Shell-shock and other neuropsychiatric problems

by Elmer Ernest Southard

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.

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 amyotrophy, and sensory disorder corresponding topographically to anatomical distribution of nerve (neuritic) topography.	1. More or less segmentary topography.
2. Amyotrophy very pronounced, regardless of localization.	2. Amyotrophy variable; ordinarily well-marked but not so severe as that of neuritis.
3. Reaction of degeneration, especially weakening or abolition of faradic excitability of muscles.	3. Reaction of degeneration absent, never marked weakening of faradic excitability, which is often normal and may even be exaggerated.
4. Tendon reflexes, corresponding to the muscular territory of the nerve, weakened or abolished.	4. If reflexes are altered, they are as a rule 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.