, =Cases= =282-285=.

  Shell-shock, terminology, 831-834.

  Shell-shock, treatment in general, 893, _ad finem_. BIB. 921, 923, 924,
    929, 930, 934, 936, 937, 953, 954, 976, 978.

  “Shock” ought to be “functional,” 883.

  Shufflebotham, =Case= =417=.

  Shunhoff, 228.

  Shuttleworth, 48.

  Sicard, 525, 544, 554, 643, =Case= =462=.

  _Simulateurs de création, de fixation_, 643.

  Simulation (see malingering, medicolegal, etc.), 42, 91, 260, 569, 592,
    605, especially 642-667, 661-662 (list of methods). BIB. 914, 916, 917,
    922, 925, 927, 928, 932, 934, 936, 939, 940, 941, 942, 945, 946, 949,
    953, 955, 956, 958, 959, 960, 962, 963, 964, 965, 967, 969, 970, 974,
    975, 976, 977, 978.

  Simulation, =Cases= =33=, =34=, =39=, =78=, =79=, =257=. BIB. 907, 909,
    910, 912, 917, 918, 920, 924, 946.

  _Sirène à voyelles_, 908.

  Situation-delirium, 699.

  Skin-lesions (see Dermatology).

  Skin reflexes, 538, 543.

  Skull, see Head and Wounds. BIB. 916 (Protection, etc.).

  Slang, 832.

  Sleep, deep, 70.

  Sleep, Shell-shock not produced in, 349.

  Sleep, hysterical symptoms persistent in, 553. BIB. 971.

  Smell (see Rhinology).

  Smirnow, 740.

  Smith, E., 471, =Cases= =175=, =284=.

  Smith, E., and Pear, T. H., 672, 740, 901.

  Smith, R. P., =Case= =192=.

  Smyly, =Cases= =116=, =117=, =219=, =283=, =397=, =520=, =558=, =559=.

  Snake killed, 678.

  Social work (see also Social Psychiatry), 2, 859, 893.

  Soldier, BIB. 927;
    Mind of, in field, BIB. 927.

  Soldiers’ heart, 44, =Cases= =138=, =139=, =451=, =452=. BIB. 905, 924.

  Sollier, 538, 554, 603, =Cases= =389=, =390=, =487=.

  Sollier and Chartier, 531.

  Sollier and Jousset, =Case= =434=.

  Somatopsychoses (“symptomatic” of bodily [non-nervous] disorder),
    843-847, =Cases= =118-146=.

  Somatopsychoses (Symptomatic, non-nervous group), =Cases= =122-146=.

  Somnambulism, 70, 499, 502, 503, 504, 506, 508, 509.

  Soukhanoff, 120, =Cases= =50=, =223=.

  Souques, 91, 342, 345, 696, 886, =Cases= =242=, =386=.

  Souques and Donnet, =Case= =371=.

  Souques and Mégevand, =Case= =401=.

  Souques, Mégevand, Donnet, =Case= =205=.

  “Spa” treatment, 718. BIB. 957.

  Spasms, 409, 548, 563, 571, 577, 588. BIB. 951.

  Spasm, facial, =Cases= =222=, =309=. BIB. 944.

  Spasm, glossolabial, 563, =Case= =309=.

  Spasm, head, =Cases= =223=, =413=, =588=.

  Spasticity, 427.

  Speech disorder, =Cases= =217=, =219=, =369=, =377=, =527= (see also
    Stuttering). BIB. 922, 932, 934, 940, 945, 947, 949, 950, 951, 955,
    968, 969, 975, 979, 981.

  Specialists in escape, 81.

  Sphincter-disorder (see also Urology). BIB. 916, 933.

  Spinal cord lesions, 562, 887, =Cases= =111=, =133=, =372=;
    especially =Cases= =375-381=. BIB. 915, 919, 920, 945, 946, 950, 965,
    978.

  Spinal fluid, 149;
    especially 276-283; 344, 398, 421, 506, 521;
    especially 524-527; 530, 535, 536, 539, 570, 576, BIB. 909, 951, 972.

  Spine (see under Camptocormia).

  Spondylitis, 342, 525, BIB. 921.

  Spondylotherapy, BIB. 909.

  Spontaneous cures in Shell-shock, =Cases= =283=, =310=, =357=, =365=.

  Spirometer, 366.

  Staircase test, 190, 533, 640.

  Stansfield, 220.

  Statistics, 222, 227, 228, 362, 753, 784, 812, 820, 831, 836, 839, 858,
    864.

  Steiner, 704, 763, =Cases= =181=, =182=, =312=, =437=.

  Stereotyped movements, 430.

  “Sterno” sign of Dupuoy, =Case= =161=.

  Sterz, =Case= =123=.

  Stewart, 741, 771.

  Stier, 222.

  Stomach, 400, 476, 479, 533, 701, 705, 716, 807. BIB. 950, 951.

  Stokes, 268.

  Stovaine anesthesia, 778, 779.

  Stransky, 866.

  Stress, 226, 227, 867 (see also Exhaustion, Fatigue and _passim_).

  “Stupefaction” of muscle, 355, 542, 890.

  Stupor, 362, 369, 435, 462, 486, 503. BIB. 933.

  Stupor, “local” (peripheral), 542.

  Stuttering, 681, 638, 817, =Cases= =219=, =527=, =579=, =586= (see also
    Speech disorder).

  Subconscious, BIB. 909.

  Suggestion (see also Auto-Heterosuggestion), frontispiece, 95, 318, 338,
    476, 477, 438, 498, 653, 872. BIB. 910, 912, 915, 931, 961.

  Suicide, 257, 258, 261, 283, 351, 460, 468, 478.

  “Superposition” of hysterical symptoms, 531, 533, 545, =Case= =68=.

  Supinator longus, 353, 355, 892.

  Surgery, 118, 158-161, =Cases= =66=, =69=, =146=, =252= (see also
    Treatment, Shell-shock neuroses, pseudo-operations). BIB. 954, 960,
    962, 964.

  _Sursimulation_, 656.

  Sympathetic nerve effect, 394.

  Sympathy, 718, 719, 901 (see also “Poor dears!”).

  Sympathy with enemy, 245, 258, 319, 851.

  Symptomatic psychoses (see Somatopsychoses).

  Syncope, pleural, 187.

  Syndesmitis, 525.

  Synesthesialgia, 433.

  Syphilopsychoses, 836-839, 875, =Cases= =1-34=. BIB. 934, 937, 941.

  Syphilis and epilepsy, 66, 67, =Cases= =45=, =55=.

  Syphilis, in the army. BIB. 972, 974.

  Syphilis, danger of vaccination in, 85.

  Syphilis, in married women, 16.

  Syphilis, in munition-workers, 16, 838.

  Syphilophobia, 260.

  Syringomyelia, 570, 663.


  Tabes dorsalis, =Cases= =4=, =20=, =21=, =22=, =23=. BIB. 930.

  Tachycardia, 76, 103, 198, 260, 309, 359, 526, 529, 533, 641, 689.
    BIB. 907, 923.

  Tachypnoea, 526, 846, =Case= =137=.

  Teeth, 701.

  Tension, arterial (see Blood pressure).

  _Tétanos fruste_, =Case= =120=.

  Temperature changes in hysteria, 331.

  Tetanus, 845, 874, =Cases= =99=, =119=, =120=, =121=, =280=, =392=,
    =403=, =409=, =419=. BIB. 913, 917, 919, 921, 927, 936, 946, 949, 952,
    954, 964, 966, 973.

  Thalamus, optic, 653, 876, =Case= =114=.

  Theopaths, 851, =Case= =106=.

  Thermanesthesia, =Case= =380=.

  Thermotherapy, 607.

  Thibierge, 16, 30, 838.

  Thirst dreams, 475.

  Thorax, 94.

  Thyroid disease, =Case= =186=. BIB. 912.

  Thyroid extract, 228.

  Tic, 282, 401, 428, 432, 446, 559, 577, 627, 742. BIB. 917, 951.

  Tinel, 356, 890, =Cases= =253=, =315=.

  Tobacco, 639.

  Todd, 804, =Case= =7=.

  Tombleson, 846, =Cases= =142=, =545=, =546=, =547=.

  Torpillage (see Treatment, Shell-shock neuroses, psychoelectric), 786,
    895. BIB. 930, 964.

  Torpor, 487.

  Torticollis, 697. BIB. 951.

  Toxic psychosis (see Somatopsychoses), BIB. 914.

  Trauma and general paresis, =Cases= =15=, =18=, =20=.

  Trauma and neurosyphilis (also see Trauma and general paresis), =Cases=
    =5=, =16=, =17=, =19=, =20=, =24=, =25=, =27=.

  Trauma, spinal, =Cases= =375-381=.

  Traumatic neurosis, 347, 359, 749. BIB. 915, 929, 930, 931, 935, 937,
    946, 948, 949, 952, 954, 956, 957, 958, 962, 967, 970, 971, 972, 976,
    977, 981, 982.

  Traumatic psychoses (see also Encephalopsychoses), 490, 534, 872, 873.
    BIB. 940, 968.

  Traumatropism, see Localization.

  Treatment, physiopathic or reflex disorder, 671, 743, 787, 892,
    =Cases= =277-279=.

  Treatment, psychoses, BIB. 918.

  Treatment, shell-shock neuroses; drugs, 675, 677, 689, 777.

  Treatment, Shell-shock neuroses, Hydrotherapy, 588, 680, =Case= =484=.
    BIB. 962, 963, 973, 978.

  Treatment, Shell-shock neuroses, Hypnotism, 347, 367, 499, 515, 532, 676,
    681 (in writing), 682, 697, 514, _especially_ =Cases= =521-548=. BIB.
    970, 975.

  Treatment: Shell-shock neuroses by induced fatigue, 789, =Cases=
    =489-493=.

  Treatment, Shell-shock neuroses, Isolation, 575, 672, 695, 708, 812, 820,
    901. BIB. 929, 930, 937, 942, 966, 967, 969.

  Treatment, Shell-shock neuroses, Lumbar puncture, 693, 778, 779.

  Treatment, Shell-shock neuroses, Mechanotherapy, 318, 560, 566, 691, 692,
    697, 698, 717, 718, 788, 821, 827. BIB. 913, 940, 941, 960, 961, 964,
    967, 971.

  Treatment, Shell-shock neuroses: rapid _versus_ slow methods, 683, 695,
    749, 751, 782-797 (rapid or miracle cures), 791, 872, 895. BIB. 965.

  Treatment, Shell-shock neuroses, Narcosis, 318, 332, 532, 676, 682
    (alcohol), 683 (alcohol), 737, 768 (alcohol), _especially_ =Cases=
    =552-559=, _but passim_; =560=, =561= (_stovaine_).

  Treatment, Shell-shock neuroses, Occupation therapy, see _passim_, 683,
    685, 711, 803, 859, 893. BIB. 938, 979.

  Treatment, Shell-shock neuroses, Pseudooperations, 344, 264, 267, 588,
    609, 646, 821 especially =Cases= =514-521=; =560= and =561=
    (_stovaine_); =562= (_X-ray_).

  Treatment, Shell-shock neuroses, Psychoelectric, 696, 815, 827,
    especially 897 and 898, =Cases= =230=, =235=, =250=, =264=, =401=,
    =404=, =418= (=428=), =478=, =513=, =514=, =555=, =559=, _especially_
    =563-574=, =584=. BIB. 929, 930, 932, 942, 943, 948, 967, 976.

  Treatment, Shell-shock neuroses: faith, rationalization, explanation,
    persuasion, “tracing back”, reassurance, etc., 463, 474, 580, 622, 695,
    701, 706, 707, 820, 900, 901. BIB. 937, 967, 969.

  Treatment, Shell-shock neuroses, Reëducation, 568, 683, 692, 735, 899,
    900, 901, =Cases= =230=, =284=, =293=, =299=, =387=, =400=, =404=,
    =447=, =514=, =550=, _especially_ =575-589=, =578= (_respiratory_).
    BIB. 913.

  Treatment, Shell-shock neuroses, Recovery without medical treatment,
    =Cases= =283=, =310=, =357=, =364=, =365=, _especially_ =473-477=,
    =520=.

  Treatment, Shell-shock neuroses, prearranged emotional shock (see
    Emotion), 680.

  Treatment, Shell-shock neuroses, relation to the front line, 675, 897.

  Treatment, Shell-shock neuroses, studied neglect, 672, =Cases= =67=,
    =533=.

  Treatment, Shell-shock neuroses, Psychotherapy undefined, 553, 554, 874,
    899 (honeymoon type). BIB. 923, 926, 950, 966.

  Tremophobia, 465, =Case= =308=.

  Tremor, 282, 466, 492, 551, 622, 742, =Cases= =224=, =308=, =325=, =327=,
    =337=, =483=, =502=, =532=, =535=. BIB. 909, 945, 950, 951.

  Tremors, head, 292, 708.

  Trench-foot, 718, 760, =Case= =132=.

  Trephining (see also Organic neurology), 490.

  Triad of Dieulafoy, 373, 609.

  Triplegia, 773.

  Trismus, 300, 771.

  Trophic changes, 603.

  Tubby, 354, =Cases= =254=, =285=.

  Tuberculosis, 239.

  Turner, 718, 804, 901.

  Turrell, =Cases= =121=, =568=.

  Tympanum, 300.

  Typhoid fever, =Cases= =123=, =124=, =135=, =276=. BIB. 229.

  Typhus (and war psychoses). BIB. 928, 955, 960, 970, 972.


  Ulnar syndrome, =Case= =136=.

  Urology, Urine, 347, 377, 427, 476, 527, 533, _especially_ 535-6, 805.


  Vago-accessorius nucleus, 265, 884.

  Vagus, 701.

  Vasomotors, labile, 260, 387, 428, 569, 639, 742 (also _passim_).
    BIB. 921 (arterial hypertension).

  Veale, =Cases= =511=, =512=.

  Venereal diseases (see Syphilis, Urology, etc.). BIB. 920.

  Verger, =Case= =61=.

  Vertigo, =Case= =105=.

  Vestibular symptoms, =Cases= =31=, =368=, =398=, =439=, =515=.

  Vicissitudes of treatment, 796 and _passim_.

  Victoria cross, 741, 891.

  Vigouroux, 44.

  Vignolo-Nutati, 429.

  Vincent, 266, 696, 723, 753, 820, 894, 900, =Cases= =277=, =278=, =566=,
    =564=.

  Vincent’s treatment (see Treatment, Shell-shock neuroses,
    psychoelectric).

  Violence, 75, 76, 252-255.

  Vision (see also Ophthalmology), 490. BIB. 931, 934, 974.

  Visual fields, contracted, 253, 254, 374, 551. BIB. 936.

  Vlasto, =Case= =519=.

  Vocational reëducation, 803. BIB. 915, 916, 917, 924, 926, 930, 940, 971,
    973, 974, 975, 978.

  Voltaic vertigo, 621, 624.

  Vomiting (see Stomach).

  Von Sarbo, 348, =Case= =410=.

  Voss, =Cases= =455=, =457=, =569=.

  Vulpian, 608.


  Wagner v. Jauregg, 348.

  Walshe, 828.

  Walther, =Case= =404=.

  War and Neurology, BIB. 915, 922, 928, 934, 938, 946, 950, 951, 952, 953,
    954, 956, 957, 967, 968, 971, 973, 974, 977, 981.

  War Neurosis (see Shell-shock, Hysteria, etc.).

  War and Psychiatry (see also Recruits, Hospital Organization), BIB. 920,
    921, 922, 925, 926, 928, 930, 931, 932, 933, 935, 938, 940, 943, 944,
    946, 953, 954, 956, 960, 962, 963, 965, 969, 971, 973, 974, 977, 979,
    980, 981.

  War stress, 226, 227, 289.

  Wassermann reaction in suspected Shell-shock, 12. BIB. 927.

  Wassermann reaction in epileptiform seizures, 65.

  Weichardt, 689.

  Wernicke, 161, 409.

  Westphal, 348, =Case= =435=.

  Westphal and Hübner, =Cases= =73=, =290=.

  Weygandt, 863, =Cases= =3=, =160=, =165=, =416=.

  White hair (see canities).

  Will therapy, 322.

  Wilmanns, 228.

  Wilson, Gordon, 812.

  Wiltshire, 404, 519, 675, =Cases= =216=, =324=, =325=, =337=, =338=,
    =345=, =357=.

  Windage, 185, 275, 276, 289, 317, 378, 550.

  Wish-fulfillment, 361.

  Wollenberg, 348, 447.

  Women, Syphilis in, 16 (see Civilians).

  Wound shock, BIB. 909, 927, 961.

  Wounds (brain), 914, 917, 918, 923, 924, 926, 929, 931, 932, 934, 935,
    943, 946, 947, 950, 953, 958, 959, 968, 977, 980.

  Wounds (skull, head), 914, 915, 916, 917, 918, 920, 922, 923, 924, 925,
    926, 932, 934, 935, 936, 939, 941, 943, 944, 945, 946, 949, 953, 954,
    960, 962, 974, 965, 967, 968, 969, 970, 971, 972, 974, 975, 977, 978,
    980, 981.

  Wright, H. P., 589.


  Xanthochromia, spinal fluid, 282.

  X-Ray, 354, 480, 529, 531, 534, 559, 561, 565, 566, 594, 596, 602,
    especially 606-608; 648, 725, 789, 798. BIB. 913.


  Yealland, 723, 753, 786, 900.

  Yealland’s treatment (see Treatment, Shell-shock neuroses,
    Psychoelectric).

  Yes-no test, 651, 770.


  Zange, 815.

  Zanger, =Cases= =294=, =482=.

  Zeehandelaar, 348, 674, 790.

  Zoopsia, 164.

  Zum Busch, 228.




      *      *      *      *      *      *




Transcriber’s note:

In the references (page 952), the first part of the citation (preceding
“med. Wchnschr., 1916, No. 44, p. 1558.”) of a publication by E. Meyer
is missing in the original printing.

The index entry on Babinski refers, possibly erroneously, to case numbers
not in this book.

Spelling, hyphenation, abbreviations and accents were inconsistent and
have been left that way.