to relieve symptoms. The lenses given were +0.375 c. Vert. and L. +0.25
S. +0.25 C. 75 do.

Hemianopsia: organic or functional?

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

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

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

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

Hysterical pseudoptosis.

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

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

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

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

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

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

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

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

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

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

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

Shell-shock Rombergism.

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

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

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

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

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

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

Otology and neuropsychiatry should go hand in hand.

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

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

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

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

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

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

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

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

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

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

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

(_c_) Extreme bilateral dulness of hearing.

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

Jacksonian syndrome: Hysterical.

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

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

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

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

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

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

Leg tic: Phobia against crabs.

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

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

Convulsions reminiscent of fright.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aprosexia and bird-like movements.

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

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

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

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

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

=Case 447.= (LIÉBAULT, 1916.)

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

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

Shell-explosion: Recurrent amnesia.

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

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

Shell-explosion: Comrade killed: Amnesia.

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

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

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

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

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

Shell-explosion: Recurrent amnesia.

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

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

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

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

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

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

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

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

Soldier’s heart, both neurotic and organic.

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

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

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

Soldiers heart, neurotic.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The officer who could not kick.

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

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

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

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

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

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

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

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

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

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

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

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

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

Forearm wound: Hysterical edema?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Yes-No test of value _re_ anesthesia.

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

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

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

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

After a number of weeks he became able to walk.

Arabian fever.

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

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

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

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

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

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

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

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

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

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

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

A newspaper cure.

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

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

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

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

Deafmutism: Explained by patient as malingering.

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

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

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

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

Deafmutism: Appearance of malingering.

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

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

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

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

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

Simulation of deafmutism.

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

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

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

A lame rascal.

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

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

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

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

Mother love and jaundice.

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

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

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

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

SIMULATION

(BLUM, DECEMBER, 1916)

_False angina_, from irritating solution.

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

_Diarrhea._ (Isolate.)

Diarrheal stools imitated by a mixture of urine and water.

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

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

_Tape worm._ Carriers supply others.

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

_Hemoptysis._ Irritation of throat surfaces with a needle.

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

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

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

_Skin diseases_:

    _Erythema._ Herbs.

    _Eruptions._ Mercury, arsenic, iodine, bromide.

    _Herpes._ Euphorbiacae.

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

_Impetigo._ With cantharides plaster and _pomade stibiée_.

_Intertrigo._ (In the infantry.)

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

_Edema of legs._ Constriction.

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

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

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

_Phlegmons._ Subcutaneous introduction of turpentine or petrol.

_Paraffine tumors._ (Apply heat.)

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

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

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

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

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

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

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

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

_Intra-abdominal projectiles._ Bullet swallowed.

Swelling of hand and forearm, seven months.

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

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

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

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

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

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

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

A German shell-shy.

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

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

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

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

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

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

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

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

SIMULATION: Question of Quincke’s disease.

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

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

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

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

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

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

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

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

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

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

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

                               CHART 14

                              SHELL-SHOCK

      GROUP I. EXHAUSTION

                 (ALCOHOLISM PERTURBS TREATMENT)

     GROUP II. HEREDITY

                 (CERTAIN POOR RECRUITS)

    GROUP III. MARTIAL MISFITS

                 (WRONG ATTITUDE OF MIND)

                                             After Farquhar Buzzard

                               CHART 15

                     NEUROSES AND PSYCHOSES OF WAR

    1. NEUROSES

         MOTOR
         SENSORY

    2. NEUROSES

         SPECIAL SENSORY
         SPEECH

    3. NEURASTHENIA

         HEMICHOREA
         EXOPHTHALMIC GOITRE
         TRENCH SPINE

    4. PSYCHOSES

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

                                               After A. W. Campbell

D. TREATMENT AND RESULTS OF SHELL-SHOCK.

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

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

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

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

                                         Inferno, Canto XXIV, 52-57.

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

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

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

Shell-shock: Deafmutism. Spontaneous cure.

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

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

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

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

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

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

                               CHART 16

                       METHODS OF PSYCHOTHERAPY

    HYPNOSIS
      VERBAL SUGGESTION
      FIXATION
      FASCINATION
      VARIOUS

    SUGGESTION (WAKING)
      VERBAL
      DRUG
      APPARATUS

    AUTOSUGGESTION

    DISTRACTION

    TERRORISM

    INFLICTION OF PAIN

    PERSUASION

    WILL TRAINING

    OCCUPATION THERAPY

    ISOLATION

    PSYCHOANALYSIS

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

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

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

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

=Case 474.= (GILLES, 1916.)

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

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

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

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

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

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

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

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

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

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

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

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

=Case 476.= (JONES, 1915.)

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

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

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

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

Course in hospital of an oniric delirium.

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

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

December 21, discharged well.

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

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

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

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

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

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

Paraplegia: Cured by administration of Iron Cross.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Shell-shock: low blood pressure: Pituitrin.

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

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

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

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

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

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

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

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

Various treatments of a contracture of hand.

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

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

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

Orthopedic case.

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

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

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

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

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

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

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

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

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

    MECHANOTHERAPY (COLOLIAN)

    [Illustration: ROTATION OF SHOULDER]

    [Illustration: ROTATION OF SHOULDER]

    [Illustration: ANKLE EXTENSION]

    [Illustration: ANKLE EXTENSION]

    [Illustration: FLEXION AND EXTENSION]

    [Illustration: ROTATION OF HIP]

    [Illustration: ELBOW FLEXION AND EXTENSION]

    [Illustration: CIRCUMDUCTION OF THIGH]

Favorable effects of lumbar puncture.

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

An accountant, 20, in the 135th infantry sustained shock from mine
explosion near his trench, March 6. He was kept two days at the relief
station. March 8, at the ambulance, he did not appear to understand
questions and had a fixed stare. He complained of a violent headache
and kept pressing his head between his hands. He kept looking about him
anxiously, and the slightest noise made him jump. He would mutter a
few incomprehensible words, and in reply to a question would give only