B. SHELL-SHOCK: NATURE AND CAUSES. (continued 4)

Shell-shock; burial: Clonic spasms; later, stupor with amnesia.

Case 317. (Gaupp, March, 1915.)

A reservist, 28 (laborer in civil life, of a nervous family; even before mobilization had attacks of weakness at his work or in the company of others) January 3 or 4, 1915, fainted in the trench while shells were striking around him. On January 5 he was brought to hospital in deep stupor. He went to the reserve hospital at N. by hospital train, January 8, and arrived at the Tübingen clinic January 18.

A slip of paper stated that after burial in the trench he had been brought from the field unconscious. Clonic spasms of the upper part of the body are said to have occurred. At the reserve hospital in N., January 10, he was still unconscious, at times twitching his face and the upper part of his body, and once at night excited and delirious.

At first in the clinic he was apathetic, speaking not a word, looking vacantly into the air as if lost in a dream. He went to the section passively, and lay passively in bed.

In the examining room, he stood speechless with unemotional face, sometimes looking up to the ceiling, slowly scratching his head, failing to answer questions, although fixing his eyes upon the physician. He could not be communicated with in writing, playing uncomprehendingly with the pencil or scratching his head with it. He would start with fright at a sudden noise or an unexpected touch. Sometimes he would heave a deep sigh, grasp his head in his hands, or lay hold of his hair with a hopeless expression of face and shake his head to and fro.

Next day, January 19, he made a few slow, low answers. He was found to be entirely disoriented and with associations impeded, although he could get out his name and residence with difficulty. Some of his color identifications were correct, such as red and green; some impossible, as yellow, brown, violet. A comrade who was called in and could speak the Cologne dialect, was talked with at first with difficulty, later more easily. Although the patient was visibly freer, he remained without apparent emotion, retaining a rigid and dreamlike expression of face. It was hard to find words, although objects were named correctly, and there was no paraphasia or agnosia. Vision and hearing were normal; walking, manual movements, eating were all undisturbed though slow. The patient had to be led to the toilet. It seemed as if all intellectual life was at rest, and that in the absence of impulses from without, there would have been complete apathy. It was made out that the patient thought he was still in the trenches.

Next day, the stupor had decreased and the patient spoke, getting his bearings for a time. There was a complete amnesia as to the cause and duration of his condition. During the next period, up to the beginning of February, 1915, consciousness cleared and the apathy was replaced with anxiety, weariness, and a dull headache.

During February, the patient gradually returned to his senses, and remained in a state of general nervous exhaustion. Amnesia was complete for at least two weeks of his life and recollections were fragmentary for the first three days of his stay in the clinic. He worked willingly in the garden with the other patients. On February 26, the patient was cured and went back to the reserve battalion in a much strengthened condition.

Battles (including liquid fire); eventually shell-shock: Hallucinatory delirium, mutism, asthenia—after a few days puerilism (history of convulsive crisis in adolescence) with regression of personality to late childhood.

Case 318. (Charon and Halberstadt, November, 1916.)

Puerilism (Dupré) appeared in a soldier, 21 (uncle and cousin insane; patient had difficulty in studies at fourteen and nervous spells for two years, with loss of consciousness, fall and convulsions probably at rare intervals; a student at eighteen) after he had taken part in a number of battles with the Chasseurs Alpins. He was exposed once to liquid fire July 21, 1916. He entered the military psychiatric center at Amiens. Mental troubles had followed the bursting of a shell near him. He said a few words, such as, “Alsace; fire; blood; snow; it hurts.” These phrases, spoken in a low tone, with an anxious appearance, eyes fixed, suggested hallucination. He seemed to be listening. Aside from the isolated words above mentioned he showed complete mutism. There was physical weakness, difficulty in walking without support, exaggeration of patellar reflexes, pains in the head and limbs. After several days, he said, “Milk; bread.” After this the anxiety and the slow and difficult walking disappeared, whereupon the puerilism appeared.

Now the soldier began to run instead of walking. He galloped and gamboled like a child imitating a horse, or he would sit on a board seeming to paddle. He would skip along the halls. The puerilistic phases were rather brief and for the most part he lay in bed. There was still a certain asthenia. He made little paper boats in bed, keeping them in a small metal box along with bits of bread, looking glass and the like. If a gesture was made to take them away, he would protest and press the box to his breast, looking childish and anxious, and if the box were taken he would weep hot tears. Sometimes he would stick out his tongue at the attendants. His mother came to see him and afterwards he would say, “Mamma told me to be good, to eat well, to get well and to go home.” He would use childish grammar,—“Me eat much.” Asked why he had hollowed out a small hole in the wall of the room, he answered, “I did it for fun, but I will not do it any more. Mother doesn’t want me to.” The patient was unwilling to answer a question correctly; would sometimes answer incorrectly at first and correctly afterward.

It appears that the man had adopted the language, occupations and attitude of a child, showing a regression of personality ten to twelve years backwards. There was a neurotic basis in the convulsive crises of adolescence. On the basis of this predisposition following shock there appeared an attack of confusion, upon which, several days later, supervened ecmnesic phenomena of hysterical nature assuming all the features of puerilism.

Bomb-dropping from airplane; unconsciousness: Battle dreams. Leaves of absence failed to relieve. Episodes of dizziness and fugue.

Case 319. (Lattes and Goria, March, 1917.)

M. Alessandro, Class ’79, baker (father a drunkard; brother an idiot, in asylum), had typhus in youth, and as a boy had periods of intense “pavor nocturnus,” but no convulsions. He enjoyed good health in the army before the following event:

On July 13, 1915, a bomb, dropped by an airplane, fell near an Italian soldier, killing many comrades, and throwing the man to the ground unconscious. He awoke several hours later at a hospital in a stunned condition. During the night, under the influence of terrifying dreams, he would leave his bed to look for enemies who, it seemed to him, were throwing stones and firing. He managed to grasp a rifle and fire at the images he saw. He was given a 60 days’ leave of absence during which he did not improve; and then again 90 days’ furlough, which he spent at his home, where terrifying dreams, tremor of limbs and asthenia continued.

He came under observation February 10, after his second leave. Nutrition fair. Insomnia. Constant terrifying dreams. Coated tongue. Tremor of hands, head, body, ceasing during voluntary movements. Episodically he had spells of dizziness followed by absent-mindedness, whereupon he wandered aimlessly about, of a sudden becoming aware of being in a place, but not knowing how he came there.

Special senses intact. Several points of cutaneous hyperesthesia, particularly mammary and pseudo-ovarian on the left, pressure whereon provoked a lively emotional reaction with acceleration of pulse, redness, lacrimation. Knee reflexes lively, cutaneous reflexes normal, except the plantar which were very lively. Restless, hyperemotional, he wept for insignificant reasons and wanted to leave hospital for fear of dying there. He was discharged unimproved after a fortnight.

Nostalgic temperament; depression on entering service; rheumatism. A box falls from an airplane near by: Fear and tears; later depression, nostalgia, dreams, hyperthyroidism.

Case 320. (Bennati, October, 1916.)

An Italian private in the infantry was recalled to military service. He was a small farmer, and being disposed to homesickness, grew depressed from the day he left for service. His sleep was disturbed, he was greatly affected by the wet and damp of the trenches, and was in a state of continual fear. Finally, pains, hypersensitiveness, and fever developed.

As an enemy airplane passed over one day, a box fell at the man’s feet and threw him into a profound fear with tears. He was conducted to a tent to rest; his regiment was shortly sent to the rear, and he remained on active service for a few days despite the fever and pains. Finally the swelling of his leg compelled him to take to bed. (Fatigue in antebellum life had always shown itself in aches of the legs.) He had now been in active service about a month and his homesickness overcame him. He was in a state of deep physical and mental depression. It was not his own troubles so much as those of his family which preoccupied him. His knees hurt him so that he had to weep; or if Sardinia was mentioned, he cried, and said, “Oh, how I love Sardinia!” He grew fatigued very easily. He had many dreams about Sardinia, his father, and the war, especially dreaming about being wounded in the legs (question of being stimulated by the joint aches). The reflexes were normal, though slight tremors set up in the legs after testing. The thyroid gland was somewhat swollen, and it appears that the patient had noticed this five days before entering hospital. The patient was rather vagotonic; pulse-rate stood at 56; oculocardiac-reflex, 56-84; Mannkopf negative; Thomayer and Erben marked (56-88 and 88-60); von Graefe marked; Stellwag present.

A shell pitches without bursting: Unconsciousness; stupor; MAMA MIA!; oniric delirium; amnesia. Recovery in five weeks.

Case 321. (Lattes and Goria, March, 1917.)

An Italian soldier of the Class of ’95, a mechanic (mother cardiac; as a boy, pains in joints and heart; since boyhood, no illness), had a big Austrian shell pitch near him, July 23, 1915. The shell failed to explode and injured no one. The patient, however, fell to the ground, unconscious, and remained in the camp hospital for two days, quite immobile. This event followed an advance by his company under very fatiguing circumstances without sleep for a period of four days.

July 26, the patient was observed in profound stupor, non-reactive, constantly and monotonously repeating the phrase, Mama mia!, with fixed gaze and smiling as if at visions. He swallowed food. The pupils reacted poorly to light, and the cornea and nasal mucosa seemed anesthetic. The tendon and skin reflexes were lively. The muscles were hypotonic; bradycardia, 56; no control over feces or urine.

July 27-28, restlessness at night, gasping movements, and poses of terror.

July 29, he called for his mother, who had been dead for several years. He was still stuporous and insensible.

From August 1 to 10, he improved slowly and became able to carry bread to his mouth after it had been put in his hands. He still did not speak and made signs when he wished to urinate or defecate. Pulse 50-60.

August 12, the patient began to react to intense light and to pain stimuli, as well as to pressure. He ate voraciously.

August 15, visual stimuli were responded to, the pulse had risen to 80, the skin reflexes were no less lively. There began to be terrifying dreams at night, with motor reactions.

August 17, the patient looked about more alertly, promptly seeing bread when placed in the center of the field of vision and saying words to the man who might try to remove the bread. He did not yet react to acoustic stimuli, nor was there any other change up to August 21.

August 22 a notable improvement set in. The hearing was now slightly diminished, questions were answered after a brief refractory period. After a few questions, however, a state of exhaustion would ensue, which would disappear only after a short rest. There was amnesia for the entire period following the day of his departure for the front, May, 1915. At this time, instead of eating voraciously, he showed anorexia. The skin and tendon reflexes, instead of being lively, were now dull. There still were battle dreams of enemies trying to kill him.

August 25, there was an area of hypesthesia on the inner aspect of the right thigh, but otherwise no disorder of sensation. The pulse stood at 80 and there were no other neurological phenomena.

August 31, the patch of hypesthesia of the thigh and the retrograde amnesia disappeared. There was still a slight diminution of hearing. The accident of the non-exploding bomb could now be recalled, but there was a memory gap for all facts up to the latter part of August.

September 2, dreamless sleep; no signs of abnormality except a slight diminution of hearing. Discharged, well.

Jostled carrying explosives; no explosion; unconsciousness: Deafmutism and foggy vision. Gradual recovery from these symptoms. Then, on rising from bed, camptocormia.

Case 322. (Lattes and Goria, March, 1917.)

An Italian of the Class of 1891 (convulsions and pains in the spine, with rigidity, as a child; typhoid fever at 18; brother sickly, neuropathic; mother subject to periodic convulsions; father alcoholic and nervous), on the night of November 26, 1915, was carrying a number of tubes of explosives. A comrade stumbled and fell over the soldier, who fell to the ground unconscious. None of the glycerine tubes exploded, and none of the soldiers round about were hurt.

The man regained consciousness at the camp hospital, but remained deafmute and also impaired as to vision. It was as if a screen of fog lay between him and objects seen.

During fifteen days of observation at the camp hospital, he had terrible war nightmares. The mutism, the visual disorder, and the deafness then gradually disappeared without special treatment.

However, when the patient rose from bed, it was found that his lumbar vertebral column was stiff. He walked bent forward and was unable to bend or straighten the back. There was a hyperesthesia along the vertebrae, especially on pressure. X-ray examination showed no bone lesion. The larynx and cornea were sensitive, and the plantar reflexes were absent. The abdominal reflexes were present. The pupils reacted to light and accommodation. There were two areas of analgesia in the nipple regions. The expression of the patient’s face was relaxed and drooping.

A heavy cannon slides and grazes a man: Unconsciousness; stupor; amnesia (anterograde amnesia persistent). Complete recovery in less than seven weeks.

Case 323. (Lattes and Goria, March, 1917.)

An Italian soldier of the Class of 1895, a peasant (family healthy; non-alcoholic; good scholar) was, July 19, 1915, helping drag a heavy cannon up hill. The big gun slid, hit several men, and grazed the patient, making a slight abrasion on his leg. He immediately lost consciousness, and arrived at the camp hospital in a stupor, which lasted so long that catheterization was necessary.

A week later he was observed in hospital, immobile and non-reactive, with a swollen abdomen and fecal impaction. The pupils were widely dilated and reacted poorly to light. The corneal reflexes were absent, and the nasal mucosa was anesthetic. Pulse 50. The patient failed to eat. Next day there was no change in his condition. He was quiet throughout the night.

On the morning of July 29, a number of answers were obtained to questions put in a loud voice, though he was unaware of much more than his name, being ignorant of the name of his country, his age, his division, where he had come from, what had happened to him, or where he was. He had now begun to eat spontaneously.

During the following days, up to August 4, the amnesia gradually dissolved for the facts before the trauma. He remembered having been greatly frightened at the time of the accident but could not remember the accident itself, and the gap for subsequent events was still complete. The pharyngeal reflex was still poor. August 5, he began to remember the details concerning the accident. About the middle of August there was no longer any diminution of hearing and ideation became more free and rapid.

September 4, he was discharged, well.

Shell explosions SEEN: Emotion; insomnia. Artillery HEARD twelve days later: “finished off.”

Case 324. (Wiltshire, June, 1916.)

A lance-corporal, 36, had had a nervous debility four or five years before the war, caused by an overstudy of music. He had not stopped work at that time, but suffered from depression, anorexia, and insomnia, lasting for some weeks.

The lance-corporal got on well at the front for 11 weeks, until finally eight shells pitched near him. Although he was unhurt, he began to suffer from anorexia, insomnia, and depression. While in billets 12 days later, some English artillery became heavily engaged, whereupon “The noise promptly finished me off.” The insomnia, depression, and anorexia became more marked, and the patient could not sleep unless heavily drugged.

Shell-shock: Emotion. More shells: Insomnia; war dreams. Head tremor and tic, two weeks after initial shock.

Case 325. (Wiltshire, June, 1916.)

The psychic trauma is, according to Wiltshire, more important than physical trauma in the following case of a sergeant of infantry, 28, a man without neuropathic taint. This man had been nine months at the front and through Mons, but had been quite well until three weeks before coming to hospital.

“Twenty-three days ago, I was issuing rations when they got the range of us—and killed the other chaps. I got blown away and knocked over. I saw everything—fellows in pieces. Then a second shell came. I got lifted and knocked about ten yards.” Then he began to shake but carried on.

Two days later, “Shells dropped on the dug-out and killed the other chaps. I have not slept properly since this. If I go to sleep, I wake up seeing people killed, shells dropping, and all kinds of horrid dreams about war.” One or two of the men killed had been pals.

A fortnight after the first incident, while in a base hospital, head-shaking began. The patient would jump at the least sound. There were spasmodic tic movements with the extension of the head, protrusion of lower jaw, and contraction of occipitofrontalis muscle. Sometimes the left shoulder girdle was affected in the same way. There was a slight fine tremor of hands and eyelids and difficulty in keeping the eyes fixed on an object.

Hyperthyroidism, hemiplegia, irritative symptoms after exhaustion (by heat?).

Case 326. (Oppenheim, February, 1915.)

A man (not previously nervous, no faulty heredity, heatstroke August 21) suddenly fell down in a great heat, after a fatiguing march, and remained unconscious for several hours, waking with vertigo, headache, paralysis of left side, vomiting, and twitching of the face. On September 23, admitted to reserve hospital. Knee phenomenon increased. Urinary retention; catheter used. Speech disturbance, facial twitching. Vomiting had stopped September 10. Catheterization could be avoided through warm sitz-baths. October 30, on sitting up, occipital pain and vertigo. November 15, urinary symptoms improved. Also improvement otherwise. December 1, gait vacillating and uncertain. Headache. Admission to nerve hospital, December 3. Here complained of twitchings in the frontals and corrugators. Wide palpebral gaps. Rare, or absent, movements of lids. The extended hands showed active, rapid tremor. Tendon phenomena increased in the arms and especially in the legs. Abdominal reflexes increased. Active tremor in the legs. Gluteal tremor. Very pronounced Graves’ symptoms. Syndactylism very pronounced in the feet, between second and third toes. Later on, improvement under half-baths, etc. Worse after ten days’ leave of absence, especially marked increase of tremor (rest tremor), augmented on movement.

Re heat stroke, Wollenberg has called attention to the effect of the heat of the summer months upon German soldiers. Cases of heat stroke have not been rare in the German army. About half the cases have convulsions or epileptoid seizures, as well as tremors and nystagmus. About a quarter of the cases have shown confusion and delusions, with anxiety and mania. A degree of mental impairment has followed a number of these heat strokes, together with sundry signs of organic disorder, such as reflex changes, pupillary changes, and difficulty in speech.

Forced marches; skirmishes; rheumatism: Generalized TREMORS. On the road to recovery in six months.

Case 327. (Binswanger, July, 1915.)

A German letter carrier, 27, entered the war at the outset, made forced marches in great heat, was in a number of skirmishes and in the capture of Namur, and fell ill early in September, with swollen and painful right foot and rheumatic pains in knees and shoulders. He was put on garrison duty; but the rheumatic pains in the joints increased toward the end of September, and he was treated in hospital for rheumatism.

He became able to walk only in the second half of December, marked tremors affecting the whole body. His bodily condition had been good. He slept well, and while at rest in bed he felt entirely well; but upon every attempt to get up and put his feet down, these violent trembling motions would always reappear. Treatment by hydro- and electrotherapy remained entirely unsuccessful. February 8 he was transferred to a nerve hospital.

He had been in the postal service from 1903. He was of normal bodily and mental development and had had no previous illnesses. His military service had been executed from 1909 to 1911. He had always been a passionate smoker but had not abused alcohol. His mother is said to have been for some time paralyzed, following a fright.

Physically, the patient was a slender but strongly-built and fairly well-nourished soldier. The first sound at the apex of the heart was rough and impure, and the heart was somewhat enlarged to the left. The pulse was irregular, 106. The arteries were somewhat stiff. Neurologically, there was a marked dermatographia of comparatively long duration. The periosteal reflexes were increased; the deep reflexes could not be properly examined. The whole leg trembled and heaved unsuccessfully on attempts to raise it voluntarily. After even a slight stroke on the patellar tendon, the trembling became excessive and irregular, and the leg passed into a heaving spasm which would outlast the percussion for some time. The patellar clonus could be obtained with the knee extended. The shaking movements were somewhat more marked on the right than on the left side. Similar phenomena occurred when the Achilles reflexes were being examined. The triceps reflexes on both sides were increased but there was no tremor or spasm of the arms. The plantar reflexes were very lively, and following these reflexes appeared tremors of the legs. When the spinous processes of the vertebral column were percussed, a general shaking spasm appeared. Tactile sense was everywhere normal, but the pain sense was increased. Upon slight pin-pricks in the skin of the legs, there would occur a marked shaking spasm of the leg, passing directly to the other leg. These phenomena were more marked on the right side than on the left. When sitting upon a chair with back supported, a slight tremor would appear when the hands were raised and stretched out, more markedly on the right side than on the left. Movements of the arms were normal. However, the hand-grasps were: right, 105; left, 80. In dorsal decubitus the movements of the leg were performed comparatively well at first, but after a few repetitions, the shaking spasm would occur on both sides, and the movements would become very awkward. The heel-to-knee test would then fail. If the patient were put on his feet, he would immediately fall into spasms, first in the right leg, then in the left. The trunk would now be involved, and soon the arms, whereupon the whole body, with the exception of the head, would be seen trembling and shaking, and the patient would fall forward, trying to get support by leaning against a wall, seizing a chair, or sinking down slowly. The spasms disappeared at once in dorsal decubitus and in sitting with supported back. Outward irritation by the acoustic, optic or tactile avenues would bring out spasms in the legs, always more markedly on the right side than on the left. Psychic irritations would cause spasms. The muscles of the limbs were held in great tension, the flexors and extensors being alternately affected. When the patient was moving along a wall with a difficult, swaying gait, his efforts reminded the examiner of the attempts of a heavily intoxicated man to walk. Upon attempts to create passive movements of the lower limbs, severe shaking and trembling movements set in, followed by a general spastic tension of the leg musculature such that it could not be further flexed or extended.

The patient was put in the psychiatric section, as too seriously ill for the nerve hospital. He improved after a few days, being then able to walk without much support although still with some shaking and tremor. If his attention was diverted, passive movement of the leg could be carried out without developing spasm. He was treated in a room by himself with removal of all outward irritation. His legs were treated for an hour, three times daily, by means of moist packs. On account of complaints of insomnia he was given small doses of hypnotics.

The main thing here, according to Binswanger, is the psychotherapy. The patient was told almost daily in the course of conversation, first, that the illness was being cured; secondly, that upon recovery he would be employed in the future only on the postal service. He was told that he would have to avoid marked physical exertion, of course, but that he still would be fit for office work and could serve the fatherland in this way. Still he could not be transferred back to the hospital, he was told, unless he became entirely well, so that he could move with perfect freedom.

February 23 the patient was performing daily exercises in walking and standing; the spasm became very slight on standing, and often would entirely cease, but it remained still plainly present in the legs; the trunk and arms were free. External irritations were now less prone to excite spasm. Sleep became quiet and dreamless. He was transferred to the nerve hospital, able to move about freely in house and garden and only tremulous after long walks and considerable bodily and mental fatigue. He was given a week’s furlough home. He wished very much to get into the postal service; at the time of the report he had not attained this goal. He had renewed attacks of trembling upon exertion, and was transferred at the end of June to a convalescent home.

Shell-shock; emotion: Hyperkinesis, fear, dreams.

Case 328. (Mott, January, 1916.)

A private, 21, was with 30 men carrying sandbags in the daylight, under shell fire. He was thrown into a deep hole by an explosion, climbed out, and saw all his mates dead.

He was admitted to the Fourth London General Hospital, June 20, 1915, having been at Boulogne for a fortnight. He was lying in bed on his back, making continuous jerky lateral movements of head, and movements of arms, especially of the left arm. He was groaning slightly, now and then raising his eyelids with a staring expression of bewilderment and terror. He was able to mutter answers to questions. He would occasionally raise his right hand to his forehead. If he was observed, these movements became exaggerated. They ceased in sleep. He muttered even when unobserved. He continually said, “You won’t let me back.” Asked as to dreams, he replied, “Guns.” Voluntary movements were made, which prevented obtaining reflexes. When his pupils were to be examined by a man in uniform, he showed a marked facies of terror; his pupils were dilated; the eyes opened wide, the brows were furrowed, and there was an anxious scowl. The flash of an electric light produced the same effect.

June 24 the patient was much better. He said the explosion which had killed his friends after he had been only a few weeks at the front, was the first serious event in his service. He kept seeing it again, with bright lights and bursting shells. Sometimes he would hear the men shouting. In dreams he both saw and heard shells and men. There was pain in the back and right side of the head.

June 26 he was improved but still had pain in the back of the head, especially when trying to remember, and a slight tremor of the hands. He had been given hot baths at Boulogne on account of being very cold and shivering. He had always felt sick at the sight of blood. He was boarded for Home Service six months after admission.

Shell fire and barbed-wire work: Tremors, anesthesias, temperature and pain hallucinations.

Case 329. (Myers, March, 1916.)

A corporal, 39, had been working under shell fire at barbed-wire entanglements. The man was big and robust, but much depressed, complaining of noises in the head, pricking pains, unsteady legs, fatigue, irritability, loss of confidence. He showed tremors of arms and legs on movement, and stood unsteadily with eyes closed. He said: “My legs have been very unsteady, especially when some one is looking at me. They must have thought me drunk at times.”

The head and tongue were tremulous, the knee-jerks exaggerated, the soles insensitive to touch and pain; but sensibility to deep pressure was retained. There was a gradual return of right answers on further trials, aided by comparison with effects of stimuli applied to the dorsum of the foot. Though he gave correct replies on heat and cold tests over the arms, he gave wrong answers over the dorsum of the feet, less often over legs, sometimes over thighs.

Later during examination, the feet became tremulous. He felt a “silly childish fear,” and his hands began to feel cold and clammy; whereupon he began to reply hot or cold when the tubes were not applied at all (temperature hallucinations). There were apparently pain hallucinations in the soles and errors in response to the compasses.

Re the temperature hallucinations noted by Myers, these are to be distinguished from true vasomotor disorders. Babinski believes that he has definitely established that, though hysteria may cause a slight thermo-asymmetry, yet never a definite vasomotor or thermic disorder.

Re hysterical pains, the most frequent are probably those of hysterical pseudo sciatica, in which true signs of sciatica are absent, namely, (1) loss of Achilles jerk, (2) scoliosis, (3) Lasègue’s sign (pain on thigh flexion with leg extension), (4) Neri’s sign (with trunk bent forward, affected knee flexed), and (5) Bonnet’s sign (pain on thigh adduction).

Shell-shock: Emotional crises; twice recurrent mutism; amnesia. A comrade in the same explosion gets off with transient phenomena.

Case 330. (Mairet, Piéron and Bouzansky, June, 1915.)

December 15, sitting back of a wall were three minor officers and an homme de liaison, when a 105 shell punctured the wall and burst, killing one and wounding another severely. One of these, a sous-lieutenant, lost consciousness for a quarter of an hour and had some severe headaches for a few days, but nothing more. The other, the homme de liaison, was found standing, bewildered, looking at the dead. When his name was called, he jumped and started off, weeping and crying out.

When caught, he was still somewhat clear, recognized his superior officer, answered yes and no, but kept asking, “Where is the other?” Next day he kept weeping and said not a word.

He was evacuated through a series of hospitals and was sent to convalesce with his sister at Montpellier, having now got back his speech. He had a seizure of fear in the street and was picked up by the police and was carried to a general hospital January 21. Here he could not speak, could hardly write, being unable to find his words. He walked slowly, bent over, eyes abnormally wide open, with a look of terror. The lighting of a match made him start off weeping. The symptom picture included tinnitus, vertigo, deafness, some reduction of the visual field (especially on the left side), hypesthesia and hypalgesia on the left side, hyperalgesia on the right, painful points (epigastric, inguinal, supra and infra mammary left), reflex, muscular and tendon, hyperexcitability on right side, jactitation, impairment of recollective memory, complete memory gap for the accident and everything thereafter, retentive memory reduced, imagination impaired, nightmares (awaking with a start).

A few days later he was able to pronounce his name with difficulty and to say yes and no. February 4 there was an appendicular crisis, whereupon mutism became absolute again and lasted into May, despite suggestive therapy.

May 10, improvement in memory for things before the accident grew better, nightmares had become less frequent, the jactitation had continued.

There was no neuropathic predisposition in this case except infantile convulsions in two sisters, followed by nervous crises in one.

Re appendicular crisis, which was the occasion of a relapse in mutism, see remarks under relapses under Case 292.

Re mutism, Babinski counts mutism, hysteria major, and rhythmic chorea as so characteristically hysterical that no nervous disturbance of an organic nature can resemble them. The description of hysterical mutism is due to Charcot. According to Babinski, mutism is just as curable as hysterical deafness, and perhaps more curable. Yet mutism persists unchanged for many months unless it is treated properly by some form of suggestion. “It may be almost said that a subject suffering from speech defect, who nevertheless succeeds in making other people understand by all sorts of varied and expressive gestures the circumstances of his condition, is a hysterical mute and not an aphasic.” According to Babinski, no true case of hysterical aphasia has been published since the beginning of the war; all the cases have been cases of mutism.

Shell explosion; fainting: Hysterical crises of emotion; fright at a frog in the garden. Hereditary and acquired neuropathic taint.

Case 331. (Claude, Dide and Lejonne, April, 1916.)

A lieutenant, 28 (mother nervous; father had nervous spells at fifteen; patient himself nervous as a child), was under a great moral strain at the outbreak of war, and was utterly exhausted in a hard battle that lasted more than twenty-four hours.

A shell burst near him September 25 at the Somme, whereupon he fainted. He was evacuated to Amiens for three weeks; kept his bed; somnambulistic; subject to nervous crises.

He passed to the hospital of Ferté-Bernard for a month, the crises becoming more frequent. He was sent to a convalescent dépôt for three days, thence for three months to La Plisse; got better; lived at home, but went to a show where they played the Marseillaise, was profoundly moved thereby, and had more crises; accordingly went back under medical care and finally to his dépôt, where, upon seeing his old comrades, he had more crises, and was finally evacuated to the neurological center of the Eighth Region.

He there seemed mistrustful when asked to tell his story. There was a noise of cannon, whereupon he got up, ran in all directions in the garden, bumping into trees in the greatest terror, yelling, “There they are!”; gesticulating, soliloquizing: “Bomb! Shell! Bayonet!” His pulse was rapid. After he was calmed down, he began to talk again in a very clear, distinct, somewhat tremulous voice. A metallic sound made him shudder and cry out, “The drums!” and another scene of rushing about followed.

In the consulting office he wept. Battle dreams and nightmares, soliloquies and terror, seminal losses, occurred during the next few days.

August 4, while alone in the garden, he heard a noise, went toward it and spied a frog, whereupon he had another crisis of fear and emotion. He got another lieutenant, and both returned, sticks in hand. Pointing to a hole in the earth, Lieutenant A. said, “Trenches! There they are!” “What? Who?” said Lieutenant B. “The Boches!” said Lieutenant A. Whereupon Lieutenant B also saw them and cried out bravely, “Go away!” However, the second lieutenant immediately saw that he had been the subject of suggestive hallucination.

Fifteen days of calm followed, during which the lieutenant became more sociable and grew better having no more crises.

Four other cases of “hysteroemotive nature” are reported by Claude, all of them showing a special constitutional basis before the war. In the differential diagnosis, alcoholism, cyclothymia, obsessive psychosis and occasionally systematized delusional psychosis may be considered. There were occasional stereotypical features in the cases, but of a very fugitive nature. Dementia praecox is hardly to be considered.

Re “hysteroemotive” cases, Babinski holds that the claim of emotion as a single factor capable of causing hysteria by itself, is a false claim. To be sure, the patients themselves may give accounts which lead to the idea of an emotional hysteria. Dide, one of the authors of the above case, states that functional disorders occur only in subjects whose emotional tone has been relaxed. The heaviest bombardments are not in line to produce these disorders when the morale of the troops is good. The bloodiest affairs may leave no single case of nervous disorder when the morale is good. Dide found in a whole year’s work but a single functional case,—an oniric delirium, following a trench mortar explosion. Roselle and Oberthür also state on the basis of intensive experience, that large projectiles do not cause any intensive emotional reactions. Clunet’s observations upon the shipwrecked La Provence II, quoted by Babinski, run in the same direction. It will be noted that the five cases called “hysteroemotive” showed a special constitutional basis antebellum.

War strain; slight wound; burials; shell-shock: Neurosis with anxiety; war dreams; apparent recovery. Relapse with depression.

Case 332. (MacCurdy, July, 1917.)

A man, 27 (normal mischievous boy, successful in work, unmarried, shy with women), enlisted October, 1914; adapted himself well to training; at first enjoyed his work, though later bored with routine; and in February, 1915, went to the firing line in France. The first shell-fire experience made him break into a cold sweat with fear and slowed him down for a time. However, he enjoyed the active operations until, after eight months in the trenches, he was invalided home with nephritis. After four months’ convalescence he was recommended for a commission, obtained after two months’ training. After two further months in the regimental dépôt, he went back to France as lieutenant in June, 1916, plunging into four months of heavy fighting on the Somme, in which he was wounded slightly once and was one day buried three times by earth from shell explosion. The last time he was buried he was unconscious for ten minutes and was relieved for three days. He got frequently knocked out for short periods by shell concussion.

At the end of October, 1916, he was sent to the Ypres section, where he worked with a pioneer battalion that buried many dead. After a month of this pioneer work he became mildly depressed; fatigue set in, and now for the first time he began to jump nervously when the shells came over. To counteract this nervousness he began to drink and in a fortnight developed insomnia. The Somme front scenes kept constantly in mind as he tried to sleep. He felt as if he had to go up to the trenches next day and that he did not want to go. There were hypnagogic hallucinations of trenches and shells, recognized as imaginary and productive of no fear. Week by week he became more nervous, became unable to locate shell falls, and felt as if they were all coming at him. Early in 1917 he had taken heavily to drink and grew greatly fatigued in the struggle to prevent betraying his fear to his men. The horror at bloodshed, to which he had long since become accustomed, reappeared. He actually wished that he might be killed.

He carried on until March, when one day on a raid seven men were killed around him and he was immediately thereafter buried. He reported sick and was found to be somewhat febrile. He carried on for two more days; had to report sick again; was sent to hospital and for two or three weeks had bad headaches back of the eyes and a sleep interrupted by sudden wakings with a start. Nightmares now began for the first time. They dealt with the Somme front, merciless shelling coming nearer and nearer. Finally, he would wake with a shriek when a shell landed on top of him. In the day time any noise would be interpreted as a shell. Hypnagogic hallucinations of Germans entering the room appeared. After a little over a week in French hospitals he was transferred to London; grew better; was sent to a hospital in the country where outdoor exercise and recreation helped him.

Two weeks later the death of one of his best friends depressed him a good deal. He failed in an attempt to sing at a concert, and then grew much worse, with the old dreams every night and hypochondriacal complaints of sweats and loss of weight. He was convinced that he was physically and nervously a permanent wreck.

According to MacCurdy, this case is a typical case of war neurosis of the anxiety type, except that a relapse with depression is somewhat atypical.

Re anxiety, Lépine counts trauma as one of the most important factors. The reduction of morale in physically injured cases may at times require their rapid withdrawal to a safety zone. The delirium of the physically injured sometimes takes on a melancholic tinge. Fatigue, loss of sleep, and cold are other factors of a physical nature. Among the moral factors, Lépine thinks responsibility (for certain âmes scrupuleuses) is hardly less important than the factor of felt danger. The contacts of highly cultivated men with the rougher soldier element, may also count, as well as the separation from home and friends, and the factor of despair concerning the ending of the war.

Re sexual influences, the factor of sexual continence, though it may have some importance in producing morbid anxiety, seems to have less importance under war conditions, when self-preservation is more in the eye than the sexual life. On the whole, the pre-existent emotional constitution (Dupré) is of greater importance. A previous wound may cause a man to acquire such a constitution. Amongst physical states, hypotensives are candidates for depression; tuberculosis is particularly important.

Re MacCurdy’s case, the factor of alcoholism was mentioned. The importance of alcoholism, Lépine has particularly stressed. He particularly emphasizes the number of men who have taken to drink to get over their emotions and to forget. Visual hallucinations, angry excitability, sudden persecutory ideas, nocturnal occurrence of the symptoms, flushing of the face, suggest alcoholism. Some of the cases of encephalitis which are supposed to be due to some unknown bacterium, may really be alcoholic in origin. A third of Lépine’s cases were alcoholic; perhaps two-thirds really alcoholic if one took into account the factor of sensitization.

Bombardment from airplanes: Fear; suicidal thoughts; oniric delirium (“moving picture in the head.”)

Case 333. (Hoven, May, 1917.)

A soldier (born at seven months, somewhat feebleminded, given to depression, early victim of convulsions, talking only at five years, with a history of once leaving his father’s house with suicidal ideas after being scolded, already invalided in peace times) on enlistment remained with the regiment but a few days and was then sent to a workers’ company of blacksmiths.

Toward the end of February, 1916, his cantonment was bombarded by an airplane escadrille. The patient was much frightened, ran away and hid in a ditch, felt sick, stopped eating, wanted to kill himself and had to be evacuated to Calais and then to Chateaugiron.

He was there found to be well oriented, but depressed and bewildered. There was an emotional tachycardia. At night he would fall into a delirium like the oniric delirium of Régis, always dreaming of the same bombardment scene, saying it was like a moving picture in his head. The delirium affected him so that he actually tried to make away with himself.

The dream delirium did not last long but recurred several times on very slight emotional occasions. It was possible to excite his hallucinatory dreams experimentally by showing him battle pictures.

Some cases of such delirium develop, according to Hoven, after moving picture shows of battle scenes.

Re oniric delirium, Chavigny states that mental confusion and oniric delirium are the two forms of mental disorder that come most frequently after explosions. He believes that at least 95 per cent of these cases are rapidly curable; and, in fact, found amongst 60 cases observed in his army service that only two were so severe as to require being sent to the interior: all the others were cured in six days at the outside. These cases, according to Chavigny, ought to be treated in special wards at the front (bed, quiet, purgation, baths). Chavigny prearranges slight emotional shock for these cases by talking with them about their families. Their apparent apathy vanishes in a trice.

Régis, who has named the state “oniric delirium,” states that the condition never lasts more than a fortnight, is caused by emotional shock, and occurs in all cases with mental disorder following battle; but similar hallucinatory conditions have begun to appear also amongst alcoholics, in garrison or at home. There is emotional constitution in most of these cases. There is not so much evidence of heredity. Out of 50 of Régis’ cases, 22 had been wounded, and 28 not. Régis states that the psychoses are rather more apt to affect men in the reserve, and are severest in officers. These cases should not be committed to institutions, but ought to be treated in special military psychiatric wards containing separate rooms. Very fine-spun diagnosis may be necessary now and again on account of the occurrence of infectious deliria and phenomena of the banal psychoses that may closely resemble oniric deliria.

Shell-shock; emotion (best friend mangled): Stupor with amnesia.

Case 334. (Gaupp, March, 1915.)

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

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

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

From September 6 onwards, he grew calmer but he was still very labile, given to lively imaginings and emotion. By mid September he could be discharged for garrison duty.

Emotional shock; shooting a comrade: Horror, sweat, stammer, recurrent nightmare. Improvement on “tracing back.” Brief recrudescence on death of child.

Case 335. (Rows, April, 1916.)

A man after a charge was placed on outpost duty. It was dark, and he was in a state of considerable tension. He heard a noise which he thought came from somewhere in front of him. Suddenly the space around him was illuminated by a flare of light, and he saw a man crawling over the bank. Without challenging, he fired and killed the man. Next morning, he found to his horror that he had killed a wounded Englishman, who had advanced beyond his comrades and was crawling back.

A physical expression of horror, together with an intense sweating and a very marked stammer, persisted for months. At the same time, he was tormented with a fearful nightmare, and in his sleep he was heard to say, “It was an accidental shot, sir; yes, Major, it was not my fault.” In the day time, also, his attention was concentrated on the memory of the incident, so that “I cannot forget it no matter how I skylark.” Carrying his story back to this trying time led to his recounting his terrible secret, and a marked improvement followed. The physical signs of the intense emotion gradually disappeared. The vividness of the dreams diminished, and his attention was less concentrated on the one subject. It is interesting to note that the production of a marked emotional state by the death of one of his children led to a recrudescence of his former symptoms: an expression of “horror and the stammer.” But they disappeared again in a short time.

Emotional shock: Phobias.

Case 336. (Bennati, October, 1916.)

An Italian corporal in the infantry, a robust man of a well-to-do family, took a good deal of pleasure in the war life. One day a comrade was injured by a missile of some sort, and died almost immediately. This comrade, after being hurt, had thrown himself against the corporal, who was asleep at the time. He woke up sharply and immediately felt sick. His status was one of great terror, lacrimation, lack of spontaneity, and insomnia. He would wake up from sleep and start from a terrible dream. He had a number of phobias and was especially interested in other persons who had the same sort of mental state as himself. He was in a state noted by Bennati as one of “emotional anaphylaxis” to various events around him. There was a horizontal nystagmus, the Mannkopf sign was positive (87-72), Thomayer 90-114, Erben 114-90. There was a slight tendency to dizziness when the Erben movements were made.

Shell-shock; fright: loss of consciousness next day: Generalized tremors; “somebody above with a mallet.”

Case 337. (Wiltshire, June, 1916.)

A sapper of 19, with a nervous mother, had had an attack two years before his war neurosis, of a somewhat similar nature. This former attack had been caused by overwork; there had been no accident or fright, but the man had been unable to work for five months.

At the front, he had been well up to ten days before observation. In a dugout a shell had pitched on top of the bank, followed by another shell bursting in front. There was a slight falling in of the dugout but no special damage.

The patient carried on that night but reported sick next morning, feeling queer and shaking slightly above the waist. He remembered getting half-way down the road to see the M. O., but nothing more until he came to in the dressing station (perhaps 2½ hours later). After two days in hospital, he was transferred to a convalescent camp, and then admitted to another hospital. He complained of twitching and slight frontal headache; funny feelings at night prevented his going to sleep. Thus: “A man was over my head with a mallet, going to hit me.” There was a dream of “somebody above me all the time.” Both arms, head, and tongue were in a state of constant tremor, and there were jerky movements of the legs. There was some spasm of the right leg. Both legs went into violent tremor on examination, and during examination there was free perspiration.

Re tremors, all sorts of tremors of unknown nature are apt to get the designation hysterical. Meige believes that the Shell-shock tremors, which are apt to be very persistent, are very possibly due to changes in the nervous system. Ballet has noted how the tremors, as in the above case, are often associated with expressions of fear. Now and then there is an obsessive disorder dubbed tremophobia by Meige, which produces a vicious circle. Tremors lead to obsessions, and the obsessions in turn exaggerate the tremors. These Shell-shock tremors are apparently not related to (though they may need differential diagnosis from) such conditions as paralysis agitans, multiple sclerosis, hyperthyroidism, cerebellar disease, neurosyphilis, and alcoholic or other intoxication.

Roussy and Lhermitte distinguish the tremors into (a) atypical ones; that is, disorderly, irregular movements seemingly determined by the subject’s caprice; and (b) typical tremors, such as those found in the well-known nervous diseases and presumably imitated in hysteria from these well-known diseases. Generalized atypical tremors are, as a rule, combined with a variety of other Shell-shock symptoms, and often exhibit a sort of mimicry of fear.

Shell-shock; burial-work: Amnesia. Shell whistling conditions idea of something nasty.

Case 338. (Wiltshire, June, 1916.)

A private, 19, in the R. A. M. C., was sent in with a field ambulance note as follows:

“Private —— was close to a shell which burst among a company standing in the road, killing 20 and wounding 20 others. He worked well in assisting the wounded, and then proceeded to clear up the fragments of the killed. Whilst doing this, he suddenly lost his mental balance and has been in his present state nearly 24 hours. He has been given bromides.”

An M. O. attached to the same ambulance wrote: “This man is suffering from mental shock caused by having to clear away the remains of a number of men killed by a shell. He does not recognize his friends, and at frequent intervals has periods of terror, exclaiming, ‘Cover it up.’ He is sleepless (without drugs); he takes food badly. He is possibly suicidal or may become so.”

According to the patient himself, he had been quite well for four months at the front. He was on the La Bassée Road with the troops after a day or two of heavy work under shell fire. “And I remember the flash of some shot and a shell burst I think, and I can’t remember anything more. I awoke in the morning, in the train” (48 hours later). “I can only remember men calling out.” He complained of a feeling in the head, as if expecting something. “Something seems to be coming,—as if something was going to happen,—something nasty, whenever I hear anything like the whistling of a shell coming towards me.” This patient was without tremor and was physically normal. So far as the patient’s own story went, the case might well be regarded as one due to physical concussion, but the notes of the medical officers give evidence of a psychic element.

Depression with suicidal thoughts after witnessing death of comrade.

Case 339. (Steiner, October, 1915.)

A farmer, 52, volunteered and was put in charge of a drinking-water still. He had never been ill nor was there any nervous or mental disease in his family. From the end of August he was frequently under shell fire, but the only effect thereof was a somewhat poorer sleep than normal.

December 14, 1914, a young comrade, a volunteer, wanted to clean his dirty kettle at the drinking-water still. The farmer later described this volunteer as a young fellow “like milk and blood” (as we might say, “like peaches and cream”) and as the handsomest young man he had ever seen in the war. The rules forbade such use of the still, and young “milk-and-blood” was told to go down to the brook, and then come back and get the distilled water. The young man complied, but while at the brook he was shot and killed in full sight of the farmer.

The farmer grew much excited and trembled all over. Thereafter he could not eat or sleep; he reproached himself, although he knew he had acted quite correctly; wished he had been in the place of this comrade; and had suicidal thoughts. He was deeply depressed, wept easily, and showed manual tremor. Steiner terms the farmer’s account of the person of the deceased “reactive idealization.” After a week there was considerable improvement. B. was sent back to work, which he felt would be beneficial. He was put in less dangerous surroundings, and this also had a good effect.

Marching and battles: Neurasthenia?

Case 340. (Bonhoeffer, January, 1915.)

A subaltern had been treated before the war for nervousness, dizziness, and “mattigkeit” (convulsions in infancy), but proved himself a good soldier, having gotten his rank after the first period of practice.

He was in three battles in Belgium, but on the march one day suddenly had a spell of weakness and is said to have had convulsions. There was, however, no biting of the tongue, and no enuresis. After a week in the field hospital, he was sent back to Berlin where he had some somatic feelings of anxiety without subjective disturbance or any disorders of consciousness except a certain amount of inhibition; he was sleepless and hypersensitive, cried easily, and was apprehensive on being touched; he winked violently on examination of his eyes, and while being tested for reflexes made violent contractions of a semi-voluntary nature.

After four days in bed, which was a prescription hard to carry out at first on account of the anxiety sensations, these sensations disappeared, and at the same time the fears. Weight began to increase; memories returned, except that even upon recovery he could not remember that he had ever had any true subjective feelings of fear. He was discharged 19 days later, desirous of going back into the field.

The peculiar absence of subjective feelings of fear in this case is something like what Awtokratow reported from the Russo-Japanese War, terming them neurasthenic psychoses.

Re neurasthenia, Babinski believes that, by means of his logical dismembering of the old hysteria concept, he has shown that the exhaustion phenomena at the bottom of neurasthenia are precisely these that cannot be cured by suggestion. There are numerous cases in which hysteria and neurasthenia are combined. From these combined cases, suggestion causes the hysterical or pithiatic symptoms to be removed.

English schoolmaster’s account of his war dreams.

Case 341. (Mott, February, 1918.)

A sergeant, who had been a schoolmaster, was asked to write down his dreams by Captain W. Brown, who had sometimes charge of Mott’s cases at the Maudsley Hospital. The first dream was as follows:

“I appeared to be resting on the roadside when a woman (unknown) called me to see her husband’s (a comrade) body which was about to be buried. I went to a field in which was a pit, and near the edge four or five dead bodies. In a hand-cart nearby was a legless body, the head of which was hidden from sight by a slab of stone. [He had seen a legless body, which was covered with a mackintosh sheet, which he removed.] On moving the stone I found the body alive, and the head spoke to me, imploring me to see that it was not buried. Burial party arrived, and I was myself about to be buried with legless body when I awoke.”

The second dream was as follows:

“After spending an evening with a brother (dead 11 years ago) I was making my way home when a violent storm compelled me to take shelter in a kind of culvert, which later turned into a quarry, situated between two houses. Men were doing blasting operations in the quarry, and whilst watching them I saw great upheavals of rock, and eventually the building all around collapsed (explosion of a mine). Amongst the débris were several mutilated bodies, the most prominent of which was legless. I tried to proceed to the body, but found that I was myself pinned down by masonry which had fallen on top of me. As I struggled to get free the whole scene appeared to change to a huge fire, everything being enveloped in flames, and through the flames I could still see the legless body which now bore the head of my wife, who was calling for me. I was struggling to get free when my mother seemed to be coming to my assistance, and I awoke to find the nurses and orderlies standing over me.”

It appears that the patient had been shouting in his sleep, beginning in a low voice and gradually becoming louder until at last he was shrieking. The legless body occurred in all his dreams; the sight of this had evidently produced a profound emotional shock. He had worried a great deal about his wife, who was much younger than himself, so that we have this incongruous association of the legless body and the head of his wife calling him; finally, what more natural than the mother to come to his help. The emotional complex is not incongruous in this dream, for fear is linked up with the tender emotion.

Re war dreams, see remarks under Case 333 concerning oniric delirium. Roussy and Lhermitte say that emotion and concussion are the causal factors; but in a case like 341 we have persistent war dreams of the same general nature. Such a case as Mott’s would not be regarded as one of oniric delirium, for the patient is not living throughout the day in a dream, but merely has certain set dreams. The true oniric delirium cases may lead to fugues of medicolegal importance. Mott’s conception is that the terrifying experiences that come to light in the dreams are repressed by the conscious activity of the mind in the waking state. For this process, the phrase psychic trauma might be used. Rows speaks of a prolongation of mental disorder through memories which get revived in dreams. The memories of past and recent events pile up on one another. Elliot Smith remarks on the number of cases in which the dreams show a coalescence and blending of episodes alien to the war. Re such combinations, see Case 342 of Rows, below.

Trench experience: War dreams, shifting to sex dreams. Recovery on giving the patient an insight into the nature of his dreams.

Case 342. (Rows, April, 1916.)

A patient broke out of a hospital after being refused permission to leave the grounds. He grew much depressed and said he had been disgraced and would commit suicide rather than bring disgrace on his family. Investigation into this emotional outburst showed that his father had deserted the family, that he had gotten into prison, and “tainted me.” The patient was worried also about an idea of loss of sex power, gathered from a book by a quack doctor, read years ago. It appeared also that this doctor had advertised a special bread and special medicine which would preserve the nervous system, and that for years the patient had fed himself and his family with the bread and medicine. When the true state of affairs was shown to the patient, his restlessness at night disappeared. The mental condition of this man in fact became practically normal, and the marked tic of facial muscles and the general tremulousness of the man disappeared.

It is of note that this man’s dreams began with a terrible incident in the trenches and then shifted to sex acts. He woke to find the clothes disturbed.

This is an example of hallucinations dispelled by tracing them to their source, and giving the patient a clear insight into their nature.

According to Ballet and de Fursac, after the acute phase of stupor and excitement with hallucinations and delirium passes, the patient remains a depressed and psychasthenic subject. In this psychasthenia we find inhibitory phenomena, hyperemotionalism, and over-imagination. Amongst the inhibitory phenomena are many of the hysterical effects. The hyperemotionalism yields anxiety, worry, tremors, respiratory and vasomotor disorder, dizziness, convulsions. The third main disorder of the psychasthenic state into which the patient relapses is over-imagination, whereunder we find bad dreams (bombardments, drum-beating, corpses, attacks), somnambulistic hallucinatory episodes. It is these hyperemotional and hyperfantastic features that distinguish the Shell-shock syndrome from ordinary psychasthenic states.

Re the sex element in this case, see remarks under preceding case (341) and also Lépine on the sex factor (Case 332). Rows believes that those cases which do not recover after a short period of rest and quiet in hospital are cases in which there is some emotional state based upon the constant intrusion of the memory of some past event. The physical expression of the emotion of fear or terror may persist for a long time quite unchanged and be proved to be due to this old factor.

Emotional shock: Recurrent dreams of war and peace incidents. Recovery followed tracing the dreams to their origin.

Case 343. (Rows, April, 1916.)

A soldier and a comrade were carrying a pail of water to the trenches. It was very cold and they set down the pail in order to warm their hands. The comrade placed his hand against the man’s cheek and said, “That hand is cold.” At that moment he was shot dead.

This incident was involved not only in dreams at night, but in the daytime too, if he were quiet and closed his eyes, he could feel the cold hand against his face.

He was troubled at the same time by another dream, in which he ran down a narrow lane at the bottom of which there was a well. He dipped his hands into the water, but on withdrawing them, he was horrified to find they were covered with blood. This dream was connected with a love affair, in which a good friend interfered and angered him so much that he attacked him when next they met. He left him on the ground so injured that it was necessary to take him to a hospital. The patient became anxious as to what the result might be and left the district. He traveled, but never heard whether his victim had died.

When these two dreams were traced back to their origin they disappeared: the patient made a rapid recovery and was able afterwards to bear a severe trial satisfactorily.

See remarks under Case 342.

War dreams, including hunger and thirst.

Case 344. (Mott, February, 1918.)

(Recorded Dream of a Second Lieutenant.)

“During the five days spent in the village of Roeux I was continually under our own shell fire and also continually liable to be discovered by the enemy, who was also occupying the village. Each night I attempted to get through his lines without being observed, but failed. On the fourth day my sergeant was killed at my side by a shell. On the fifth day I was rescued by our troops while I was unconscious. During this time I had had nothing to drink or eat, with the exception of about a pint of water.

“At the present time I am subject to dreams in which I hear these shells bursting and whistling through the air. I also continually see my sergeant, both alive and dead, and also my attempts to return are vividly pictured. I sometimes have in my dreams that feeling of intense hunger and thirst which I had in the village. When I awaken I feel as though all strength had left me and am in a cold sweat.

“For a time after awaking I fail to realize where I am and the surroundings take on the form of the ruins in which I remained hidden for so long.

“Sometimes I do not think that I thoroughly awaken, as I seem to doze off, and there are the conflicting ideas that I am in the hospital, and again that I am in France.

“During the day, if I sit doing nothing in particular and I find myself dozing, my mind seems to immediately begin to fly back to France.

“A dream that keeps on coming up in my mind is one that brings back a motor accident I had about six years ago, which gave me a severe nervous shock. I had, of course, entirely forgotten about it, except when in a motor, when I always thought of it.

“Of the fifth day I have absolutely no recollections.”

This is the one instance in which a man has dreamt the experience of hunger and thirst in addition to battle experience.

Olfactory dreams: Hysterical vomiting.

Case 345. (Wiltshire, June, 1916.)

A lieutenant in the infantry (mother, of a nervous disposition) had been at the front for 3½ months when he started vomiting everything he ate.

He was transferred a fortnight later to a base hospital as “gastritis.” Physical examination proved negative, but the man complained of his nerves. He slept badly owing to trench-life dreams, from which he would wake in a sweat. He was quite unwilling to refer to these dreams.

In point of fact he had had to supervise the burial of many decomposing bodies, after which he had been haunted “by that awful smell of the dead.” Then developed states of abstraction, in which he went over and over the burying experience. He cried by himself.

It seems that the vomiting was secondary to hysterical hallucinations.

Re affections of smell and taste, Roussy and Lhermitte remark that they are rare following shock or trauma in war. Medical suggestion may produce a hemiageusia or a hemianosmia. Mott’s case above (344) showed unusual dreams with hunger and thirst. For another olfactory case, see Case 510 (Rivers) in the Treatment Section of the book, a case in which Rivers was able to find no redeeming feature upon which to ground his re-educative suggestions.

Re vomiting, Roussy and Lhermitte state that this relatively common condition is diagnosticated readily enough but that pyloric ulcer and other organic causes must be eliminated. They remark that there is no tendency to spontaneous cure of neuropathic vomiting, and commend strict dietetic régime and psychotherapy. They ally the condition in its nature and genesis with so-called false or hysterical incontinence of urine in soldiers. Wiltshire’s case early received the diagnosis “gastritis.” It is remarkable how little emaciation need follow such vomiting.

Shell-shock: Amnesia; dreams of falling. POST-ONIRIC suggestion—surprise produced fear of falling.

Case 346. (Duprat, October, 1917.)

A man was subjected to shell-shock August 11, 1916, at the Somme. He lost consciousness for five hours and was picked up stuporous with verbal amnesia, which soon passed leaving only a difficulty in getting the right word promptly. He began to have frightful dreams of falling into a hole and of exertions to avoid falling, whereupon he would awake with a feeling of anxiety that would last some time. Treatment caused the dreams to disappear.

There remained, however, a powerful post-oniric suggestion. Any slight surprise would cause the fear of falling to reappear. There was a sort of derived phobia, against any military act that would need to be performed upon sudden order. He developed a blind anger against any commanding officer who gave a brusque order. After the crisis of anger he would fall into tears and a feeling of profound depression coupled with precordial anxiety. There was also a chronic aortitis physically determined. The man himself had a vague idea of the relationship of his fear of surprise to the old nightmares.

Re persistence of fear and its relationship to nightmares, see remarks under Case 342 (Rows).

Four months’ SERVICE IN THE REAR: Depression; war HALLUCINATIONS (not based upon actual experiences); psychasthenic symptoms.

Case 347. (Gerver, 1915.)

A Russian lieutenant, 32, arrived at the front in November, 1914, but never served on the front line, or had occasion to visit the line or the trenches. Toward the close of February, mental symptoms appeared, which caused the man’s evacuation to the interior.

He was a tall, well-built, well-nourished man, who was physically normal except for sharp twitching movements of the tongue, eyelids, and face; tremors of extended hands, occasionally spreading to the whole body; well-defined dermatographia (in places, stereodermatographia); exaggerated tendon reflexes; tenderness of skull and spine; hyperesthesia of chest; pulse 120.

Mentally, the patient was markedly depressed, irritable, at times lacrimose. His complaints were of a psychasthenic tinge. He feared incurable disease. He feared to go to the front, and was terrified at what he might do there. He feared crowds of soldiers; he was afraid of forests and mountains; the Germans were going to break through and capture him; shells were about to burst over his head. He was also disturbed about his family, regarding his wife and son as helpless, sometimes even as dead. Suicidal thoughts at times.

At night, though he had never been at the front, he had hallucinations of shots and the voices of soldiers, as well as those of his wife and son. He smelt an unpleasant corpse-like odor. He was unable to distinguish these hallucinations in any respect from reality. He complained of general weakness, headaches, palpitation of the heart, vertigo, and insomnia, and of a variety of pains.

He was non-alcoholic and non-syphilitic, and had been in perfect health before the war.

Re war hallucinations with service back of the line, compare remarks of Régis (see under Case 333).

A case of hysterical astasia-abasia develops “big belly” (“catiemophrenosis”), perhaps by hetero-suggestion from a ward neighbor.

Case 348. (Roussy, Boisseau and Cornil, May, 1917.)

A farmer, 22, of the foot chasseurs, who had been in various hospitals with a variety of diseases before his injury, was evacuated June 2, 1916, for “contusion of back,” to the temporary hospital at Bussant, from which he was evacuated to Pontarlier for “contusion of back and cerebellar shock” and thence, July 21, to Besançon for “internal contusion and cerebellar shock”; thence to four other hospitals from July 31 to February 17, 1917; finally to the Hospital at Veilpicard with “functional disorders, paraplegia, trepidant astasia-abasia.”

It seems that he had lost consciousness for fifteen days and had thereafter been paraplegic with retention of urine. The abdomen had then increased in size in such wise as to be termed a nervous pregnancy, grossesse nerveuse. The evolution of this pseudotympanites was probably related to the presence of the same so-called “big belly” of a patient who had been in a neighboring bed from May, 1916, onwards. The feet were in equine position with toes flexed, suggestive in all ways of hysterical paraplegia. The abdomen looked like that of a woman six months pregnant and measured 78 centimeters in a plane passing through the anterosuperior iliac spines and the umbilicus. The abdomen was hard, tense, swollen, and on palpation, gave out a low, tympanic note. When the diaphragm was mobilized progressively and slowly, the tympanites could be made to disappear. Slow pressure on the abdomen with flat hands effaced the swelling for the time being; but upon release of the hands the abdomen would swell up again as before. Pressure on the abdomen produced a contracture of the recti. Forced flexion of thighs on pelvis (as suggested by Denéchau and Matrais) also caused the swelling to go down. Faradization of the phrenic nerves in the neck caused respiratory movements with a slight diminution in the volume of the abdomen. There was an obstinate constipation requiring daily lavage. Respiratory movements were short and rapid and of the thoracic type. Abdominal compression caused the respiration to assume almost a normal rhythm. X-ray examination of the abdomen, after 50 grams of bismuth carbonate had been taken in three spaced doses the evening before, showed the intestine to be distended by gas in such wise that the lower border of the liver became clearly visible, as after insufflation of the stomach. The bismuth was found in the large intestine. The splenic angle filled with bismuth was low. On compression the splenic angle was raised with the diaphragm.

The main features of this disease are the large abdomen, simulating what has hitherto been found chiefly in females under the name of nervous pregnancy, but also suggesting a tuberculous peritonitis (one patient was actually evacuated to a hospital for tuberculosis with this disease); gastro-intestinal disorder with aerophagy, aerocoly, and obstinate constipation (one case also showed almost daily vomiting). The genesis of the condition appears to be a contracture of the diaphragm in a low position of forced inspiration. The condition may be termed a diaphragmatic neurosis.

Psychotherapy was applied, the patient was requested to walk, and the movements made in walking required such an intense respiration that the diaphragm was forced to function, whereupon the “big belly” disappeared. The digestive disorders then rapidly disappeared. These authors suggest the name of catiemophrenosis.

War stress; collapse going over the top: Neurasthenia (hereditary taint; alcoholism).

Case 349. (Jolly, January, 1916.)

A German soldier, 35, of a nervous make-up (his mother was nervous, and he had been nervous and tremulous and easily excitable, and alcoholic to the extent of at least 5 glasses of beer every night), was called to the colors in September, 1914. He got through his training well; in May, 1915, was on very strenuous duty in a very exposed position, had frequently to stand up under heavy shelling, had a number of frightful experiences, was surrounded by corpses and mutilated bodies, and frequently took part in storming attacks. His nervousness came to a head with some suddenness; just as he was about to “go over the top,” he had no strength for the effort and collapsed. Thereafter he could no longer stand shelling, could not speak, and was inattentive to surroundings. When he was examined by a physician he fell asleep in his presence, although sleep had latterly been almost impossible on account of the shelling. He was immediately put on the hospital train and taken to the reserve hospital in Nuremberg, where he presented an appearance of extreme exhaustion, wept, seemed much fatigued, and trembled all over whenever he started to do anything. He was very easily excited and especially sensitive to noise. There was a fine tremor of the whole body and especially of the head; the knee-jerks were increased; there was a moderate vasomotor reddening of the skin after stroking; his tongue was heavily coated; but there was no other evidence of internal disorder. His pulse was strong and not rapid.

The patient got well gradually, complained at first of bad dreams, and was given to weeping. The tremors slowly improved. The patient grew better in a hospital at home.

As to the diagnosis of this case, Jolly regards it as one of nervous exhaustion. The remarkable feature is the tardiness with which the symptoms developed under the stress of war. Such a patient would probably never develop a neurasthenia under normal peace conditions. After recovery these patients may be sent back for garrison duty or for other work not directly connected with the firing line. As for the tendency to desire a pension, this wish, according to Jolly, must be strenuously opposed, both in the interest of the state and that of the patient. If there is no will to get well, some of these patients are found vibrating from garrison service to furlough and to hospital.

The above case is one of the simplest observed; yet there is evidence both of hereditary taint and of alcoholism. According to Jolly, the majority of the severe exhaustion states of a neurasthenic nature have been, in his experience, distinctly nervous before the war, and frequently show hereditary taint as well.

Re neurasthenia, see views of Babinski relative to differentiation from hysteria (under Case 340).

Series of battles: Sudden mania followed by confusion with fixation of mind upon war experiences, possibly hallucinatory; general analgesia.

Case 350. (Gerver, 1915.)

A Russian private, looking much older than his years (35), had been in a number of battles without mental disorder. Where he was posted, however, there was a heavy artillery fire in the last of the battles. Suddenly the man became excited and leaped upon his comrades’ shoulders crying, “The devil is here! This is hell and murder, and here are the devil’s imps!” The commanding officer accordingly ordered him to the rear. His regiment had suffered severe losses in a succession of attacks upon a certain strategic height.

Upon evacuation to the field hospital and thence to the interior, his excitement did not lessen. He went about with a lost look, trembling, talking a great deal and gesticulating. His talk was incoherent and pointless. After every few phrases, he would repeat, “Don’t ride there! That’s hell! Murder is being done. Devils and unholy powers are beating and killing people.” As he said this, he would tremble, and hands and feet would stiffen with a suggestion of catalepsy. There was general anesthesia to pain; no response was made to deep pin-pricks. The pupils were dilated and failed to react, either to light or to pain. The tendon reflexes were exaggerated. No contraction of visual fields. The man was disoriented for time and place and much confused. No paralysis. No wound or contusion.

Re analgesia, we may only say that hysterical anesthesia appears in a variety of forms; sometimes (a) in the form of a classical stigma of hemi-anesthesia; (b) in a segmentary form; again (c) in isolated patches; (d) in a very rough way approximating the peripheral nerve distributions. Babinski gives an unpublished note by Lasègue, in which he states that hysterical patients not enlightened by the doctor’s investigations do not make mention of anesthesia. But in case 350 a psychotic factor may have entered.

Ten months of military service (several battles) without reaction; then, hot machine gun battle: Mania with disorientation and war hallucinations.

Case 351. (Gerver, 1915.)

A Russian private, 24, in a scout company, entered the war on mobilization and took part in several battles without reaction. May 11, 1915, he was sent with the scout party into a hot encounter, hand to hand with machine-guns. After the battle, the man began to yell incoherent phrases at the men around him, started to climb over the top, and shot off his gun without permission. He was accordingly sent to hospital, where he was under observation for a week, during which he had occasional flashes of excitement, jumping out of bed and making movements of cutting or shooting, and then in a few minutes subsiding into inactivity.

He was a short but well-built and well-nourished man; the pupils responded rather weakly in accommodation; there was a small fibrillar tremor of the face, eyes, and tongue. The skin reflexes were diminished and there was a general hypalgesia; considerable mechanical overexcitability of muscles; no other neurological disorders. The mental state was one of confusion. Although he was in one of the corps hospitals, he said he was in a dug-out; the doctors were lieutenants; the attendants were privates in his company. Answers to questions were irrelevant or incoherent; there were a number of delusional expressions. He was to be shot because he had not himself shot enough Germans. If he were not to be shot, anyhow the soldiers would poison him. Rather than this he should be allowed to go into an attack. He would take a German fort and the Czar would name him a colonel. His regimental commander was saying to him, “You will be a hero, you will soon get a company.” His hallucinations sometimes included the voices of Germans saying, in broken Russian, “We will hang you and cut your belly open!” There was considerable amnesia for dates and even his last battle.

Numerous attacks and counter attacks in one day: Sudden incoherence with disorientation and the rapid development of war hallucinations of a scenic type. Suggestion of catatonic phenomena.

Case 352. (Gerver, 1915.)

A Russian lieutenant, 28 (no mental disease, non-alcoholic), was in battle August 14, 1914, on which day his company attacked and was itself attacked several times. An officer who observed the lieutenant said that he came to him and informed him that the Germans must first be burned and then fought with. Thereafter the lieutenant began to speak loudly and incoherently, sometimes yelling incoherent orders. He was accordingly removed from the battle-field to the hospital back of the line. Upon examination, he was found to be of middle height, with dilated pupils, responding weakly to light and not at all to accommodation; twitchings of face, eyelids, and tongue, digital tremor, marked dermatographia, general analgesia, tendon reflexes somewhat exaggerated, cataleptic tendency in feet and hands.

Mentally, the patient was in a stupor, sitting or standing in one place, without initiative; uncomplaining but occasionally uttering deep sighs or occasional isolated phrases. He answered no questions or only after a long pause. He was disoriented for time and place, but gave evidence of delusions and hallucinations. He thought, for example, that he was the chief of staff and had brought with him a squad of captured Germans who were standing nearby. Some wanted to be fed and let go; others were yelling and saying they would burn down the house. Sometimes the patient would hear shots and shells bursting, at which he would shudder and turn away. Apparently he would see his comrades falling under the shrapnel hail. However, he stood his ground and commanded the rest of the soldiers to go forward to the attack. Now and then he was negativistic, flexing the hands upon request to extend them, refusing food and drink. He was still apathetic on evacuation to the interior.

Shell-shock after two days in trenches: Hysterical STUPOR seven days. Cure in three weeks, barring amnesia for stuporous period.

Case 353. (Gaupp, March, 1915.)

F. S., in civil life a wreath-binder in a flower shop, and from childhood very nervous and excited, subject to frequent nosebleeds and fainting spells (e.g., at sight of blood), enlisted at 22, November 3, 1914, as a reservist. January 18 he went into the field.

The wreath-binder was only two days in the trenches before going unconscious under the whistling and exploding shells. Physically uninjured, he was received in reserve hospital C in a deep stupor, January 22. He was unresponsive at first, once however saying, lost in a dream, “When will mother come?” His gait was unsteady and he had to be led and held. He slept a good deal in the daytime.

He became somewhat more active mentally, January 24 (remarking that he had slept well), and made his toilet, but he did not yet have bearings and wanted to go to his place of business. The next day his condition was similar. Asked what troop he was with, he said, “In the flower business.” January 26 he was much better, telling of the army training and a little about the war, and wrote a postcard to his parents. The stupor disappeared after January 27 and the patient became mentally normal. Amnesia persisted for the time, January 20 to 26. Headaches. February 9 he was well, except for the limited amnesia still persisting. He was eventually sent back to garrison duty, cured.

Re stupor, Grandclaude remarks that stupor is probably the most frequent of the mental symptoms of Shell-shock, and that it may last from a few moments to a week. During the stupor the patient is asthenic, stertorous, and staring. Upon recovery from the stupor, a condition of dulness with amnesia and disorientation ensues. There may be a third phase of a more hyperkinetic character, with hallucinations and delusions concerning the war. These stuporous cases are among the most serious of the conditions found, as some of the victims may even suggest dementia praecox from the persistence of childishness and silliness. As in Gaupp’s case, Grandclaude finds that headaches and amnesia persist. Relapses are frequent on the basis of a kind of sensitization.

Re amnesia and Shell-shock, Roussy and Lhermitte speak of amnesia as ordinarily a phenomenon of confusion. Amongst the mental disorders of the Shell-shock psychoses, these authors describe a group due to inhibition or diminution of mental activity, including the rare narcolepsy, or pathological sleep, and the confusional states proper. Simple confusion involves slowness in thinking, and amnesia often anterograde from the moment of the shock. Simple confusion ought to be distinguished from so-called “obtusion” or torpor, in which there is a disorientation for time and space, such as was shown in Mallet’s case. Chavigny has described an aprosexic form (with “birdlike” movements). More common is the amnestic form of torpor. The amnesia may not merely be anterograde from the moment of shock, but may extend to a prolonged period prior to the accident. Sometimes the amnesias are selective, producing phenomena of pseudo aphasia.

Amnesia, monosymptomatic. Progressive recovery.

Case 354. (Mallet, January, 1917.)

An infantryman, 36, arrived without information at a psychiatric center, March 15, 1916, looking confused and knowing little more than his name, believing himself in a distant town. The disorientation lasted to March 21, on which day the man recognized the doctor as such, knew that he was at a hospital, but felt that he had just left home and wife. From this time on, he began to pick up his surroundings, evidently not knowing that there was a war or that he was a soldier. He did not recognize one of his own company. It was not until March 31 that the first memory of the war reappeared, namely, a memory of the call to the colors, drums, bells, and crowds. April 11 he recollected that he was a soldier and that his wife was in the country, where he had left her on the eleventh day of the mobilization. In the next few days, memories came back bit by bit. He had been at first a little thin and showed a slight fever, oliguria, and poor digestion. All these symptoms now lapsed, and the man became apparently perfectly well.

Such states, according to Mallet, are relatively frequent in soldiers, both in epilepsy, and in infectious deliria,—more than in the deliria of exhaustion.

Aviator shot down: Organic mental symptoms.

Case 355. (MacCurdy, July, 1917.)

A Canadian, 20, of normal makeup, in 1915 lost part of his left foot in a railway accident, but, notwithstanding, was finally commissioned in the Royal Flying Corps. He enjoyed the nine months of English training greatly. In France he made several successful flights over the lines, but was shot down and crashed to the ground within the British lines after two weeks of service. He got black eyes and bruises and lost consciousness for about four days, though a week later he was still hazy about recent events and was not quite sure in what hospital he lay. After another week he arrived in a London hospital.

Here he would not answer questions, but stared at the examiner, finally shouting: “I want to get up.” He said he was in a certain suburb of Toronto, which, however, he insisted was a part of London not far away. He wanted a taxicab to go thither. He pondered, but seemed content when told that Rosedale was across the ocean. A superficial machine gun wound of the hip the patient said must be the mark of a hospital in France; it was a secret mark, meaning that he could return to the line and fight whenever he wanted to and that he could use the lavatory whenever he wanted to. He sometimes uttered brief phrases after questioning. Asked if he dreamed, he looked up cunningly and said, e.g., “I down the Boche. I am a live wire.”

Next day it was clear that he had gained a good deal of information from the nurses, and the day after he had become oriented for time and able to recognize the physician, though still confused about hospital names and his recent movements. The 7 from 100 test he did slowly and made several bad unrecognized mistakes. He was over-fatigueable, complained of foggy eyesight, showed haziness and redness and obscure margins in the optic discs, with the remains of one hemorrhage, and presented nystagmus on looking to the extreme left. Two weeks later he complained less of his memory and said that he was beginning to remember what had happened during the last day of his fighting; the chase by the German airplane and the maneuvers. He worried about being sent back to France by a medical board, which would not realize that he was incompetent to fly again. The left pupil was slightly larger than the right.

In this case there were no neurotic symptoms and according to MacCurdy the difficulties here are strictly those of organic type.

Re organic cases of traumatic psychosis, Lépine sums up the subjective phenomena as follows: There is (a) a cephalea, often a feeling of weight, varying at different times of the day; often frontal; often subject to marked alteration on movement. There may be (b) a number of visual phenomena like those mentioned under Case 355, part and parcel of a sort of absence, suggesting an epileptoid effect. Sometimes (c) there is vertigo, but this is rare. There are also congestive attacks. The patients are unable to work, and have strange head sensations when they attempt to work. The memory disorder is not as a rule markedly accentuated. This amnesia is usually a disordered fixation of current events, but there is also a retrograde amnesia. Insomnia and impulsiveness are also found, and more rarely is a depressed and melancholy state suggesting that which Case 355 exhibited. Lépine has tried to define the traumatic psychoses (not neuroses) on the basis of phenomena found in trephined cases. He remarks upon the extreme analogy, not to say identity, between the late sequelae of trephining and the syndrome of commotio cerebri.

Daze with relapses; mutism—following shell fire and corpse work.

Case 356. (Mann, June, 1915.)

A soldier lost his voice apparently from two factors: shell fire and the emotional shock of helping to fill the big common graves. The man could never tell for certain (retrograde amnesia) whether he went from corpses to shell fire or from shell fire to corpses.

Several weeks of daze followed in which he hardly reacted to outward stimuli, but occasionally said “It smells!” “Leave me still!”

He recovered gradually from the daze. But merely hinting at his experiences, especially the smells, sufficed to throw him into another daze.

The loss of voice lasted for some time after he had wholly stopped lapsing into the dazed states.

There was some alcohol in the previous history of this case, which is the only case among twenty-three Shell-shock cases reported by Mann which had a psychiatric disorder of any lasting nature due to shell fire.

Re mutism and the two factors of shell fire and emotion spoken of by Mann, compare the views of Babinski to the effect that emotion alone is unable to cause such a hysterical manifestation as mutism.

Re the corpse work, see remarks under Case 342.

Mine explosion: Mental confusion. Amnesia effected through Y. M. C. A.

Case 357. (Wiltshire, June, 1916.)

A sapper, 21, was admitted to a base hospital semi-stuporous, unable to answer questions and mistaking the identity of persons about him. At first he slept, but next day found he was in hospital. His mind was “all of a blur.” He did not remember coming to France; “It all seems a mist.” He felt he was ill and was afraid of becoming insane. There was no physical sign of disease except coarse tremor of hands.