A. PSYCHOSES INCIDENTAL IN THE WAR (continued 3)

Emotion; shell fire: Epileptic equivalents.

Case 85. (Mott, January, 1916.)

A man, 19, suffered from shock due to emotional stress and shell fire. He had terrifying dreams. After a short time, he developed paroxysmal attacks of maniacal excitement. Just before the first attack he had been helping in the kitchen, lay down on his bed, went to sleep, woke, startled, flushed, and sweating, and made for the door as if terrified. He remained in this state as if suffering from hallucinations of sight and hearing, and without ability to recognize his wife, the doctors, or the Sisters. When two strangers in uniform came in to observe him, the adjutant became violent, as if the uniforms had started terror anew. The attacks lasted from a few hours to a few days, coming on suddenly, without apparent cause. One day he tried to get over the wall of the playground. He came back and buried his head in his hands. Major Mott spoke to him, whereupon he got up, looking terrified, made for the door, and four orderlies were required for his restraint. At Napsbury Hospital, to which he was sent, he made a complete recovery.

Mott suggests that we are dealing with a psychic equivalent of epilepsy.

Re epileptic equivalents, compare notes from Lépine under 58 and 59.

IV. PHARMACOPSYCHOSES (THE ALCOHOL, DRUG, AND POISON GROUP)

Pathological intoxication.

Case 86. (Boucherot, 1915-6.)

A Territorial infantryman, aged 37, was in the habit of drinking a good deal without getting drunk, and at the front drank a good deal of bad brandy. He had just taken a considerable quantity when his regiment got the order to charge. The charge was hardly over when the man became greatly excited and hallucinated. He thought he was surrounded by Germans and tried to transfix his comrades with the bayonet. Howling and struggling he was carried to the rear.

He was soon brought to the asylum at Fleury after howling all night and seeing the Boches and animals fighting among themselves. His hands and tongue were tremulous and there were cramps in the calves of his legs. On the 6th he expressed astonishment to find himself in hospital and was found to have but slight memory of what had happened. He remembered, however, that he had tried to kill his comrades. With the deprivation of alcohol he became rapidly normal and was sent back to the dépôt in a few days.

Re alcoholism under army conditions, Lépine remarks that alcohol has played in this war a rôle analogous to that of malaria in the epidemiology of some countries. Many of the victims are, to start with, unbalanced subjects and détraqués who are hereditary alcoholics. Alcoholism, according to Lépine, dominates the pathology of the interior and has a marked bearing upon conditions at the front. In fact, alcoholism would have been disastrous in France had not measures been taken against it; measures still insufficient (1917). More than one-third of 6000 cases studied by Lépine during three years have shown alcohol as a sole or, at all events, principal cause of the difficulty. It would be within reason to state, according to Lépine, that if we throw in cases in which alcoholism was a partial factor, more than half, or even more than two-thirds, of the mental cases had been strongly influenced by alcohol. Lépine thinks there may be effects like those of anaphylaxis. Certainly, the startling and sudden effects in so-called pathological intoxication, as in Case 86, suggest the critical and vehement effects seen in the sensitized anaphylactic subject.

Chart 4 PHASES OF WAR PSYCHIATRY IN FRANCE

I.Antebellum phase of Psychiatric Neglect: Groundless fear that recruiting would be disorganized by psychiatric sifting processes.

II.Phase of Alcoholism of Mobilization: Hospitals unprepared.

III.Phase of the Marne: Alcoholism restrained by law; psychoses few; psychiatrists optimistic.

IV.Phase of Trench Warfare: Overemotionality; and of High Explosives (January, 1915); now psychiatric services were systematically established along evacuation lines.

V.Phase of Systematic War Psychiatry: Filterwise system of management (a) near trenches, (b) in main body of army, (c) on evacuation lines, (d) special hospitals.

Chiefly from data of Chavigny, 1915.

Pathological intoxication: criminal prosecution stopped.

Case 87. (Loewy, 1915.)

An orderly, in private life a teacher, one day about noon-time, when going on duty, called the commanding officer to account because he (the orderly) had had to wait. He said he had been ordered to come at two o’clock and it was already long thereafter! He was severely reprimanded but addressed a number of the officers present with questions having no relation to military service. In fact, he seemed to have forgotten entirely that he was on military service.

This was the more remarkable as the teacher-orderly had many times distinguished himself upon dangerous patrol expeditions and in critical situations, winning the confidence of his superiors and the likelihood of promotion to corporal. He had been a discreet, earnest, and clever soldier.

Loewy observed him during this affair and noticed that he did not by language or movement suggest intoxication or hilarity but merely a certain excitement. He was entirely oriented for time, place and person, and his outward behavior was correct enough except for his military rank.

Sent to his quarters near by, he gave the impression to his immediate superior officer of deep drunkenness. He murmured something and soon fell into a deep sleep. After waking, he had an almost complete amnesia, knowing only that something disagreeable had transpired. He remembered that he had been offered several little glasses of cognac brandy by a comrade, and that he had drained them off quickly before going on duty. He said that he had never drunk cognac before, and in fact had drunk nothing for a long time.

The diagnosis of pathological intoxication was made, and the soldier was thereby cleared of his dangerous situation; a criminal prosecution was not instituted. He thereafter behaved with entire sobriety and modesty, and he achieved his corporalcy and later became file leader.

Desertion in alcoholism may deserve the term “pathological.” Case of fugue.

Case 88. (Logre, July, 1916.)

A “deserter” said: “I went because I drank a glass. I just went, comme ça, without any motive.” He was somewhat feebleminded and, in explaining the impulsivity of his act, he added: “I went like a broken-down beast. I walked straight ahead, without knowing where I was going and if I had been going to be killed, it would have been all the same to me.” He could not that afternoon remember very well; but next morning, after having slept, he regained full consciousness. He said that he then found himself in a field near a cemetery. He had carried his gun and equipment with him, but had lost them somewhere, and from a military point of view, his desertion was complicated by loss of effects. On coming to, he said to himself, “Where am I? How foolish after fifteen months in the line! Probably I have deserted again.” In fact, he had a month before left his post under exactly the same conditions in the midst of a period of alcoholic excitement.

This alcoholic fugue is typical: drunkenness, impulsive and subconscious ambulatory automatism, with partial amnesia, disorientation, with mislaying of objects, followed by sleep and immediate return to normality.

Re fugue, see discussion under Cases 58 and 59. The French military code cannot excuse victims of fugue even though executed in a quite unconscious state, if the fugue is due to alcohol. There was a certain procursive suggestion in the fugue of Case 88, who went “like a broken-down beast,” straight ahead, without knowing where he was going.

Alcoholism: Amnesia experimentally reproduced.

Case 89. (Kastan, January, 1916.)

February 15, 1915, a German soldier drank beer in the canteen and at roll-call appeared tipsy. He then went to bed, but rose an hour later to go to town. A quarter of an hour later, he went to a clerk’s house and asked for paper, on the ground that the next day he was going to march to Warsaw. The clerk gave him no paper, which he then tried to get by force. A policeman arrested him and he said, “You just wait, lame dog!” Upon examination he denied that he had ever been guilty of any crime but had been in institutions on account of delirium. In point of fact, this man had grown up in very bad surroundings, amongst quarrels and disputes of his parents, who kept a disorderly house. At 19 he had been convicted of incest. He finally admitted having been convicted for rape. It was found that he had once run out into the front trenches; had been removed by an advance guard to a stable, and then wondered why he was not in school. He described a number of attacks of delirium although he had not drunk more than moderately.

He was given an experimental dose of 50 c.c. of alcohol, and in ten minutes became excited, tried to get out of bed, attacked other patients without reason, and was able to speak neither spontaneously nor in response to questions. In a period of two hours he became clear and asked what the trouble was. He knew only that he had taken alcohol.

Re the experimental excitement produced in Kastan’s case by the exhibition of alcohol, it is of note that Bérard has been much impressed by the agitation that surgical cases of alcoholism undergo when anesthetized. It may be that the anesthetics act similarly to the experimental alcoholism of Kastan’s case. According to Bérard, these phenomena of the anesthetized wounded (who are men recently evacuated from the front and other hospital cases) are of larval alcoholism brought out by the anesthesia. Bérard wonders whether rum issues at the front are at all responsible therefor.

Desertion, drunk. Contributory factors.

Case 90. (Kastan, January, 1916.)

Gottlieb S. left the barracks, January 25, 1915, met friends and drank with them, remaining all night in the railway restaurant and waiting room. He was promptly arrested.

According to the patient, he had always drunk a good deal and had once fallen from his horse in the campaign, and become unconscious. After this fall, he said he had been able to stand less alcohol than before.

There is doubt as to the syphilis of Gottlieb. He said he had been infected once, but his further statement that he had six relapses is, of course, questionable. As to the hypothesis of feeblemindedness, it appears that in childhood he had learned badly and had been a stammerer. He had been a herdsman, and after that a laborer. He finally became a travelling man for a specialty photographer.

He had previously been convicted of an embezzlement, brawling, and breach of the peace.

As to his military crime, he said he had been celebrating the emperor’s birthday the last three days, being urged on by acquaintances and drinking whiskey. He was, in fact, on a spree and did not eat properly. He had met a student in the railway station and had forgotten all about his military service. He remembered having spoken with the waiter, remembered telling the student that he was going to commit suicide, and the student had drunk seltzer with him. January 29, he for some reason drank no more, and then it occurred to him that he ought to go back to duty. He remembered that he was easily led astray. He had once thought of becoming a tanner but had been dissuaded from the trade because of its bad smell.

The analysis of this case must consider, first, syphilis. Supposing, however, that this hypothesis is not substantiated by laboratory findings, the hypothesis of feeblemindedness might well be raised. It seems possible, if not probable, that this patient was in the subnormal group, lying between normality and feeble-mindedness proper. The value of mental tests would here be extreme. There seems to be no evident epilepsy, and the majority of the phenomena can perhaps best be explained by alcoholism. Possibly the case is one of so-called pathological intoxication. The patient’s own story that, although he had been always subject to drink, he had been less tolerant of alcohol since a fall from his horse, seems to be entirely consistent with the post-traumatic history of numerous cases, so that it would hardly be wise to consider that alcohol accounts for the whole story. We must raise then in succession the hypothesis of syphilis, feeblemindedness, alcoholism, and coarse brain disease, bearing in mind also early stammering. As to the utilization of such a man, it would appear that a supervision of him with absolute countermanding of alcohol in view of the decrease in tolerance of alcohol since the fall from his horse might perhaps preserve this man for some form of military service.

Re German and French war alcoholism, Soukhanoff remarks that the conditions in these countries were in strong contrast to those in Russia. In Russia there was a great decrease in the number of cases of acute alcoholic psychosis; particularly at the time of mobilization, there were few cases of alcoholic psychosis. He says that during the Russo-Japanese war, alcoholic psychoses constituted a third of all the mental cases observed. This figure corresponds with that quoted above from Lépine (see under Case 86). Soukhanoff, writing in 1915, had not observed personally a single case of alcoholic psychosis. Incidentally, the number of cases of psychosis in the Russian army had remained in general small.

Desertion by mild alcoholic dement.

Case 91. (Kastan, January, 1916.)

Emil S. made a number of statements when he came for examination. He had once had a treatment by injections. Both his mother and his grandmother had been insane. He said that his brother was an officer in the navy, but this statement was found to be false.

According to his story, he had lost touch with his troop at the end of September, 1914, and had lived in several lodgings in T—— up to October 19, when he was arrested. He said that he did not know that a man who had lost touch with his troop had to report.

A week after his arrest, S. entered a shop and asked for coffee, saying that he had a furlough of 24 hours and wanted cake for his comrades. He said he was the owner of an estate and would send a roebuck for the cakes. The shop-man gave him cakes to the value of one mark. Bystanders said that he had been lodging in T—— for about two weeks. It seems that he had told his landlady that a city official had quartered him upon her and that he was on furlough. He went away in the morning and came back in the evening. He had written to a bank of which he had once been a representative, asking for money. One night he had lodged with another landlady, being given a meal, and he had there stated that he was in the City of T—— on duty and that his horse was in the barracks. He offered a thousand marks for his board and lodging.

At another lodging he had given himself out as a courier. In fact, the letter to the above-mentioned bank had been signed “Otto S., Land-owner, at present, courier.”

“If I do not revoke this in person or by writing on January 1, 1915, I beg you to pay to Mr. and Mrs. M. of T——, one thousand marks and deduct it from my balance.

“This is to be considered as my last will. As witness: present: Joseph B.”

The letter was addressed “To the direction of Commercial-Counsellor P——.” There was no stamp on the letter.

A second letter reads:

“Honored Sir, Commercial Counsellor:

I beg you to send by return mail to the address given below 1000 marks, and deduct this amount from my account. I have been in Russia. Well, things are moving now. Thank God, we have reached the point we have. Write me please more in detail about my property and estate and give me your very valuable advice.

With best regards to your esteemed wife, I remain

Sincerely and respectfully yours,

Otto S., at present courier, otherwise, land-owner.”

As for this Commercial-Counsellor P., P.’s son stated that his father had been dead for three years and a half.

S. gave himself out in T—— as a land-owner, falsifying his name, asking for beer to the amount of a mark a day, borrowing from his landlady ten marks, paying nothing, but remaining on friendly terms with the landlady and her women lodgers, making a contract with a superintendent ostensibly for his estate, and borrowing money from him.

Observed in the clinic, he said he was a bank representative and had been very nervous since being divorced in 1911. The divorce was due to his wife’s adultery. Sometimes he would not know really what he was doing, once even tried to shoot himself, and again once threw a burning lamp into his wife’s face without knowing it.

He had gone to the City of T—— without furlough in October because others used to, too. Only five days later had he noticed that his troop was no longer there; and upon inquiring about the troop he could find nothing as to its whereabouts.

He had been a heavy drinker and was always somewhat intoxicated, which, according to the patient, made him forget everything. He had drunk 20 glasses of beer and liquor daily. He wrote to P. because he knew his father.

As for the frauds, he said he knew nothing about them. He did not know even the baker from whom he had gotten the cakes. In fact, he had been drunk the whole day long.

He said that he had learned badly in school and had not passed any examinations. In active service he had already been convicted of drunkenness once. Referring to his treatment by injections, he said he would rather be dead. He had only sought diversion in looking over estates. Both his ability to reckon and his memory had suffered greatly. He and another patient eloped from the clinic one day but were captured a few hours later.

Remarks: Details are lacking as to the physical and laboratory side of this case. On the whole, there appeared to be no convincing features of paresis or cerebrospinal syphilis. The phenomena are very possibly in part alcoholic. There appeared to be no sensory disorders, and in particular no hallucinations. The intellectual disorder is chiefly amnestic. There is little or no evidence of emotional abnormality. The curious conduct seems hardly to indicate a primary disorder of will. The main feature psychologically appears to be amnesia coupled with an inability to reckon. To be sure, the letters are written externally in sufficiently good form; the amnesia does not appear to extend to details. It is a question of whether the disorientation which one suspects is not merely amnestic. On the whole, however, it would appear that there must have been at various times disorder of consciousness, as indeed is indicated by the patient’s own account of his ignorance of the cake-roebuck episode.

Dismissing the hypothesis of a syphilitic dementia, we might cling to that of alcoholic dementia more or less punctuated by acute alcoholism. Yet it is also possible that the patient was actually somewhat feeble-minded; this would be consistent with his own statement. The question might arise whether this soldier could have been excluded by careful psychiatric examination before entering service. It would seem that a knowledge of the insanity of the mother and grandmother, and an inspection of school records, if available,—to say nothing of the episodes which may or may not have been accurately related, between himself and his afterwards divorced wife—would have sufficed to throw doubt upon the military effectiveness of this man. We know also that he had already been convicted of drunkenness on military service before the episodes mentioned.

Desertion by alcoholic. Contributory factors.

Case 92. (Kastan, January, 1916.)

Carl B. was a soldier about whom the captain thought that his intellectual power had been weakened by drink. An inquiry after arrest showed that he had been odd also at home. He had once been sued for perjury, but the suit had been stopped for lack of evidence. He had been several times convicted of drunkenness. It appears that on March 30, 1915, after mounting guard, he said nothing and went home, remaining at home until the next day and then returned to the guardhouse in the street-car. He declared, this time, that the non-commissioned officer had given him permission to leave, although this statement was not correct.

Again, on April 6, B. was about to leave the quarters, but the surgeon, finding him drunk, kept him back. He did not go home that night, and the next day when he was wanted at the hearing, he could be found only in the afternoon. He replied confusedly and somewhat irrelevantly to the questions asked. On arrival at the clinic he was in tears and much depressed. Given 50 grams of alcohol, he became somewhat livelier. Upon examination, his perceptions were found diminished; he felt, he stated, a cracking and crackling in his neck. In his cell he had felt as if sparrows were roosting in his face; he had heard voices and seen pictures, and had not known what he was doing. He asserted his innocence, blaming his imprisonment for all his troubles. He had been in the habit of drinking three liqueurs and two glasses of beer a day. He had been drawing a pension since a fall from a scaffold.

A sister had suffered from continual headaches. The patient himself had three sickly children and ten of his children were dead; there were also two premature births.

The analysis of this case would clearly show the benefit of considering, first, the hypothesis of syphilis. Not only is the history of his children suggestive, but the impairment of mind noted by the captain as due to alcohol may very possibly be syphilitic in origin. Examples in division he could not solve, and it is a question whether his leaving guardmount is not in part related to disorientation for time. There appears to be no evidence of feeblemindedness and none of epilepsy (though a sister suffered from continual headaches). Alcohol may account possibly for the entire picture and is particularly consistent with the false voices and figures, the sparrows in the face, and the sensations in neck and the tickling in the ears. It is possible, also, that intolerance to alcohol had set in since the fall from the scaffolding for which a pension was being received. It does not appear necessary to consider any further of the groups of mental disease. Syphilis, alcohol, and a post-traumatic brain condition, all may play a part. Alcohol is able probably by itself to produce a number of these symptoms, and these alcoholic symptoms would be probably the more readily produced in virtue of the post-traumatic intolerance that we may assume.

A disciplinary case: Alcoholism.

Case 93. (Kastan, January, 1916.)

A German soldier, brought up for examination for disobedience and insubordination with intoxication, was found already to have been convicted 33 times of a variety of crimes. Once he had drunk a bottle of shoemaker’s polish, evidently with suicidal intent.

In the canteen he had assaulted superior officers and tried to strike a sergeant. He said he had been attacked by the sergeant and pushed into a cell, whereupon he had lost his mind.

He came from a family of drunkards, and had been himself very alcoholic formerly. On the day in question, however, he had drunk very little. According to his account, he had fits of this sort if any one injured him. He was amnestic and had forgotten his previous convictions. Anything he might have done, he said, had happened a long time ago, in his youth. For example, concerning a theft, he said that it was merely that he had fallen into some Christmas trees and stuck fast there, and no one wanted to be paid. Tremors of hands, feet, head. Analgesia of thorax.

Re alcoholism and disciplinary cases, we find alcoholism bulking large in Lépine’s account of military delinquency. Fugue subjects are not infrequently alcoholic. Minor disobedience is also often alcoholic. Acts of violence are characteristically alcoholic, or executed by subjects with hereditary alcoholic taint. (Such acts were in France especially common before the anti-absinthe law in 1915.) Alcoholic episodes and impulses often culminate in arson. No doubt, espionage employs alcoholism for a portion of its technique, though delusional mystics and subnormal hypersuggestibles are more often the purveyors of information to the enemy. The theft list, also, shows its share of alcoholics. Alcoholics are less common amongst those who, contrary to rules, assume shoulder-straps or other decorations. Here the sub-normals and victims of imbalance, as well as the drug cases, are more likely to figure if the matter is psychiatric at all.

Remarks upon an atrocity.

Case 94. (Kastan, January, 1916.)

April 15, 1915, a German soldier went with three comrades to a farm, to select a sheep for slaughter; they were obliged to go to three farms. The man carried a revolver and cartridges in his pocket. He threatened the farmer that he met with this revolver, and desired to rape the farmer’s daughter. He was very drunk, and said to the non-commissioned officer who was called in at the time, “You have served only a year longer than I have.” He staggered, struck violently with his hand at the sergeant, and gave insolent replies.

He had already choked the peasant’s daughter, scratched her face, and bitten her fingers, hand and arm. She could not run away as she was lame. The soldier held the revolver to her face and shot it off several times, offered sex assault, scratched her feet with his spurs, and tried to twist her neck. The non-commissioned officer threatened to shoot him, and he then became still. He said to the first-lieutenant before whom he was taken, that he would do anything but allow himself to be beaten, and at this moment moved his arms about in the air, and bloody foam came from his mouth. The first-lieutenant previously had always thought him to be normal except for a strange flicker and unrest of the eyes. There was a history that he had already once attacked a servant girl. The man had amnesia for the affair, only remembering how the non-commissioned officer had come on a white horse. He remembered nothing about the peasant and the girl. He said that he had been given to earache on the right side in winter. There was a history of his having fallen from a tree in childhood, becoming unconscious. He had been a sufficiently good scholar up to the second class in school. He had been an excellent soldier.

Alcoholism: Atrocity.

Case 95. (Kastan, January, 1916.)

September 15, 1914, a German soldier was missed. He had said that he wanted to get to the enemy quickly, and that he was going to march alone against the Russians. A shot was fired that night by this soldier, on the ground that he had been insulted by a civilian, although no civilian was present.

September 21, a farmer in a wagon reached a farm, where he found the soldier aiming at a woman. He fired, wounded the woman severely, and jumped on the farmer’s wagon and rode off with him. It seems that the soldier had come to the farm at noontime and accused the woman of treachery, ordering her to come with her husband to a certain farmhouse, where she should be placed against the wall and be shot. The soldier had shot her and wounded her husband also. According to the woman, the idea was to take revenge because she had denounced certain persons as spies.

He was arrested during the night, and told how he had left his troop because he could not get at the enemy. He had been informed that there were spies who ought to be shot; there had been talk in a certain inn about it. He did not know he had wounded the husband, and he only wanted to give that dangerous woman a piece of his mind.

After wounding the woman, he had given himself no further thought about her, but had gone to partake of the holy sacrament at the pastor’s. He then had drunk another glass of beer and gone to bed. He was, in fact, still drunk at the time of arrest. He had not been aware that he would be punished for the crime of going alone against the Russians.

Some days later, he wrote that he did not intend to kill the woman, that he had been drunk at the time and was always a bad man when drunk; that he had other times when he absented himself from home for days when drunk. He had had, he said, a number of attacks of delirium, in which he had seen animals. At one time, he had fallen on his head. On the day in question, he had drunk 1½ litres of liquor. He was remorseful for his deed.

A disciplinary case: Alcoholism; amnesia.

Case 96. (Kastan, January, 1916.)

A German soldier, New Year’s Eve, 1915, got away from his company, drank whiskey, and came back drunk. He bothered his comrades so that the non-commissioned officer had to call for help; whereupon the soldier said, “A man who comes on late and hasn’t been in much, hasn’t much to say. If it is a non-commissioned officer, I shall hit him in the snout.” The officer kept talking to him kindly but he cried “Halt’s Maul, you crooked …!” He staggered up to the lieutenant without saluting, but at a slight push fell prone into the straw.

It transpired that the man had not been intoxicated enough to lose all control of himself. He did not remember anything about what he had done; he had drunk a half-bottle of rum during the evening. There was a demonstrable lack of memory. He did not know the German provinces, and thought that Bismarck had once been war minister. There was a tremor, hypalgesia of the left leg and analgesia of the left arm and left shoulder.

It was found that he came from a strongly tainted family, with two insane sisters and three insane cousins. He had been a good soldier during his service, but had accused his father of alcoholism baselessly. He had always been difficult to manage when drunk and had been convicted nine times: five for dangerous assault and battery. He drank up to 1⅓ litres of whiskey a day if he got time, and also took ether. For some ten years he had been amnestic for what he did while drunk; nor, according to his wife, had he been able recently to stand so much alcohol. He said that he had had a fall from a wagon in 1911 or ’12, after which he had been unconscious.

Antebellum, run over by an automobile; intolerance of alcohol; episodes of amnesia after moderate alcohol.

Case 97. (Kastan, January, 1916.)

A German soldier was advanced in rank February 26, 1915, and in honor thereof drank six or seven glasses of beer. On his way home, he met a captain and failed to salute him. When called to account, he said he could not see, and made remarks about regrettable behavior. He refused to go along with the officer. Afterwards he remembered that he had been stopped by an officer but had forgotten subsequent happenings.

March 24, he was riding in an electric car with a lieutenant. He said to the lieutenant who had unbuckled his sabre, “It is a piece of insolence and improper to unbuckle the sabre.” He repeated the phrase on questioning. He was then asked to give his name, and replied, “I know my name but what is your name, Mr. Lieutenant?” He looked drunk at the time but afterwards remembered nothing.

Physically he was tremulous and showed blepharospasm. His face grew red on bending over.

This man had been run over by an automobile in 1910, after which he had become excitable, slow-thinking and forgetful. The spinous processes were painful on pressure, as was also the hip joint. The history showed that he had been convicted six times of various crimes, such as disturbing the peace, embezzlement, and the like. Since this accident he had not been able to work effectively. He had gone into the army in a spirit of enthusiasm.

Adventure with a stranger in Paris.

Case 98. (Briand and Haury, 1916.)

A soldier had seven days’ leave in Paris, beginning December 27, 1915, and the first day drank a good deal of wine with another man on leave. They met, in some place that the patient had forgotten, a well-dressed man whom they did not know, and all three fell to drinking. The stranger told them he knew a trick to prolong the leave to 3 or 4 weeks. “All I have got to do is to prick you, and it will cost only 100 sous.” The operation was done at the café after payment in advance. The operation was a puncture with a needle between the middle and ring fingers of the left hand. Next day there was a phlegmon of the dorsal surface of the hand, and he was put into hospital saying that he had gotten a barbed wire prick in the trenches. The surgeon who opened the phlegmon was surprised at its gummy appearance, gangrenous odor, and greenish tint. In point of fact, petrol had been injected.

Morphinism: Tetanus.

Case 99. (Briand, 1914.)

Mdm. L. was a morphinist. After the outbreak of the war, she went to a general hospital to recover from morphinism, but was too excited to be kept there. Accordingly, she had to be sent to Sainte-Anne, but upon arrival she developed distinct signs of tetanus.

It seems that Mdm. L. was the widow of a Colonial who had given her the first injections ten years before, for dysentery. She tried several times to stop. Daily dose 1.5 grams.

She was in a cachectic state, and according to her mother, took no care of her syringe, trailing it about everywhere. Her thighs, arms, and anterior aspect of the body were covered with scars. There were small phlegmons in places. Did she inoculate herself with bacillus tetani from an infected needle? In any case, she died of tetanus.

Medicolegal question concerning a morphinist.

Case 100. (Briand, 1914.)

A man worked in Paris on the ’Change, where there are a number of syringe victims. He had been brought up in Paris but was not a Frenchman. Enthused by his friends and the prey of deep emotion, he enlisted. He was of an introspective nature and himself wondered whether the morphine did not have something to do with his enlisting. He said, “I had been unnerved for a number of days by reading the papers, and after a number of heavy injections, I went to a recruiting station and signed on.” In his regiment, he continued the injections, but shortly found that he would be unable to replenish his diminishing stock of drug. He explained his unhappy fate to the corps physician, and was sent to Val-de-Grâce. He asked to be retired, alleging that he was under the influence of a poison when he went to the recruiting office and had therefore committed an illegal act.

Social effects of the war on two drug addicts.

Cases 101 and 102. (Briand, 1914.)

Fernand and Emilienne were two recidivists in morphinism. Although neither was over 22 years of age, both had been several times convicted of shop-lifting. They stole only if they had no money for morphine. Prostitution served to care for Emilienne, while Fernand was at times a cocaine seller, and at times made money in devious ways at Montmartre. Emilienne’s patronage scattered with the war, and it was the same with Fernand’s. Accordingly, there was no money for either morphine or cocaine. Moreover, the shops being not crowded were easier to watch. As Emilienne did not care to be arrested and sent off as an undesirable, she presented herself at the hospital for the insane at Sainte-Anne. Fernand shortly joined her there.

V. ENCEPHALOPSYCHOSES (THE FOCAL BRAIN DISEASE GROUP.)

Left-sided hemiplegia and aphasia: Contrecoup and local lesions.

Case 103. (Lhermitte, June, 1916.)

A soldier of 23 was wounded in the left parietal region and showed a left-sided hemiplegia with aphasia. The speech difficulty, although very marked, retrograded almost completely, but the hemiplegia remained severe. This hemiplegia was a spastic one, of a classical nature, with Babinski sign and exaggeration of tendon reflexes. Lhermitte thinks that the left hemisphere was directly affected by the contusion, as in point of fact there was an actual loss of bony tissue, but that it would not be necessary to suppose the ipsilateral hemiplegia was due to an absence of pyramidal decussation. The transient aphasia was probably due to direct affection of the tissues on the left side of the brain; the permanent hemiplegia was doubtless due to a lesion of the opposite hemisphere produced by contrecoup. It appears that sometimes a surgeon may be led to superfluous surgical intervention in a case of such paradoxical hemiplegia, since the surgeon may believe that a bullet or shell fragment has traversed the brain substance to the opposite side of the skull, when as a matter of fact the brain parts have been injured merely by contrecoup.

Re such amnesia, it is of note that many head cases, even if they do not show amnesia, show a conspicuous euphoria and lack of understanding of the seriousness of the injury in question and of the necessary treatment. According to E. Meyer, there are constantly to be found in head cases disturbances of perception and lack of coördination (especially for time), perseveration, difficulty in thinking and calculating.

Chart 5 COMMOTIO CEREBRI

I.Senses: Asymmetrical hyp- or anesthesia (with hyperalgesia and osseous hyperesthesia).

II.Motility: Disorder, muscular or reflex. General or unilateral hyperexcitability.

III.Vasomotor Control: Dermatographia. Cardiac, splanchnic disorder; also, Headaches, Vertigo.

IV.Emotions: Disorder.

V.Intake of Ideas: Disorder. Persistent lacunae of memory.

VI.Intelligence: Disorder of recollective memory. Speech-disorder. Intellectual inertia. Overimagination (hallucinations, tremors).

Mairet, Piéron, Bouzansky.

Gunshot wound of head; alcoholism: Amnesia.

Case 104. (Kastan, January, 1916.)

A German soldier had a bullet pass through his right eye and lower jaw, leaving a fistulous opening from the mouth. He said that he was completely blind, but ophthalmological examination cast doubt upon the blindness. There had been immediately after the injury a number of severe attacks of dizziness, which lasted several hours; and another attack developed after he had come back from hospital, to which he had gone by reason of his pains.

He was to be arrested on account of a disciplinary crime and had ostensibly gone to his mother’s house, there to await arrest. The non-commissioned officer found him in a saloon. As soon as the phrase, “You are my prisoner!” was said, the soldier lost track of his surroundings. He had drunk a few glasses of beer but did not himself think he was drunk at the time. He was insulting and violent when asked to proceed with the officer, and a policeman was called in to take charge. He then lay down in the street and had to be put upon a wagon, still firing abusive phrases at his captors.

Upon examination, aside from the effects of the gunshot, excessive knee-jerks and tremors of the body were found. The eyebrows met but there was no other sign of bodily stigmata. There seems to have been no hereditary disease, or any history of severe alcoholism, though the man had been convicted previously of violence and theft. The amnesia is to be ascribed to effects of the head injury.

Bullet in brain: Crises; cortical blindness; vertigo; hallucinations.

Case 105. (Lereboullet and Mouzon, July, 1917.)

An invalided soldier, 40, was sent to be observed, Oct. 23, 1916, because he wanted his pension renewed. He had been retired a year before for diminution of binocular vision with impaired perspective of objects in the right half of the visual field. He had now become completely blind.

He had been wounded, March 12, 1915, in the Argonne, without losing consciousness. He was wounded at ten o’clock at night and waited until the next day to walk to the ambulance and was at this time able to see perfectly. Arriving at the ambulance he lost consciousness. He was trephined but remembers nothing about the trephining.

His memory grew better from his arrival at a hospital in the rear in April. An attempt was made to remove the bullet in May, 1915. Though the surgeon’s finger was pushed as far as the tentorium the patient did not lose consciousness or sight, but on leaving the operating room he fainted and, after a few days of restlessness and delirium, he became completely blind. There was a cerebral hernia difficult to reduce. Vision became a little better and light and persons could be distinguished at the time when he was retired. A month after the operation there was a convulsive crisis beginning in the left arm, affecting the legs and ending in unconsciousness. Several similar crises occurred in August, sometimes with and sometimes without loss of consciousness. Later these crises began to be limited to the left side and then to be ushered in by visual hallucinations. At home he was unable to care for, clothe or feed himself. The crises became more frequent. The visual hallucinations began to dominate.

This situation lasted to February, 1916, when the blindness which had been increasing since the onset of the hallucinations became complete. The crises now became less frequent and intense. Headaches not severe were exaggerated after seizures. The patient acted like a totally blind person and said that he had before him a uniform and constant gray without any light or dark spots or any color. Upon this background bizarre pictures, caricatures, disguised persons, animals or nameless things appeared colorless without relief, in silhouette, but highly suggestive of reality to such a degree that at first, according to the patient, he had made gestures to reach, or push aside these pictures. The crises were Jacksonian.

Pallor, perspiration, shivering, irresponsiveness, clonic spasms of left arm followed. The patient always had a premonition permitting him to get into bed if he was sitting, for example, in his chair. Sometimes there was a dizzy sensation as if the body were being rotated to the left. This sensation did not occur at the beginning of the seizure and the patient fought against it, turning to the right. Sometimes he felt as if he were sliding at great speed down an inclined plane. Headaches and sleepiness followed, but there was never any complete loss of consciousness of memory.

The eye grounds proved normal and all the photomotor reflexes were normal, though there was no pupil reflex to pain. The patient could write readily to dictation printed letters. It would seem that these printed letters mean that he had visual memories, as he traced the characters as if from a design. Speech was monotonous with some stuttering; but his speech had always been of this sort according to information. He walked with difficulty, not merely on account of his visual but on account of his equilibration disorders. Outside of his seizures he always turned to the right and if left to himself standing he turned to the right. If asked to walk straight ahead, he always turned to the right. Silent and uncommunicative, he was amiable and sometimes even gay. He often had troublous dreams, sometimes seeing his relatives. He said he could bring up in his mind the faces of his relatives and even the appearance of the Salpêtrière. Reflexes and sensations were normal. There was a traumatic rupture of the tympanum. Lumbar puncture showed a slight excess of albumin and 1.8 lymphocytes to the cubic millimeter. The Mauser bullet was found by X-ray in the left calcarine region with its base touching the median line, and applied to the inner table of the skull about a centimeter above the internal occipital protuberance pointing forward, outward, and upward. He was treated on a salt free diet with bromides. The seizures grew fewer and at the time of report two months had elapsed with nothing but a slight vertigo and frequent nightmares. Intellectually also the patient had improved.

The case is one of cortical blindness. The seizures are explained by the vicinity of the right Rolandic region to the lesion. The rotatory vertigo is to be explained by the contact of the Mauser bullet with the tentorium and vermis of the cerebellum, which may also explain the difficulties in orientation that occurred between the crises. The visual hallucinations are doubtless due to lesion of the calcarine region.

Tunisian theopath with mystical hallucinations; gun-shot wound of occiput (bullet extracted): After the trauma, Lilliputian hallucinations and micro-megalopsia.

Case 106. (Laignel-Lavastine and Courbon, 1917.)

A. ben S. was sent to Villejuif with the diagnosis: “depression, feeling of impotence, discouragement,” having been found on the public street. He was indifferent, almost completely mute, and was at first considered not to understand French. In a fortnight, however, he was talking freely and was then found to be afflicted with hallucinations, melancholia, and delusions, apparently following trauma to the skull.

A. ben S. might have been about thirty years old, and was of a rich family, indigenous in Tunis, well educated in the Koran and Arabic literature.

Upon examination, this Tunisian gunner showed contraction of visual fields, poor color vision, and general hypalgesia. During examination, the man seized the needle and plunged it deeply under his skin, exclaiming that a prophet felt nothing and that he could be cut into bits without feeling pain.

It seems that he had had divine visions from early childhood. In his youth he had once gone to a mountain near his home and talked with Mohammed and Allah. Of course, Allah did not appear in human form, but he appeared like a ball or a wheel of fire, slowly turning. Mohammed was a tall man, with a long white beard, his eyes darting rays of fire, and his forehead bearing a gleaming bright body. Allah was heard talking to Mohammed. Orders were given concerning the sun and stars. Subterranean treasures were displayed, as well as Paradise full of yellow, blue, and green houris, transparent, such that, when food was taken, it could be seen going down their throats. Hell too was visible, and the devil very tall and black, an eye behind and another on top. There were also many genii—little men who climbed over the Tunisian’s body. Sometimes in dreams, Allah carried him to all countries of the earth. It was hard to tell whether these effects were hallucinations or vivid imaginings. The Tunisian had been wounded after several months of service by two bullets in one day: the one causing an insignificant lip-wound; the other entering the skull behind. After several months the bullet had been extracted by trephining.

His further history was obscured by the fact that he wove delusional elements into his story. He said, for example, that he had been court-martialed, though there was no evidence that this was a fact. It is probable that after his wound the patient in a delirium felt that he was going to be shot. The visual hallucinations were very interesting, being Lilliputian. He would see three or four hundred Tunisian gunners walking along, knee-high or taller. Sometimes they all would stop and aim at him. He also showed micromegalopsia, real objects changing their height under his eyes. Both the Lilliputian hallucinations and the micromegalopsia dated from the trauma to the skull. There was no change whatever in the mystical delusions concerning Allah and Mohammed. These he had before the trauma.

Meningococcus meningitis with apparent recovery: Dementing psychosis.

Case 107. (Maixandeau, 1915.)

A soldier in the Heavy Artillery, 42, developed occipital headaches and Kernig’s sign, December 27, 1915.

December 31, at the Hôtel-Dieu, he showed myosis, slight photophobia, meningitic tâche, temperature 39.6, pulse 84, heart sounds dull. Lumbar puncture: hemorrhagic fluid.

January 1, the headache was intense, neck stiffness increased, Kernig’s sign less marked; morning and afternoon temperature 39.2. Lumbar puncture yielded hypertensive cloudy fluid and 30 cubic centimeters of serum were administered.

This dose was repeated January 2 and January 3, on which date there was no headache.

January 4, Kernig’s sign and neck stiffness were diminished; fine râles at the bases without dulness. 30 cubic centimeters of electragol were injected intravenously.

January 5, Kernig and neck stiffness slight. Meningitic tâche; exaggerated knee-jerks; unequal pupils; temp. 36.6 morning, 39.4 afternoon; respiration 36; pulse 120; no râles; splenic enlargement.

6, no headache or photophobia; constipation; fine râles, right base; spartein; meningococci found in hypertensive spinal fluid. 30 cc. serum.

7, more râles; exaggerated heart sounds; intestinal worms in stools.

8, temperature fell to 37; pulse to 90.

9, patient worse; involuntary stools; Kernig’s sign; stiff neck; fever. 30 cc. serum injected.

10, 20 cc. injected.

11, delirious all night; tetaniform stiffness of neck; more râles.

12, delirious, incoherent words, Cheyne-Stokes breathing.

13, less stiffness, Kernig almost absent; pupils normal; Romberg sign slightly developed; pulse 120.

14, a few râles at right base.

15, pains in elbows, knees and hands with joint swelling; moist râles; temp. 38.4; pulse 140. Digitalon.

16 and 17, serum erythema of thorax; edema of left knee; pulse 150; spartein 16.

17, ice pack over heart.

18, edema of knee diminished; no headache, delirium or pupillary sign.

19, improvement. Temperature normal thereafter.

20 and 21, fine râles. Then all symptoms disappeared.

Recovery was predicted, but on January 28 it was observed that the patient was untidy, made mistakes in dressing, such as trying to put his legs into the armholes of his shirt, and denied the most evident facts: His képi on his head, he said it was not. Face drawn; skin yellow. Appearance of asthenia. Deep depression and hebetude. At this time the knee-jerks were exaggerated, pupils unequal, vermicular tremor of tongue; the patient walked on a broad base with tremulous legs suggesting contracture and weakness.

February 8, in a similar state the patient wandered about his room, moving his bed and chairs about, answering questions with an absent air. He had now been taught to be less untidy.

March 5, stiff neck and Kernig’s sign were distinct. He made believe he was on his farm. Ecchymosis of right upper eyelid: he had fallen (his sheep had pushed him over!). The improbability of this idea did not persuade him to think it had not happened. He walked after the manner of a tabetic.

In April he became bedridden, unable to walk, with marked stiffness and Kernig’s sign. He had at this time periods of excitement in which he would tear the bedclothes. He was invalided as demented.

Meningococcus meningitis.

Case 108. (Eschbach and Lacaze, November, 1915.)

During his eleven months captivity at Grafenwöhr, Eschbach and Lacaze had the opportunity of observing the case of a soldier, 24, who sustained a shell-wound in the left lung and was made prisoner August 20, 1914, at Chateau Salins. He got well of his wound, but February 16, 1915, began to cry out and was restless in the night. He was found on the straw muttering words among which only the word, “Head, head,” could be distinguished. He was irresponsive, possibly deaf. Suddenly he had a convulsive crisis and whenever touched he would have jactitations and cry out. Otherwise, he was calm and stuporous. The pupils were widely dilated. In short, he showed a mental confusion associated with paroxysmal excitement due to cerebral and cutaneous hyperesthesia. The first symptoms had occurred the morning before, when he leaned his head against a wall and complained.

Lumbar puncture yielded intra- and extracellular meningococci. The patient was isolated. In the afternoon he became less agitated, kept his eyes closed, mumbled, repeated gestures, would spit in his hands, rub his hands together, rub his neck, shoulders and body, or else he would pass his hands over his forehead and through his hair. Occasionally he would seize the straw and draw it to him with all his strength. Once when asked, “What is your name?” he said, “Not true. Not true.” Hallucinations appeared to have been added to the situation. The neck was a little stiff to forced flexion. Temperature 37.8. Lumbar puncture under chloroform anesthesia; antimeningococcus serum was injected. Next day quieter; able to get up and walk. Slept, mumbled less, was able to answer simple questions, desired to urinate and finally succeeded.

February 19, no mental disorder. Headache and lassitude. Neck stiff, Kernig’s sign marked. Lumbar puncture yielded a fluid now puriform; antimeningococcus serum injected. February 20, lifting the head produced opisthotonos. Labial herpes. The fluid yielded, besides meningococci, also endothelial cells. Serum injected. February 21, fibrin in fluid; serum injected. February 22, no head symptoms. Herpes more intense, involving also arms. Tongue coated. Temperature 37.5, evening 38.3. February 23, meningococci and lymphocytes in fluid. February 24, left knee swollen. Serum injected; puncture fluid showed meningococci and polynucleosis. Fluid from knee showed polynuclear cells without organisms. February 25, patient reached evening temperature of 39.5; serum injected. A few meningococci, altered polynuclear leucocytes. February 26, patient rigid, tongue coated, serum injection. Rare meningococci, degenerated polynuclear leucocytes. February 27, rigidity decreased, evening temperature 37.7. February 28, Kernig’s sign absent. Herpes dry. Serum injection. Fluid clear; lymphocytes and polynuclear cells; no meningococci. March 6, painful inguinal gland on the left side. March 7, epididymitis left (mumps two years before, with headache two weeks and double orchitis). March 9, serum eruption. March 17, epididymitis practically absent. Lymph node painful. Later data impossible to get, except that there was apparently an arthritis of the hip and a sacral decubitus with eventual recovery.

Shell-explosion: Meningitic syndrome, fourteen months.

Case 109. (Pitres and Marchand, November, 1916.)

A soldier sustained shell-shock at the distance of a meter at Saint-Hilaire, September 26, 1915. He lost consciousness and blood flowed from his ears. He arrived, September 28, at the neurological center in Bordeaux in a semistupor, knowing that he had been shocked and had lost consciousness. He groaned, cried out, and kept stroking his head with his right hand; lay on the right side; showed Kernig’s sign right, ptosis, and stiff neck. Headache was increased on moving and noises. Patient constantly asked for food, but refused to drink. Lumbar puncture yielded a yellowish fluid, due to laked blood. October 3, headache, ptosis, left internal strabismus, temperature 38.5. October 4, lumbar puncture, slightly blood-tinted fluid. October 5, improvement; gap in memory for period since shock. No strabismus, ptosis diminished, temperature normal, improvement continued. Kernig’s sign and headache persisted. He lay doubled up on the right side, eyes closed, right hand on pillow. Defense movements on touching the neck or occipital region. The condition of semistupor often passed off in the afternoon, when he could talk, write or play cards. He had always smoked, even at the beginning of his disease. Lumbar puncture yielded a normal fluid December 12, 1915. He was sent February 23, 1916, to a hospital in the country, but came back May 9.

It seems that several days after transfer he had had an attack of delirium in the night, having lost consciousness, and tried continually to get up out of bed, saying that he wanted to go to Verdun to fight. This spell lasted several hours and on the days following came mutism, refusal of food, and a state of stupor. Nutritive enemata were given. As he grew better he sometimes ate a great deal, sometimes nothing, even wanted poison from his family, and wrote to a comrade that he wanted to commit suicide.

May 9, he was clearer, told of seeing the shell, which he said he had not heard, nor did he know how he had gotten to a hospital. His head and spine had hurt him ever since the shock. He had had difficulty in urination for two days after the shock. He could not remember the delirious attack in the country hospital. He gave various data about his life, but not fully. He refused to lie on the left side, or to walk, because of pain. He could lift either leg from the bed, but hardly both. There was an irregular coarse tremor of the extremities. The right hand was weaker than the left; there were no reflex disorders; no change in the eye grounds. There was a patchy analgesia. May 26, stupor reappeared as before, with semimutism. June, the patient presented the appearance of a dementia praecox in stupor, with stereotyped gestures and attitudes, without catatonia. The patient was sent to a hospital for the insane at Cadillac. November 9, 1916, he returned to the neurological center, as mental and cerebral disorder had disappeared. There still persisted a difficulty in remembering facts since the shock and there was still a functional paresis of the legs.

We here deal with a case of a meningitic syndrome following shell-shock and lasting fourteen months.

Brain abscess in a syphilitic: Matutinal loss of knee-jerks.

Case 110. (Dumolard, Rebierre, Quellien, 1916.)

An unmarried subaltern officer, 30, entered an army neuropsychiatric center, April 8, 1915, looking exhausted and bearing a ticket “nervous asthenia, evacuated for neurological examination.” He said he had had scarlet fever at ten; strongly denied syphilis, of which he presented no trace; had not been excessively alcoholic and had had no nervous seizures. Detailed information showed that he had been a normal child. He left his two years’ military service with promotion and was a man of above the ordinary intelligence.

He was wounded in the right buttock with a shrapnel bullet about the end of September, 1914. He went back to his regiment two months later and had shared in a number of actions up to the time of his evacuation. He said he had been very tired for several weeks, and had finally been sent to the physician. There were pains in the kidney region and in the head, especially on the right side. The head felt empty. He could not sleep, but did not dream. Ideas were not distinct. Memory had become impaired. He could not keep his accounts right, and was afraid something might go wrong.

There was no pain or nervous or reflex disorder of any sort except for the knee-jerks and Achilles jerks (see below). A special examination proved complete normality of eyes. There was a slight hesitation in words, but no dysarthria. There was a slight tremor of the tongue and fingers.

As to the tendon reflexes, April 9, on waking, the knee-jerks were absent, but later in the day gradually came in evidence again. The Achilles jerks were also absent at first, but could be obtained after a prolonged examination and after percussion of the calf. In the afternoon, after exercise, the knee-jerks and Achilles jerks were easily demonstrable. The left Achilles jerk was always a little weaker than the right. Massage brought these jerks out to virtual normality. April 10 and thereafter, similar findings; percussion of the muscular masses of the thighs and calves always brought out the reflexes.

Lumbar puncture yielded a clear fluid with hyperalbuminosis, 20 cells per c.mm. (lymphocytes and mononuclear cells 95 per cent) and a positive W. R. Iodide of mercury treatment was given April 18.

April 23, the patient went into a coma, with trismus, stiff neck, Kernig’s sign, sluggish pupils, incontinence. He was transferred to a special hospital, showed on lumbar puncture, April 23, 85 per cent polynuclear leucocytes, and died April 27. The autopsy showed a yellowish, quasidiffluent softening of the size of a small egg in the first occipital gyrus on the right side. The authors comment on the fact that the only objective sign in this case was the variable tendon reflexes of the lower extremities, “l’unique cri de souffrance des centres nerveux.”

Early recovery from a spinal cord lesion.

Case 111. (Mendelssohn, January, 1916.)

Mendelssohn reports a soldier, who was sent to a Russian hospital, April 12, 1915, with a diagnosis of chronic appendicitis. Operated on next day, the patient appeared to be passing through a normal convalescence, when ten days later, he had an intense headache and some trouble in vision, which disappeared the next day, only to be followed, two days later, by the patient’s complaint that he could no longer urinate or rise from bed.

In fact, Mendelssohn found a complete flaccid paraplegia with urinary retention, without fever or pain. Knee-jerks and Achilles jerks were absent, and there was a slight extension of the great toe on plantar stimulation. There was disorder of sensation, with heat sensibility abolished, painful points poorly localized, and position sense poor. Electric reactions normal. Pain on pressure in and about the lumbar vertebral region. Cerebrospinal fluid showed lymphocytosis and an excessive albuminosis.

This paraplegia lasted six weeks. At the end of May, the patient began to be able to move his toes and to lift his heel. Improvement was gradual and progressive. Early in June he could walk if supported. The weak knee-jerk then began to reappear and the urinary retention gradually disappeared.

This patient was not hysterical, although a bit emotional. Perhaps, according to Mendelssohn, an organic lesion was grafted on a neurosis. Perhaps the spinal lesion was infectious. At any rate, a presumably organic paraplegia had recovered in two months and a half.

Shell-explosion: Meningeal hemorrhage: Pneumococcus meningitis.

Case 112. (Guillain and Barré, August, 1917.)

An infantryman, 20, came to the Sixth Army Neurological Center, October 13, 1916, as a case of “choluria, due to shell explosion; epistaxis needs watching.” He was somnolent, had waked vomiting, pulse 108. Kernig’s sign, defensive movements of the legs on stimulation, with flexion of leg on thigh and of thigh on pelvis, plantar reflexes flexor. Puncture showed typical meningeal hemorrhage. Two days later, temperature 40, pulse 70, that is to say, a bradycardia in proportion to the fever. Vomiting, pulse persisted. Next day the patient was moaning and semi-delirious and showed stiff neck, Kernig’s sign, accentuation of vasomotor disorder, plantar response flexor with leg retracted, thigh flexion both homolateral and contralateral. The spinal fluid upon the next day, that is, four days after his arrival at the clinic, showed a purulent fluid in which there was an excess of albumin, no sugar, diplococci extracellular (proving on culture to be pneumococci and able to kill a mouse in twenty-four hours).

As a rule such hemorrhages remain aseptic, and in fact meningeal hemorrhage is said by Guillain and Barré to have, as a rule, a favorable prognosis. The above described case was the only one of infected meningeal hemorrhage that had occurred in the Sixth Army Neurological Center.

ANTEBELLUM cortex lesion: right hemiplegia; recovery. Struck by shrapnel on right shoulder: Athetosis.

Case 113. (Batten, January, 1916.)

A British soldier, aged 27, showed a somewhat remarkable phenomenon. It appears that at five years of age, this man had had poliomyelitis, affecting the left leg. At 20 years of age, he had had pneumonia, and this had been followed by a paralysis of the right arm and leg with a loss of speech. The man recovered from this illness, although he never quite regained full control of the right hand. It is evident that this lack of control was not marked, else the man would not have been enlisted, and it is Dr. Batten’s opinion that at all events he could not have shown pathological movements of the right hand at the time of enlistment.

However this may be, in October, 1914, the soldier was struck on the right shoulder with shrapnel. Apparently he was not wounded, but thereafter he was not able to use the right arm well, and in two months’ time he had become unable to manipulate his rifle. On January 13, 1915, he was sent home. The remnants of the old poliomyelitis of the left leg were shown in a general weakness of that leg as compared with the right. The movements of the right hand were those seen in athetosis. The movements were independent of volition. The patient had difficulty in releasing his grasp. He improved rapidly during the six weeks he was in hospital, although the movements of the right hand never became entirely normal.

In this case, according to Batten, “the stress was sufficient to bring into prominence the symptoms due to an old cerebral lesion.”

Hysterical versus thalamic hemianesthesia.

Case 114. (Léri, October, 1916.)

A soldier, 40, had been suffering for a number of months with pains in the left side of the trunk and feelings of weakness in the left arm and leg. In the summer of 1915 he was on leave and while walking, fell, lay down, and found he could hardly move his left arm and leg. Two or three weeks later he got up, walking with a stick. After some time in hospital, he was sent back to the trenches, a little weak.

He had shortly, however, to be examined neurologically again. He could hardly raise the left leg and his passive resistance was poor on this side. The left side was almost completely anesthetic to all forms of stimulus, although an intense faradic current yielded a feeling like that of a fly. Nor was the tactile sensation absolutely nil, as it could be got with a flat finger on the upper arm and thigh. Cold and heat sensations not well localized. The hemianesthesia was sharply limited at the median line and affected the buccal, lingual and nasal mucosa. Deep sensibility was almost abolished on the left side. Stereognostic sense was lost and the sense of position was lost absolutely for hand and foot.

The patient said that he heard less well on the left side. There was also a slight contraction of the left visual field. The reflexes were lively, but equal on both sides. A diagnosis of hysterical hemianesthesia was apparently called for, but psychoelectric treatment failed. The plantar reflex was, in fact, completely absent on the left side, as well as the corneal reflex. The faradic current failed to produce as marked a dilatation of the pupil on the left side as on the right. The forehead wrinkles were less marked on the left side. The mouth deviated slightly to the right. The left nasolabial fold was a little less marked. The tongue did not deviate, but was a little narrow on the left side. The palate deviated a little to the left. The left side of the trunk seemed a little less developed than the right, and the scapula stuck a little less closely to the body on the left side, when the arms were raised. The left buttock was a little narrower than the right and the left gluteal fold was less marked. In combined flexion of thigh and trunk the left foot readily left the floor. There was a left-sided hypotonia in forced flexion of the forearm. There were no tremors of the limbs in repose, except a few contractions of the left lower extremity. In movement, however, there was a marked tremor and in coördination the finger to nose test could not be performed. Speech was slow and hesitant, sometimes stuttering. Food was sometimes taken into the air passages. Headaches were localized on the right side. They had begun when the first symptoms began. There was mental disorder, with gaps in memory. In short, the case is probably one of thalamic disease, though there were no pains except a few in the left side of the trunk at the beginning of the disease. The diagnosis of hysteria was at first made in this case, but the rule that hysterical hemianesthesia is never found without auto- or hetero-suggestion caused the alteration of diagnosis to thalamic.

Shell-explosion: Syndrome suggesting multiple sclerosis.

Case 115. (Pitres and Marchand, November, 1916.)

A soldier, 40, carriage painter, underwent shell-shock at Voquois, May 2, 1915, following ten hours’ bombardment. At the time he felt tinglings. The bombardment had just ceased when he fainted suddenly while repairing a telegraph line. There was no loss of consciousness. He could not move his arms or legs, was able to spit, and did not suffer at all except for the tingling. He was evacuated to the interior, where the diagnosis of psychopathic double paraplegia, Kernig’s sign, zones of anesthesia in the legs, was made. He was immediately treated with gray oil, and got an injection of neosalvarsan, and iodides. He grew slowly better. He could lift a leg from the bed, but then both legs began to tremble. The arms had recovered their movement, before the legs, but always trembled in movement.

November, 1915, he was able to get up; two months later, he walked alone.

At the neurological center, which he entered December 17, his gaze was fixed and there was a slight exophthalmos. The folds of the face were smoothed out. The nose was deep set (as a result of a fall at the age of eight). In the upright position he could not remain still, but trembled markedly on the left side, so that he had to make a few steps to keep his balance. He was unable to stand on his left leg. He walked on a broad base, in little steps, and rather unsteadily on account of tremors augmenting upon movement. General muscular weakness; left hand slightly weaker than right. He could not lift both legs more than 20 cm. from the bed and in the process they both trembled, trembling together. There was also intention-tremor of the arms, a little less marked than that of the legs, of an irregular rhythm. The arms trembled as a whole. In a state of rest there was no tremor. There was a slight muscular stiffness and the patient himself felt difficulty in relaxing. Patellar reflexes absent, even on reinforcement; Achilles jerks absent. Speech monotonous and tremulous, but not scanning; syllable doubling observed by the patient. Manuscript tremulous and, on account of tremors, illegible. Hypalgesia of legs, more marked distally. Deep sensibility of tendo Achillis and patellar reflexes lost. Pain on compression of eyes diminished. Formication in arms. W. R. of blood negative. Slow improvement followed and the patient left the neurological service May 4, 1916, able to walk more easily and without tremor. The knee-jerks and Achilles jerks were still absent.

We here deal with a syndrome in part that of a multiple sclerosis, that is, the intention-tremor, gait disturbance, muscular rigidity, and weakness.

Re multiple sclerosis, Lépine remarks that there are numerous army cases of pseudo multiple sclerosis which are actually hysterical or hystero-traumatic cases of hypertonus and tremor. The true cases of multiple sclerosis, according to Lépine, are of interest inasmuch as they are usually found in officers. These men have apparently at first but a slight motor disorder, quite compatible with desk work. We have usually under-rated the cortical element in multiple sclerosis. Spells of confusion, delusional ideas, sometimes grandiose, start up without warning in these cases. To be sure, alcohol and syphilis sometimes also enter these cases etiologically. Any case of localized tremor ought to be carefully examined psychically, and such cases in general ought not to be given responsibility.

Coexistence of hysterical and organic symptoms in two cases of mine explosion.

Cases 116 and 117. (Smyly, April, 1917.)

A soldier was blown up by a mine and rendered unconscious. Upon recovery of consciousness, he was dumb, unable to work, very nervous, paralyzed as to left arm and leg. The paralysis improved so that in the hospital at home the patient became able to get about. However, he threw his legs about in an unusual fashion. Several months later, the patient was much improved.

Shortly, however, there was a relapse. Transferred to a hospital for chronic cases, the patient was unable to walk without assistance on account of complete paralysis of the leg. Insomnia, general tremor, and a bad stuttering developed, with a habit of starting in terror at the slightest noise.

Hypnotic treatment was followed by almost complete disappearance of the tremor. The patient began to sleep six or seven hours a night; nervousness diminished, and the stuttering slowly improved; but neither the paralysis nor the anesthesia of the left leg was affected by suggestion. The leg remained cold, livid, anesthetic, and flaccidly paralyzed to the hip. Though a slight improvement has since been produced by faradization, the patient still can walk only with assistance.

A man was injured in 1906 by the fall of a heavy weight on his back. In 1914 he went to France as a soldier, and eight months later was hurled into a shell hole so that his back struck the edge. He was rendered unconscious. Upon recovery of consciousness, the right leg was found to be swollen, and there were severe pains in the legs and back.

Since return home the patient had gone from one hospital to another, for the most part unable to walk, suffering from agonizing pain in the head and eyes, unable to sleep, and in the night subject to horrible waking dreams.

Chart 6 MINOR SIGNS OF ORGANIC HEMIPLEGIA (LHERMITTE)

I.Hyperextension of forearm (hypotonia).

II.Platysma sign: Contraction absent on paralyzed side.

III.Babinski’s flexion of thigh on pelvis (spontaneous, upon suddenly throwing seated subject into dorsal decubitus).

IV.Hoover’s sign: Complementary opposition (on request to raise paralyzed arm, presses opposite arm strongly against mattress).

V.Heilbronner’s sign of the broad thigh (hypotonia).

VI.Rossolimo’s sign: flexion of toes on slight percussion of sole.

VII.Mendel-Bechterew sign: flexion of small toes on percussion with hammer of dorsal surface of cuboid bone.

VIII.Oppenheim’s sign (extension of great toe on deep friction of calf muscles); or Schaefer, or Gordon (on pinching tendo Achillis).

IX.Marie-Foix sign: withdrawal of lower leg on transverse pressure of tarsus or forced flexion of toes, even when leg is incapable of voluntary movement.

At first able only to bring himself to an upright position and to rush a few steps, he later acquired considerable control of his feet and legs through crutches. The insomnia persisted.

Smyly regards this case, like Case 116, as more neurological than mental.

Re organic neurology, much of great value has been reported.

Sargent and Holmes say that, contrary to expectation, there have been few war cases of bad sequelae of cerebral injuries, such as insanity and epilepsy. During early stages, after infection of the head wounds, there is dulness and amnesia, irritability and childishness,—symptoms which disappear during and after repair of the wounds. Mental disorder requiring internment is surprisingly rare. During 12 months only eight cases were transferred from the head hospital in a year to the Napsbury war hospital, where cases of insanity attributable to the service are sent; and in but two of these could the persisting mental symptoms be attributed to head injury.

Col. F. W. Mott confirms the opinion of Col. Sargent and Col. Holmes, remarking that from all the London County Council Asylums, only one case of insanity associated with gunshot head wound had been admitted, and that this was one of a Belgian who died from septic infection of the cerebral ventricles. Yet all cases of insanity in invalided soldiers belonging to the London County Council area (about one-seventh of the population of the United Kingdom) are transferred to these asylums.

Again Sargent and Holmes point out that both generalized and Jacksonian epileptiform seizures are comparatively rare in patients suffering from recent head wounds; even convulsions in later stages have been as yet less common than was feared. Thus, after evacuation to England, fits occurred in 37 (6 per cent) of 610 cases with complete notes, and in only eleven of these 37 cases were the convulsions frequent. Sargent and Holmes remark, however, that the practice of giving bromides regularly to all serious cranial injuries until the wound is healed, and for some months afterwards, seems advisable. In 33 of the 37 convulsive cases there have been severe compound fractures of the skull, and in four of these a missile was still present in the brain. Five secondary operations were performed with good results, after drainage of small abscesses in two and removal of spicules of bone in three. The In-patient and Out-patient records of the National Hospital for the Paralyzed and Epileptic were searched for epileptics already discharged from the army, but notes of but two patients attending this hospital for epilepsy were found.

As for other neurological complications aside from septic infection and hernia formation, there are a few subjective symptoms that may necessitate the invaliding of soldiers. The most common of these is headache, usually in the form of a feeling of weight, pressure, or throbbing in the head, which headache is increased by noise, fatigue, exertion, or emotion. Attacks of dizziness also occur, and nervousness or deficient control over emotions and feelings. Changes of temperament are found in some soldiers, who become depressed, moody, irritable, or emotional, and unable to concentrate attention.

Foix, under the direction of P. Marie, worked upon aphasia in 100 cases, reporting results at a surgical and neurological meeting, May 24, 1916, in Paris. Only lesions on the left side of the brain have produced important and lasting speech disorder, although lesions on the left side may leave behind them a little dysarthria or difficulty in finding words in conversation. It is, of course, hard to tell speech disorder from stupor or clouding of consciousness. Foix notes certain specialties in speech defect according to which region of the left brain is affected.

First: Prefrontal lesions produce a transient dysarthria, lasting but a few weeks, and right-sided prefrontal lesions produce just as much disorder.

Occipital lesions produce no speech disorder.

Second: Patients with right-sided hemianopsia due to lesions of occipital regions were not aphasic and could read or write perfectly. Lesions of the left visual centers certainly do not affect reading. If, however, the injury is not to the visual centers, but is upon the lateral part of the occipital lobe, then alexic phenomena appear, and these the more the lesion approaches the temporal-parietal region.

Third: Central convolutional lesion produces a variety of disorders according to the site and extent of the lesion. There is no aphasia with the crural monoplegia due to superior paracentral disorder. But slight aphasic disorder accompanies the brachial monoplegia of middle central lesion, though writing, reading, and calculation are slightly affected, and the more so the more the lesion extends posteriorly to the stereognostic regions. The lower down in the precentral region the lesion appears, the more likely is the Broca syndrome to be observed. But if the hemiplegia is chiefly a brachial monoplegia, the aphasic disorder may remain slight, involving reading, writing, understanding of words, the spoken word, articulation, and calculation.

Fourth: Lesions of the lateral-frontal region produce more or less marked aphasic disorder, just as do those of the inferior part of the precentral gyrus. This aphasia is more apt to occur when the wound is deep. However, no case of permanent aphasia has been observed in cases of lesion of the lateral-frontal region (termed in Foix’s nomenclature, the precentral region, but referring to the tissues in front of the precentral (or ascending frontal) gyrus of the more familiar nomenclature). Almost absolute, or absolute, anarthria follows the wound, and the patient is hemiplegic. This hemiplegia may last from ten days to two or three months. After a time there is no longer more than a slight dysarthria, and writing becomes good again; reading remains, perhaps, a little difficult. A complete or almost complete cure is the rule.

Fifth: When the retrocentral region is injured, various aphasic syndromes appear. The retrocentral region is the parietal-temporal lobe except the superior part of the parietal lobe and the anterior part of the temporal lobe, which latter two regions when injured do not allow any marked aphasic disorder. Lesions of the middle or posterior temporal region are particularly important for speech, and produce more marked disorder than lesions of the angular gyrus or the supramarginal gyrus. At first, words cannot be spoken, for a period of a fortnight to three months. Speech returns progressively, with an increased power of comprehension. At the same time, the patients begin to read and write. But there is no further spontaneous progress after a period of six or eight months, and then special reëducation must be started. These speech disorders of retrocentral (parietal-temporal) origin are either aphasic syndromes or slight remains of psychical disorders, or again, a disorder practically limited to alexia. The true aphasic syndromes concern the spoken word, understanding the words, writing, and calculation. The disorder is not especially dysarthric and consists particularly in loss of vocabulary. It might be called an amnestic aphasia (Pitres). These cases have well-marked intellectual disorder and their power of calculation is especially poor. As to the aphasic traces, which are more important to understand than they are extensive in point of fact, they relate particularly to calculating power, to vocabulary (slowness in finding words), and to reading (reading without comprehension). As to the cases of alexia, these are cases of lesions of the posterior part of the parietal-temporal lobe, and are usually accompanied by a hemi- or a quadrantanopsia.

To sum up, cases with central lesions (precentral and postcentral gyrus) have hemiplegia and a Broca aphasia without much tendency to cure. Cases with lesions anterior to the central convolutions have a transient anarthria and their recovery is ordinarily complete. Cases with retrocentral lesions have an aphasia suggestive of Wernicke’s aphasia, and ordinarily leave behind them extensive defects in intelligence and language. These cases should be taken account of from the standpoint of compensation, since they are much worse off for work than many cases with amputations; and though their disorder looks slight, it quite interferes with working at a trade. From the point of view of military effectiveness, the retrocentral cases are not very good soldiers, and especially not good officers, as they do not understand commands completely.

Neuropsychiatric phenomena in rabies.

Case 118. (Grenier de Cardenal, Legrand, Benoit, September, 1917.)

A farmer, 34, mobilized in veterinary work, fell sick at a station for sick horses, April 25, 1917. He breakfasted well, drank coffee, and went to the abreuvoir at eleven o’clock. He told his mates that he felt bad in his head. He fainted over a table at the eating house, refused to eat or drink. At noon he went out into the court, vomited and went to lie down. A physician thought he was suffering from angina because of the pronounced dysphagia. He entered the hospital at eleven o’clock at night on the 25th. He was found next morning on his back, with a fixed and haggard look, crimson face, masseter and phalangeal spasm at times. Respiration irregular, interrupted by moans. The pulse would go up to 120 during agitation and then go down to 50 as soon as the patient lay down again. Pupils slightly dilated and unequal. As the patient came from a sick horse dépôt, the first question was that of tetanus, suggested somewhat by the jactitation of the limbs and the trismus. A violent headache began and the patient cried out, “My head! My head!” Painful vomiting movements, with very slight bilious material. Convulsive movements increased. The pulse was slow. The diagnosis “meningitis” was suggested, despite the absence of fever and the absence of Kernig’s sign. Lumbar puncture gave limpid fluid with a normal lymphocytosis, without increase of albumin or reducing substance. The bacteriological smear and culture were negative.

Soon another sort of symptoms appeared. The patient would rise, cry out, threaten his neighbors. He was calmed with morphine. There were periods of excitement alternating with periods of calmness, during which he would reply sharply but accurately, being somewhat vexed by the questions, and would walk up and down without offering a word. When a glass of water was offered to him, as soon as his glance met the glass his eyes expressed fear. He drew back in repulsion and cried out in terror. When the liquid was out of his sight the hydrophobic spasm ceased. This hyperesthesia of the sensorium was so intense that the mere sight of the shining glassware of the laboratory brought out a sharp crisis.

He was sent that evening to the neuropsychiatry center, walking jerkily and as if slightly drunk, with a number of small gesticulations and murmurings. He was immediately isolated, undressed himself and went to bed. He did not move in his bed, and seemed to sleep. The next day he got up, dressed and had a small spell of excitement, but was quiet enough on the medical visit, though the floor was soiled with urine and vomitus and the clothing was in disorder. He now had a pronounced phase, deep sunk eyes, drawn features and anxious look; dilated pupils and an expression of mixed fear and anger. His breathing was hard and he kept his hand on his heart. He was oriented. He suddenly rose and said, “I am thirsty.” A glass of milk was given him. He hesitated a moment, plunged his mouth and hands into it and aspirated the drink without making any swallowing movements. He pushed away the glass, spat a little, and vomited a small quantity of a black liquid. Then followed an anxious crisis, and he fell upon his side, absolutely immobile, without breathing for a few seconds. Again in the sitting posture, he was taken with contractions of the limbs and face. The tendon reflexes were at this time normal.

A quarter of an hour later the attendant found him dead, in the sitting posture, leaning against the wall, mouth open, arms dependent, hands extended, pupils dilated—a death in syncope. The brain was found congested. There was a slight effusion of blood over the posterior aspect of the brain. There were no hemorrhages or softenings in the brain substance. The muscles were of a dark red to black. The adherent lungs were very slightly congested at the base. The stomach contained a quarter of a liter of black, inodorous fluid in which there was much bile and little blood. There were numerous small hemorrhages of the mucosa near the great curvature. The spleen was large, the liver congested. The Pasteur Institute confirmed the diagnosis of rabies. There is no history of the man’s having been bitten by a dog.

Tetanus: Psychosis.

Case 119. (Lumière and Astier, 1917.)

A soldier wounded May 18, 1916, was given antitetanic serum May 26th. The wounds healed, but on June 16, that is, 29 days after the trauma, contractures began, at first localized. There had been numerous wounds of legs and scrotum by shell fragments and the contractures were limited to the right leg and scrotum. There was no trismus or any lumbar symptom.

During the next few days the contractures became general, the temperature rose, a shell fragment was found by X-ray at the root of the thigh and was surgically extracted. B. tetani was found upon inoculation of media with material from the shell fragment. Persulphide of soda and antitetanic serum 90 cc. in three days were given intravenously. The temperature fell and the general health was greatly improved. July 6, hallucinations and terrors, worse at night, set in. The man believed himself surrounded by flames, that daggers were being plunged into his old wounds, that his hair was being pulled. These symptoms lasted a fortnight only, whereupon the patient recovered.

This case and six others accompanied by cerebral disturbances all recovered, and all the patients retained a perfect memory of their delirium and of their hallucinations.

The chronological distribution of these cases was odd. One case was found early in the war; then no other cases of cerebral disorder presented themselves until the group observed at the end of 1916. Besides flames and daggers, zoöpsia was several times observed. One of the cases showed these symptoms without having been given antitetanic serum.

Re tetanus in the war, see in the Collection Horizon a book by Courtois-Suffit and Giroux on Les formes anormales du tétanos.

Tetanus fruste versus hysteria.

Case 120. (Claude and Lhermitte, 1915.)

Claude and Lhermitte describe a condition of tetanos fruste. The neck was absolutely rigid. The patient had not been wounded in any way and, being regarded as a pure neuropath, was sent to the Centre Neurologique at Bourges.

The differential diagnosis lay between true tetanus and the hysterical pseudotetanus or pseudomeningitis. In pseudotetanus there is a contracture of the superficial and deep neck muscles, especially the trapezii, sternomastoid, and deep muscles. The condition somewhat suggests that of acute meningitis or tetanus, and especially suggests tetanus because it is often associated with masseter contracture (hysterical trismus). The head is immobile, stiff, and inclined backward; eyes directed above, throat slightly prominent. Upon attempts to move the head, intense pain occurs. The pain and contracture sometimes even suggest a suboccipital Pott’s disease. This form of hysterical pseudotetanus is of sudden onset, as a rule following burial in a trench or else contusion, or a slight wound in the cervical region. Pressure on the spinous processes produces no pain, nor does a blow upon the head; and an X-ray examination will definitely eliminate the hypothesis of Pott’s disease.

To return to the Claude-Lhermitte case of limited true tetanus: It showed marked modifications in the tendon and bone reflexes. Upon percussion of the zygoma, of the occiput, or of the clavicle, there was a marked further contraction in the contractured muscles. Although there was no apparent spasticity in the legs, there was an ankle clonus and a bilateral patella clonus, combined with a distinct exaggeration of all bone and tendon reflexes. In such cases also there is hyperexcitability of the nerves and muscles to faradic and galvanic currents.

An officer’s letter concerning local tetanus.

Case 121. (Turrell, January, 1917.)

The following letter from an officer who had had local tetanus and was treated by Turrell by ionization Dec. 6 and 7, 1915, by diathermia Dec. 7 to 22, and occasionally by static breeze ionization and chlorine ion to relieve contractions from Dec. 29, 1915, to Feb. 4, 1916. The tetanus was in the muscles of the legs. Of course diathermia is a purely symptomatic treatment and does not replace antitoxin serum or other specific treatment; thus its effect in relieving the contractions of local tetanus is precisely like its effect in the treatment of sciatic neuritis or lumbago.

November 15, 1916.

“Dear Major Turrell,

“I have been meaning to write to you for some time, as I knew you would be interested to hear how I was getting on. Your letter has just been received, and I am only too happy to give you any information I can with regard to my leg. I was wounded in the left leg on October 13, 1915, by high explosive shell, and arrived at Oxford on October 22. There was no operation as the surgeon in charge did not consider it advisable to remove the pieces of shell: my leg seemed to be getting better, and after about a month I was able to hobble round with sticks. My foot at this time used to swell a great deal towards night, and the foot seemed then to gradually stiffen up with violent pains at intervals, this gradually spread up the whole leg to about the knee, and I was compelled to take to my bed again. The pain at times was very bad, similar to a very bad attack of cramps, and then my leg became rigid and stiff, and at other times used to get horrible jumps and it was impossible to keep it still, and whenever the doctor or nurse looked at it it used to stiffen up at once. The night seemed to be the worst, and consequently I got very little sleep. I often had to get up in the middle of the night on crutches to try and obtain relief, my leg was so cramped and sore. It was about this time that you first visited me and prescribed a course of electric treatment for my leg, and I shall never be able to thank you enough for the relief it gave me. I cannot remember the names of the different treatments, but the first one—diathermy, or heat pads—certainly relieved the pain, and after the first two or three visits to you I got immense relief. I never looked back after this, and, although the progress was slow, I gradually lost all pain and was able to get sleep at night. The nervous jumps slowly disappeared and my leg became gradually normal except for contraction of the tendons. I was unable to straighten my ankle or knee, and it was thought at one time that my tendo Achillis would have to be severed. Gradually the knee straightened and I was able to get my heel to the ground. I was for some time on crutches, and was able to leave the hospital on February 5, 1916, walking with sticks.… I am now able to walk comfortably, but am unable to flex the ankle more than at right angle to my leg. The circulation is not very good, and I feel anything tight round my calf. I am still getting Boards, and have not been passed fit for overseas yet.”

VI. SOMATOPSYCHOSES (THE SYMPTOMATIC, NON-NERVOUS, GROUP)

Dysentery: Psychosis.

Case 122. (Loewy, November, 1915.)

Out of a large number of dysentery patients, many of whom had very serious symptoms, but one of Loewy’s patients became psychotic. Loewy in fact had discharged this one as normal, and he had been put on the wagon train (no opium or alcohol) to go to a sanatorium. As the fighting shifted, the sanatorium site changed and could not be reached with the wagon. Finally, the wagon train met the battalion once more and Loewy was told that the man was “dying.” At this time he was afebrile, without collapse symptoms, with a strong and normally frequent pulse, and with few signs of exhaustion. Yet the guard had thought that he looked moribund. Both upper eyelids were drawn rigidly up but conveyed a different impression from that in maniacal or anxious conditions. The expression was that of staring astonishment, helplessness, and apathetic lack of orientation. The patient recognized Loewy, spoke to him as “Herr Doctor,” said he was doing quite well; he was found to be well oriented. There was no fabricating tendency even as to the number of stools (although Loewy had noted such in bad dysenteries of the Shiga-Kruse type). He was apparently hard of hearing, as if at the beginning of a typhoid fever. He showed a retardation in his intake of ideas, and his voice in answering sounded absent-minded. There was an expression of absent-mindedness, and the patient seemed markedly unconcerned about his health, the direction of the journey, the terrible rain, etc. These phenomena are attributed by Loewy to attention disorder.

The patient had been out of reach of fire for days. Loewy reports the case as one of beginning amentia or as an exhausted state resembling a Korsakow condition, recalling one of emotional hyperesthetic weakness (Bonhoeffer).

Typhoid fever: Hysteria.

Case 123. (Sterz, December, 1914.)

A soldier entering hospital for typhoid fever, October 2, 1914, was discharged to another hospital and again, November 10, to a hospital for nervous disease. The typhoid was serious and complicated by delirium. After defervescence, the patient was weak and could not stand or walk, especially on account of pains and weakness in the left leg. Sometimes he had had pains in the sacrum and left hip. He complained of tinnitus, deafness, dizziness, headache. He said he had fallen from a cart, had been sick for three months, since which time he had been under medical treatment for his present condition. He had, he said, been given a small pension.