Shell-shock and other neuropsychiatric problems

by Elmer Ernest Southard

Chart 13

SHELL CONCUSSION

Cause physical from explosives—amnesia for shell episode and for a subsequent period—followed by traumatic neurosis

SHELL HYSTERIA

Shell heard—victims already unstable—rum issue preparatory?—overemotionalism—sensory and motor disorder

SHELL NEURASTHENIA

Headache, dizziness, insomnia, anorexia, visceral pain—victims, older men

After H. P. Wright

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

Case 421. (Babinski, 1916.)

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

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

Re refrigeration, see [Case 309] (Binswanger) of glossolabial spasm.

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

Organic Monoplegia	Reflex Contracture and Paralysis
1. Paralysis often affects the whole extremity, either arm or leg.	1. Paralysis almost always partial. In arm paralysis, affects as a rule fingers and hand. The leg is often affected at its origin, and then only partially.
2. After several weeks of flaccid paralysis, as a rule contracture occurs.	2. Paralysis may remain flaccid for a long time, and frequently coexists with contracture, hypertonicity and hypotonicity of different muscular groups.
3. The upper extremity shows flexion with clawhand. The lower extremity shows contracture of extensors. The patient walks throwing his leg sidewise (Démarche helicopode).	3. The upper extremity in hypertonic cases often shows the main d’accoucheur, the main en bénitier (holy-water vessel hand), the doigts en tuile (crowded fingers). The lower extremity does not exhibit the sidewise movements.
4. Tendon reflexes, a few weeks after paralysis begins, exaggerated.	4. Reflex status variable. Hyperreflexia often absent even in hypertonic forms.
5. Babinski sign in crural monoplegia.	5. Babinski sign absent. The skin reflex may be abolished but may be reproduced on warming the foot.

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

Case 422. (Babinski and Froment, 1917.)

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

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

Was it a question of hysteria or of simulation?

Babinski was struck by the following symptoms:

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

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

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

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

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

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

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

Chloroform to demonstrate asymmetry of reflexes.

Case 423. (Babinski and Froment, 1917.)

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

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

Reflexes under chloroform.

Case 424. (Babinski and Froment, October, 1915.)

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

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

Reflexes under chloroform.

Case 425. (Babinski and Froment, October, 1915.)

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

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

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

Case 426. (Babinski and Froment, 1916.)

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

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

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

Case 427. (Oppenheim, January, 1915.)

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

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

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

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

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

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

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

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

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

Paralysis: Hysterical? organic?

Case 428. (Gougerot and Charpentier, May, 1916.)

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

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

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

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

Paralysis: Hysterical? organic?

Case 429. (Gougerot and Charpentier, May, 1916.)

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

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

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

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

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

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

Paralysis: Hysterical? organic?

Case 430. (Gougerot and Charpentier, May, 1916.)

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

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

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

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

Cases 431 and 432. (Delherm, September, 1916.)

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

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

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

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

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

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

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

(a) No change.

(b) Subexcitability.

(c) Overexcitability.

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

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

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

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

Muscle galvanized:

(a) No change.

(b) Subexcitability.

(c) Overexcitability.

(d) Suddenness of galvanic contraction with subexcitability.

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

Shell-shock: Functional blindness (monosymptomatic).

Case 433. (Crouzon, January, 1915.)

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

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

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

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

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

First, Congenital amblyopia.

Second, Amblyopia due to cerebral intoxication.

Third, Retrobulbar neuritis and toxic amblyopia.

Fourth, Amblyopia ex anopsia.

Fifth, Hysterical amblyopia.

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

Retrobulbar neuritis (nitrophenol).

Case 434. (Sollier and Jousset, April, 1917.)

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

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

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

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

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

Case 435. (Westphal, September, 1915.)

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

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

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

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

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

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

Case 436. (Harwood, September, 1916.)

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

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

Hemianopsia: organic or functional?

Case 437. (Steiner, October, 1915.)

A 19-year old volunteer, never ill (no nervous disease in the family), after a period of training went into the field, October 3, 1914. November 5, a shell struck the trench nearby but failed to explode. Up to that time everything had been quiet. The soldier had been looking out of the loophole, surveying the terrain. He felt a great fear, got a blow in the neck, fell down unconscious, remained unconscious for an unknown time, and later walked back with his comrades. About an hour later, this volunteer,—who was a very intelligent young man, possessing much knowledge of biology, including the nature of visual fields,—noticed a black spot in the field of vision, which came and went, but after a few hours remained continually without disappearing. Otherwise, there was no complaint except a feeling of dizziness when stooping.

Upon examination there could be found no disorder of the internal organs. Neurologically there was blinking, vasomotor excitability, slight reddening of the face, and dermatographia. An expert in ophthalmology confirmed the existence of a homonymous defect in the fields of vision. This defect could not be influenced by suggestion or by any other treatment, nor did any other change whatever occur in the condition.

Steiner inquires whether this hemianopsia is to be taken as organic or functional. The air-pressure of the shell hissing past might have produced a concussion, or the falling unconscious might have produced a commotio cerebri or a slight hemorrhage. The tic-like blinking and vasomotor excitability, however, suggest functionality.

Hysterical pseudoptosis.

Case 438. (Laignel-Lavastine and Ballet, January, 1916.)

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

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

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

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

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

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

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

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

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

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

Shell-shock Rombergism.

Case 439. (Beck, June, 1915.)

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

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

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

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

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

Otology and neuropsychiatry should go hand in hand.

Case 440. (Roussy and Boisseau, May, 1917.)

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

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

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

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

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

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

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

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

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

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

(c) Extreme bilateral dulness of hearing.

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

Jacksonian syndrome: Hysterical.

Case 441. (Jeanselme and Huet, July, 1915.)

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

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

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

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

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

Leg tic: Phobia against crabs.

Case 442. (Duprat, October, 1917.)

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

Convulsions reminiscent of fright.

Case 443. (Duprat, October, 1917.)

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

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

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

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

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

Case 444. (Mallet, July, 1917.)

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

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

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

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

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

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

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

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

Case 445. (Mallet, July, 1917.)

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

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

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

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

Aprosexia and bird-like movements.

Case 446. (Chavigny, October, 1915.)

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

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

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

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

Case 447. (Liébault, 1916.)

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

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

Shell-explosion: Recurrent amnesia.

Case 448. (Mairet and Piéron, April, 1917.)

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

Shell-explosion: Comrade killed: Amnesia.

Case 449. (Gaupp, April, 1915.)

F. K., a 23-year old soldier, in civil life a turner, of Polish descent, and of a somewhat nervous and easily excitable disposition, early in August went from Strassburg into the Vosges and Lorraine. On the 26th a number of shells exploded near him. The troop was excited and took refuge in a cellar. K.’s best friend was torn to pieces by a shell. When his body was removed, K. felt sick and lost consciousness. He arrived at the clinic in Tübingen in a stuporous condition, by hospital train, on August 31, 1914. He walked weakly to his bed, supported by two men, and lay in the bed, apathetic and reacting to questions only with a stare. Things put in his mouth were swallowed. He remained motionless.

Next evening he answered a low Yes to a nurse’s question about eating. A little afterwards he said he supposed he was a prisoner in the enemy’s country. A little later he got properly oriented but still did not know how he had come. September 2, however, he was much clearer and said he had awakened out of a long dream. There was a complete amnesia, however, from the moment when he went to help remove the torn body of his friend up to September 1. Memories became clearer for the period before the shell explosion. The patient became very lively, talking vividly of war experiences, imitating shell hissing with an expression of intense anxiety, getting accustomed to battle scenes, saying that he was now seeing everything again as if real. He remained anxious for some days, complaining of weight on his chest and of feelings of internal restlessness and tension.

Amnesia for the period of August 26 to September 1 remained; all that K. could add to the story of those days was that he had been thrown sidewise for some distance by the air pressure of the shell.

From September 6 onwards, he grew calmer but he was still very labile, given to lively imaginings and emotion. By the middle of September he was well and discharged for garrison duty.

Shell-explosion: Recurrent amnesia.

Case 450. (Mairet and Piéron, July, 1915.)

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

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

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

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

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

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

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

Soldier’s heart, both neurotic and organic.

Case 451. (MacCurdy, July, 1917.)

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

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

Soldiers heart, neurotic.

Case 452. (MacCurdy, July, 1917.)

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

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

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

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

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

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

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

Case 453. (Myers, March, 1916.)

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

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

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

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

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

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

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

The officer who could not kick.

Case 454. (Mills, January, 1917.)

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

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

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

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

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

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

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

Case 455. (Voss, November, 1916.)

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

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

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

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

Forearm wound: Hysterical edema?

Case 456. (Lebar, July, 1915.)

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

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

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

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

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

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

Case 457. (Voss, November, 1916.)

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

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

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

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

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

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

Case 458. (Collie, January, 1916.)

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

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

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

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

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

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

Yes-No test of value re anesthesia.

Case 459. (Mills, January, 1917.)

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

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

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

After a number of weeks he became able to walk.

Arabian fever.

Case 460. (Roussy, April, 1915.)

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

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

Case 461. (Briand and Kalt, February, 1917.)

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

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

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

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

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

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

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

A newspaper cure.

Case 462. (Sicard, October, 1915.)

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

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

Re malingering, see discussion concerning simulateurs de création and simulateurs de fixation under [Case 453].

Deafmutism: Explained by patient as malingering.

Case 463. (Myers, September, 1916.)

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

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

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

Deafmutism: Appearance of malingering.

Case 464. (Myers, September, 1916.)

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

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

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

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

Simulation of deafmutism.

Case 465. (Gradenigo, March, 1917.)

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

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

A lame rascal.

Case 466. (Gilles, April, 1917.)

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

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

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

Mother love and jaundice.

Case 467. (Briand and Haury, January, 1916.)

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

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

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

SIMULATION

(Blum, December, 1916)

False angina, from irritating solution.

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

Diarrhea. (Isolate.)

Diarrheal stools imitated by a mixture of urine and water.

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

Appendicitis. Complaint of pain at the well-known McBurney point.

Tape worm. Carriers supply others.

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

Hemoptysis. Irritation of throat surfaces with a needle.

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

Diabetes. Phloridzin, or oxalate of ammonia. Glucose added to urine.

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

Skin diseases:

Erythema. Herbs.

Eruptions. Mercury, arsenic, iodine, bromide.

Herpes. Euphorbiacae.

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

Impetigo. With cantharides plaster and pomade stibiée.

Intertrigo. (In the infantry.)

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

Edema of legs. Constriction.

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

Recurrent wounds. (Cover with wax sealed bandages.)

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

Phlegmons. Subcutaneous introduction of turpentine or petrol.

Paraffine tumors. (Apply heat.)

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

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

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

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

Muscular weakness. Arsenious acid in eggs. Voluntary lead and mercurial intoxications.

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

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

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

Intra-abdominal projectiles. Bullet swallowed.

Swelling of hand and forearm, seven months.

Case 468. (Léri and Roger, September, 1915.)

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

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

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

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

Re evading service, Gleboff’s classification is as follows: 1. False assertion of disease of (a) internal organs, (b) vision, (c) hearing, (d) joints. 2. Simulation of temporary disease of organs. 3. Mutilation of limbs.

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

A German shell-shy.

Case 469. (Gaupp, April, 1915.)

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

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

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

Case 470. (Marie, April, 1915.)

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

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

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

SIMULATION: Question of Quincke’s disease.

Case 471. (Lewitus, May, 1915.)

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

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

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

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

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

Case 472. (Collie, May, 1915.)

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

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

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

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

Chart 14
SHELL-SHOCK

• GROUP I. EXHAUSTION
• (Alcoholism perturbs treatment)
• GROUP II. HEREDITY
• (Certain poor recruits)
• GROUP III. MARTIAL MISFITS
• (Wrong attitude of mind)

After Farquhar Buzzard

Chart 15
NEUROSES AND PSYCHOSES OF WAR

• 1. NEUROSES
• Motor
• Sensory
• 2. NEUROSES
• Special Sensory
• Speech
• 3. NEURASTHENIA
• Hemichorea
• Exophthalmic Goitre
• Trench Spine
• 4. PSYCHOSES
• Minor
• Gun-shy, Insomnia, Dreams, Phobias, Psychasthenia, Hypochondria
• Stupor, Anergia, Acute Dementia
• Psychoses (Civilian Forms)

After A. W. Campbell

---

D. TREATMENT AND RESULTS OF SHELL-SHOCK.

“E però leva su, vinci l’ambascia

con l’animo che vince ogni battaglia

se col suo grave corpo non s’accascia.

“Più lunga scala convien che si saglia:

non basta da costoro esser partito

se tu m’intendi, or fa sì che ti vaglia.”

“And therefore rise! conquer thy panting

with the soul, that conquers every battle,

if with its heavy body it sinks not down.

“A longer ladder must be climbed:

to have quitted these is not enough;

if thou understandest me, now act so that it may profit thee.”

Inferno, Canto XXIV, 52-57.

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

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

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

Shell-shock: Deafmutism. Spontaneous cure.

Case 473. (Mott, January, 1916.)

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

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

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

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

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

Chart 16
METHODS OF PSYCHOTHERAPY

• HYPNOSIS
• Verbal Suggestion
• Fixation
• Fascination
• Various
• SUGGESTION (WAKING)
• Verbal
• Drug
• Apparatus
• AUTOSUGGESTION
• DISTRACTION
• TERRORISM
• INFLICTION OF PAIN
• PERSUASION
• WILL TRAINING
• OCCUPATION THERAPY
• ISOLATION
• PSYCHOANALYSIS

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

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

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

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

Case 474. (Gilles, 1916.)

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

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

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

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

Case 475. (Purser, October, 1917.)

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

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

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

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

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

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

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

Case 476. (Jones, 1915.)

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

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

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

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

Course in hospital of an oniric delirium.

Case 477. (Buscaino and Coppola, January, 1916.)

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

December 21, discharged well.

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

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

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

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

Case 478. (Buscaino and Coppola, January, 1916.)

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

Paraplegia: Cured by administration of Iron Cross.

Case 479. (Nonne, December, 1915.)

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

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

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

Case 480. (Proctor, October, 1915.)

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

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

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

Case 481. (Anon, May, 1916.)

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

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

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

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

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

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

Case 482. (Zanger, July, 1915.)

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

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

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

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

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

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

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

Case 483. (Binswanger, July, 1915.)

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

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

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

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

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

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

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

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

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

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

Case 484. (Hirschfeld, February, 1915.)

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

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

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

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

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

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

Shell-shock: low blood pressure: Pituitrin.

Case 485. (Green, September, 1917.)

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

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

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

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