473. Deafmutism: Spontaneous cure _Mott_, 1916 672
474. Two returns to the front _Gilles_, 1916 675
475. Vicissitudes in 15 months _Purser_, 1917 676
476. Deafmutism: Spontaneous cure _Jones_, 1915 678
477. Course of an oniric delirium _Buscaino_, _Coppola_, 1916 679
478. Same _Buscaino_, _Coppola_, 1916 681
479. Paraplegia: Cure by Iron Cross _Nonne_, 1915 682
480. Mutism cured by getting drunk _Proctor_, 1915 682
481. Mutism cured by working in vineyard _Anon_, 1916 683
482. Deafmutism: Spontaneous recovery of speech.
Recovery of hearing by isolation _Zanger_, 1915 684
483. Excess of sympathy on furlough _Binswanger_, 1915 685
484. Hysterical seizures treated by hydrotherapy _Hirschfeld_, 1915 688
485. Low blood pressure treated by pituitrin _Green_, 1917 690
486. Manual contracture: Various treatments _Duvernay_, 1915 691
487. Massage and mechanotherapy _Sollier_, 1916 692
488. Mine explosion; headache: Lumbar puncture _Ravaut_, 1915 693
489. Hysterical clenched fist: Treatment by fatigue of flexors
_Reeve_, 1917 694
490. Hysterical adduction of arm: Treatment by induced fatigue
_Reeve_, 1917 695
491. Hysterical cross-legs: Treatment by induced fatigue
_Reeve_, 1917 696
492. Hysterical torticollis: Treatment by induced fatigue
_Reeve_, 1917 697
493. Claw foot (2 years): Cure by induced fatigue _Reeve_, 1917 698
494. Traumatic and post-traumatic effects: Surgical treatment
_Binswanger_, 1917 699
495. Vomiting: Cure by restoration of self-confidence
_McDowell_, 1917 701
496. Self-accusatory delusions: Treatment by “autognosis”
_Brown_, 1916 702
497.} Deafmutism in three men shell-shocked at one time
498.} _Roussy_, 1915 703
499.}
500. Vomiting; incontinence, abasia: Cure by persuasion
_McDowell_, 1916 705-706
501. Hysterical convulsions cured by an explanation _Hurst_, 1917 706
502. Course of a case with crises of trembling _Roussy_, 1915 706
503.} Two cases of lameness cured by persuasion _Russel_, 1917 707
504.}
505. Head trauma: Treatments by bandage, isolation,
open air and to-and-fro transfers _Binswanger_, 1915 708
506. Rationalization of war memories _Rivers_, 1918 712
507. Same _Rivers_, 1918 713
508. Same _Rivers_, 1918 714
509. Same _Rivers_, 1918 715
510. Same, without redeeming feature as nucleus of
rationalization _Rivers_, 1918 716
511. Paraplegia cured by removal of crutches _Veale_, 1917 717
512. Same _Veale_, 1917 718
513. Paraplegia: Chocolates _versus_ isolation _Buzzard_, 1916 719
514. Blindness, mutism, deafness. Immediate spontaneous
recovery from the first; gradual recovery from
second; deafness cured by “small operation” _Hurst_, 1917 720
515. Deafness: Treatment by stimulating vestibular apparatus
_O’Malley_, 1916 721
516. Mutism: Treatment by operative manipulation _Morestin_, 1915 722
517. Visual impairment: Treatment by suggestion,
faradism injections _Mills_, 1915 724
518. Aphonia: Treatment by manipulation in larynx _O’Malley_, 1916 725
519. Same _Vlasto_, 1917 727
520. Mutism, amnesia: Treatment by faradism;
climatic cure in dream _Smyly_, 1917 728
521. Blindness: Cure by injections in temple _Bruce_, 1916 729
522. Deafness cured by suggestion in writing _Buscaino_, 1916 730
523. Reproduction of Shell-shock story in hypnosis: Recovery
_Myers_, 1916 732
524. Same _Myers_, 1916 733
525. Automatism, amnesia, deafmutism: Recovery by hypnosis
_Myers_, 1916 734
526. Mutism: Recovery by hypnosis _Hurst_, 1917 736
527. Stammering: Cure by hypnosis _Hurst_, 1917 737
528. Mutism and amnesia: Cure by hypnosis _Myers_, 1916 739
529. Victoria Cross winner: Bayonet clutch contracture
revealed by hypnosis _Eder_, 1916 741
530. Contracture: Hypnotic cure “indecently quick” _Nonne_, 1915 742
531. “Doll’s head” anesthesia: Mutism: Cure by hypnosis
_Nonne_, 1915 744
532. Mine explosion: Tremors (also _ante bellum_ tremors):
Cure by hypnosis _Grünbaum_, 1916 745
533. Astasia-abasia: Cure by hypnosis _Nonne_, 1915 747
534. Crural monoplegia: Cure by hypnosis _Hurst_, 1917 748
535. Tremors and sensory disorders: Cure by hypnosis _Nonne_, 1915 749
536. Paraplegia of gradual development: Cure by repeated hypnosis
_Nonne_, 1915 751
537. Visual impairment and dysbasia: Cure by hypnosis
_Ormond_, 1915 752
538. Blindness cured by hypnosis _Hurst_, 1916 753
539. Postoperative retention of urine: Relief by hypnosis
_Podiapolsky_, 1917 754
540. Postoperative pains: Relief by hypnosis _Podiapolsky_, 1917 755
541. Stereotyped war dream and _ante bellum_ headache:
Cure by hypnosis _Riggall_, 1917 756
542. Amnesia and _ante bellum_ headache: Cure by hypnosis
_Burmiston_, 1917 757
543. Convulsions cured by hypnosis _Hurst_, 1917 759
544. Two attacks of mutism: Spontaneous recovery from
one in 18 months, from the other by hypnosis _Eder_, 1916 759
545. Neurasthenic symptoms cured by repeated hypnosis
_Tombleson_, 1917 760
546. Neurasthenic symptoms: Improvement under repeated hypnosis
_Tombleson_, 1917 761
547. Convulsions “Jacksonian” and dysbasia: Cure by hypnosis
_Tombleson_, 1917 762
548. Agoraphobia: Cure by hypnosis _Hurst_, 1917 763
549. Manual tremors: Treatment by forcing and isolation
_Binswanger_, 1915 764
550. Mutism: Psychoelectric cure _Scholz_, 1915 766
551. Hemiplegia and deafmutism; (also convulsions by
heterosuggestion): Improvement by faradism;
full recovery by suggestion _Arinstein_, 1915 767
552. Deafmutism, cures, relapses and eventual cure by anesthesia
_Dawson_, 1916 768
553. Deafness: Cure by suggestion on emerging from ether
_Bruce_, 1916 770
554. Aphasia, hemiplegia, hemianesthesia, and (by medical suggestion)
trismus: Cure by anesthesia and suggestion _Arinstein_, 1915 771
555. Triplegia, mutism, jumping-jack reactions: Cure by
anesthesia, verbal suggestion, faradism _Arinstein_, 1915 773
556. Mutism and musical alexia: Cure by anesthesia _Proctor_, 1915 775
557. Deafmutism: Deafness cured by anesthesia _Gradenigo_, 1917 776
558.} Interaction of two cases (deafmute and mute)
559.} under treatment _Smyly_, 1917 777
560. Dysbasia: Cure by stovaine anesthesia _Claude_, 1917 778
561. Same _Claude_, 1917 779
562. Deafmutism _Bellin_, _Vernet_, 1917 780
563. Monoplegia: Cure by electricity administered with a
bored and authoritative look _Adrian_, _Yealland_, 1917 782
564. Monoplegia after sling: Technique of electrical suggestion
and “rapid” reëducation _Adrian_, _Yealland_, 1917 783
565. Hysterical “sciatica”: Treatment by faradism and
verbal suggestion _Harris_, 1915 785
566. Prognosis of intensive reëducation in reflex
(physiopathic) disorder _Vincent_, 1916 786
567. Hysterical contracture (with physiopathic features)
brutally conquered _Ferrand_, 1917 788
568. Paraparesis: Cure by exercises electrically provoked
_Turrell_, 1915 790
569. Astasia-abasia: (“Lourdes-like” cure) _Voss_, 1916 791
570. Abasia: Rapid cure _Schultze_, 1916 792
571. Heterosuggestive brachial paresis: Electric suggestion
and recovery in five days _Hewat_, 1917 794
572. Contracture of right index finger and thumb:
Psychoelectric cure _Roussy_, _L’Hermitte_, 1917 795
573. Brachial monoplegic able to descend ladder with arms only
_Claude_, 1916 795
574. Brachial monoparesis: Vicissitudes of treatment
_Vincent_, 1917 796
575. Paresis and sensory disorder: Reëducation _Binswanger_, 1915 798
576. Seizures (of _ante bellum_ origin), astasia-abasia,
anesthesias: Reëducation _Binswanger_, 1915 800
577. Progress in case of paresis of foot and spasticity of hip
_Binswanger_, 1915 805
578. Mutism (Reëducation) _Briand_, _Philippe_, 1916 808
579. Stammering: Isolation and reëducation _Binswanger_, 1915 810
580. Deafmutism: Phonetic reëducation _Liébault_, 1916 814
581. Aphonia: Pressure on sternum and respiratory gymnastics
_Garel_, 1916 816
582. Stammering: Reëducation _MacMahon_, 1917 817
583. Speech disorder: Reëducation _MacMahon_, 1917 818
584. Camptocormia: Psycho-electric cure: lameness cured by
reëducation _Roussy_, _L’Hermitte_, 1917 819
585. Deafmutism: Speech recovery by suggestion and reëducation:
Hearing by reëducation _Liébault_, 1916 822
586. Mutism; stammering; Reëducation; hypnosis _MacCurdy_, 1917 823
587. Anesthesias: Spontaneous gradual recovery: “Paralysis”
cured by reëducation _Binswanger_, 1915 824
588. Deafmutism; head movements, anesthesia: Cure by
faradism, massage and reëducation _Arinstein_, 1916 827
589. Amnesia and paralysis: Reëducation _Batten_, 1916 828
SECTION E. EPICRISIS
PARAGRAPH
TERMINOLOGY 1-8
DIAGNOSTIC DELIMITATION PROBLEM 9-39
THE NATURE OF WAR NEUROSES 40-74
DIAGNOSTIC DIFFERENTIATION PROBLEM 75-99
GENERAL NATURE OF SHELL-SHOCK 89-102
TREATMENT: GENERAL OBSERVATIONS 103-114
A. PSYCHOSES INCIDENTAL IN THE WAR
La divina giustizia di qua punge
quell’ Attila che fu flagello in terra.
Divine justice here torments that Attila, who
was a scourge on earth.
Inferno, Canto xii, 133-134.
The data from all the belligerent countries, collected in this book, go
far to prove that, whatever at last you elect to term Shell-shock, you
must pause to consider whether your putative case is not actually:
A matter of spirochetes?
The response of a subnormal soldier?
An equivalent of epilepsy?
An alcoholic situation?
A result of neurones actually _hors de combat_?
A state of bodily weakness (perhaps of _faiblesse irritable_)?
A bit of dementia praecox?
One of the ups and downs of the emotional (affective, cyclothymic)
psychoses?
An odd psychopathic reaction in which the response is abnormal not so
much by reason of excessive stimulus as by reason of defective power of
response?
On a simpler basis, is not our Shell-shocker just a banal example of
hysteria, neurasthenia, psychasthenia; and is not this psychoneurotic
more peculiar in his capacity to be shocked than are the conditions
that purvey the shocks?
Put more concretely in the terms of available tests and criteria,
open to the psychiatrist, does not every putative Shell-shock soldier
deserve at some stage a blood test for syphilis? Should we not be
reasonably sure we are not facing a man inadequate to start with, so
far as mental tests avail? Should we not verify (even at considerable
expense of time and money by so-called “social service” methods) the
facts of epilepsy and epileptic taint? Of alcoholism? And so on? There
can be no two answers to these questions.
Upon the following page is a practical grouping of mental diseases,
devised in the first place, not for war psychoses, but for the
initial sifting of psychopathic hospital cases. Now the psychopathic
hospital group of cases constitutes in peace practice the closest
analogue of the mental cases met in active military practice, because
the “incipient, acute, and curable”[1] cases, for which psychopathic
hospitals are built and which flock to or are sent to the wards and
outdoor departments of such hospitals, are precisely the cases that
early come forward in active military practice. They are precisely the
cases in which that pathological event--whatever it is--we know as
Shell-shock may be expected to develop. It is precisely the “incipient,
acute, and curable” instances of mental disease which we hope to
exclude from our American army by cis-Atlantic winnowing-out at the
hands of neuropsychiatric experts--the best preventive we hope both of
Shell-shock and of other worse mental conditions, if such there be.
Military mental practice plainly deals, not so much with frank and
committable insanity, as with mental diseases of a medically milder but
a militarily far more insidious nature.
[1] Official phrase for the scope of the Psychopathic Hospital,
Boston, Massachusetts.
A further inspection of this grouping of mental diseases shows not
only that it contains many conditions not usually termed “insanity”
(such as, e.g., feeblemindedness, epilepsy, alcoholism, sundry somatic
diseases, psychoneuroses), but that these conditions are presented for
practical purposes in a certain seemingly arbitrary order. Without
attempting to justify this selection of scope (not too wide for modern
psychiatry, most would readily acknowledge), I shall draw out a little
further what I consider to be the virtues of the order selected. In
the first place, all will concede, _some_ order of consideration of
collected data is a prime necessity to the tyro. Without an order of
consideration the diagnostic tyro is but too apt to find in the best
textbooks of psychiatry (even more easily the better the textbook)
all he needs to prove that the case in hand is--almost anything he
selects to make his case conform to! And how much more dangerous this
debating-society method of diagnosis (by choice of a side and matching
a textbook type) may become in the fluid and elastic conditions
of psychopathic hospital practice, can readily be observed by one
who contemplates the _formes frustes_ and entity-sketches that the
“incipient, acute, and curable” group of cases presents.
CHART 1
PRACTICAL GROUPING OF MENTAL DISEASES
The order adopted for these groups (which roughly correspond
to botanical or zoological orders) is a pragmatic order for
successive exclusion on the basis of available tests, criteria,
or information: the actual diagnosis is a product of still
further differentiation within the several groups.
The case-histories of this book will show that
(_a_) most shell-shock is in group X, Psychoneuroses,
(_b_) the diagnostic delimitation problem is chiefly against I.
Syphilopsychoses, III. Epileptoses, VI. Somatopsychoses,
(_c_) the finer differentiation problem is between X.
Psychoneuroses and V. Encephalopsychoses. (See Epicrisis,
propositions 9-12, 40-43, 72-73.)
I. Syphilitic Psychoses SYPHILOPSYCHOSES
II. Feeblemindedness HYPOPHRENOSES
III. Epilepsy EPILEPTOSES
IV. Alcoholic, Drug, and Poison
Psychoses PHARMACOPSYCHOSES
V. Focal Brain Lesion Psychoses ENCEPHALOPSYCHOSES
VI. Symptomatic (Somatic) Psychoses SOMATOPSYCHOSES
VII. Presenile-Senile Psychoses GERIOPSYCHOSES
VIII. Dementia Praecox and Allied
Psychoses SCHIZOPHRENOSES
IX. Manic-Depressive and Allied
Psychoses CYCLOTHYMOSES
X. Psychoneuroses PSYCHONEUROSES
XI. Other Forms of Psychopathia PSYCHOPATHOSES
No conclusions are intended to be drawn in these introductory pages.
Such conclusions as are risked are placed in the Epicrisis (see
Section E). But so much can be said: If we are ever to surround the
problem of Shell-shock (_intra bellum_ or _post bellum_), we must
approach it with no artificial and _à priori_ limitations of its scope.
We must not even agree beforehand that Shell-shock is nothing but
psychoneurosis: that would be a deductive decision unworthy of modern
science. In the collection of these cases, I have tried to place the
topic upon the broadest clinical base. Samples of virtually every sort
of mental disease and of several sorts of nervous disease have been
laid down, some obviously not instances of Shell-shock, some mixed with
clinical phenomena of Shell-shock, others hard to tell offhand from
Shell-shock--the whole on the basis that we shall earliest learn what
Shell-shock, the pathological event, is by studying what it is not. As
the sequel may show, we are perhaps not entitled to regard Shell-shock,
the pathological event, as always associated with shell-shock, the
physical event. We shall, therefore, find in Section A (see tables on
pages 6 and 7).
(1) Cases without either physical shell-shock, or pathological
Shell-shock--psychoses of various kinds incidental in the war (--+).
(2) Cases with physical shell-shock but without pathological
Shell-shock--psychoses of various kinds seemingly liberated by,
aggravated by, or accelerated by the physical factor of shell-shock
(+-+).
(3) Cases without physical shell-shock but with both symptoms of
pathological Shell-shock as well as of other psychosis (-++).
(4) Cases with physical shell-shock, with clinical phenomena of
Shell-shock, as well as of other psychosis (+++).
At the end of Section A, accordingly, we shall be left with two more
formulae for discussion in Sections B, C, and D, viz:
(5) Cases without physical shell-shock but with symptoms of
pathological Shell-shock (-+-).
(6) Cases with physical shell-shock and pathological Shell-shock (++-).
The data of Section A will solidly prove that Shell-shock, however
picturesque the term for laymen or in the _argot_ of the clinic, is
medically most intriguing. As we cannot get rid of the term (even by
suppressing it in parentheses or by condemning it to the limbo of the
_so-called_), we must make the best of it by calling Shell-shock just
the ore in the clinical mine. To say the least, the _term_ is harmless:
it merely stimulates the lay hearer to questions. These questions he
must ask of the expert. But every time that the expert suavely states
that Shell-shock is nothing but psychoneurosis, that expert runs the
risk of hurting some patient who may or not have a psychoneurosis but
has been _called_ psychoneurotic. All the while, of course, the suave
expert is perfectly right--_statistically_. In fine, the man you have
called a victim of Shell-shock is probably a victim of psychoneurosis,
_but only probably_!
Section A shows how he may--not probably, but possibly--be a victim of
say ten other things. But it is not that he has an even chance of being
one of these ten other things. As the reader watches the procession
of cases in Section A, he will perceive that, amongst the ten major
groups there studied, some have far greater diagnostic likelihood than
others. Thus, syphilis, epilepsy, and somatic diseases will in the
sequel prove more dangerous to our success as diagnosticians than, e.
g., feeblemindedness or even perhaps alcoholism. But now let us look at
these cases systematically, just as if we dealt with so many cases of
Railway-spine or any other “incipient, acute, and curable” cases.
CHART 2
PSYCHOPATHIA MARTIALIS
⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫
⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫
SHELL-SHOCK SHELL-SHOCK PSYCHOSIS
(THE PHYSICAL FACTOR) (NEUROTIC SYMPTOMS) (SYMPTOMS NON-NEUROTIC)
ABSENT ABSENT INCIDENTAL
PRESENT ABSENT LIBERATED,
AGGRAVATED,
ACCELERATED
PSYCHOSES
ABSENT COMBINED NEUROSES
AND PSYCHOSES
[2](FORMULA -++)
PRESENT COMBINED NEUROSES
AND PSYCHOSES
(FORMULA +++)
ABSENT NEUROSES ABSENT
(QUASI SHELL-SHOCK)
PRESENT NEUROSES ABSENT
(TRUE SHELL-SHOCK)
[2] For formulae see Chart 3 on opposite page.
CHART 3
PSYCHOPATHIA MARTIALIS
FORMULAE
⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫
⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫
S, N, P[3] = SHELL-SHOCK SHELL-SHOCK PSYCHOSIS
(THE PHYSICAL[4] (NEUROTIC SYMPTOMS) (NON-NEUROTIC
FACTOR) PRESENT PRESENT SYMPTOMS) PRESENT
P = - - +
SP = + - +
NP = - + +
SNP = + + +
N = - + -
SN = + + -
[3] In the literal formulae, S = Shell-shock, N = Neurosis, P =
Psychosis.
[4] These plus-or-minus formulae are not intended to imply
that the physical factor, where present (+), must have worked
a physical effect upon the nervous system: the effects of the
physical factor might be wholly emotional or otherwise psychic.
I. SYPHILOPSYCHOSES (SYPHILITIC GROUP)
An officer of high rank deserts his command in a crisis: alienists’
report.
=Case 1.= (BRIAND, February, 1915.)
M. X. was an officer ranking high in the French army, having military
duties of a critical nature and of great importance (social reasons
forbid Briand’s giving informatory details). Suffice it to say that he
was brought before court-martial for abandoning his post at the very
moment when his presence was most urgently required. He turned tail,
without taking the most elementary military precautions.
M. X. was passed up to alienists. He was not a case of Shell-shock
unless of the anticipatory sort. He was somatically run-down and of
lowered morale and now 65 years of age. The campaign had been fatiguing.
The alienists decided that the officer had not been responsible for
his non-military acts. He had been, they found, in a state of mental
confusion at the time of desertion, such that amnesia for his duties
and heedlessness of consequences had allowed him to leave the front
without looking behind him or securing substitution. This state of
mental confusion had been preceded by overwork and several nights of
insomnia.
Moreover he was palpably arteriosclerotic. Blood pressure was high. The
history was one of slight shocks and a mild hemiplegia. The confusion
at the front was only the most recent of a series of transitory attacks
of confusion. At the time of examination this high officer was actually
in a state of mild dementia.
M. X. was an old colonial man, malarial, and had been a victim of
syphilis.
A naval officer sees hundreds of submarines: General paresis.
=Case 2.= (CARLILL, FILDES, and BAKER, July, 1917.)
A naval officer, 36, during August, 1916, asserted that he could see
hundreds of submarines. At one time he imagined that he was receiving
trunk calls in the middle of the ocean. He was admitted to Haslar, and
the Wassermann reaction of the serum was found strongly positive. The
spinal fluid was not at this time examined. The officer recovered to
some extent, was given no special treatment, and was sent on leave.
He came under observation again in October, 1916, having become very
strange in his manner, on one occasion passing water into the coal box,
and talked about impending electrocution. His ankle-jerks were found
sluggish and there was a patch of blunting to pin pricks. The diagnosis
of general paresis was made. The spinal fluid was afterward examined
and found to be negative to the Wassermann reaction but contained 15
lymphocytes per cubic mm.
Three full doses of Kharsivan freed him from delusions and left him
apparently absolutely sane. It was recommended that he should be kept
at Haslar to continue treatment. However, he had been certified insane
and was therefore sent to Yarmouth, from which he was discharged in
February, 1917, having been in good mental health throughout his stay
there.
_Re_ syphilis and general paresis of military officers, as in Cases 1
and 2, Russo-Japanese experience was already at hand. Autokratow saw
paretic Russian officers sent to the front in early but still obvious
phases of disease. These paretics and various arteriosclerotics,
Autokratow saw back in Russia in the course of a few months.
_Re_ naval cases, see also Case 5 (Beaton). Beaton thinks that
monotonous ship duty, alternating with critical stress of service,
bears on morale and liberates mental disorder.
Neurosyphilis may be aggravated or accelerated under war conditions.
=Case 3.= (WEYGANDT, May, 1915.)
A German, long alcoholic and thought to be weakminded, volunteered, but
shortly had to be released from service. He began to be forgetful and
obstinate, cried, and even appeared to be subject to hallucinations.
The pupils were unequal and sluggish. The uvula hung to the right.
The left knee-jerk was lively, right weak. Fine tremors of hands.
Hypalgesia of backs of hands. Stumbling speech. Attention poor.
It appeared that he had been infected with syphilis in 1881 and in 1903
had had an ulcer of the left leg.
The military commission denied that his service had brought about the
disease.
=Case 4.= (HURST, April, 1917.)
An English colonel thought himself perfectly fit when he went out with
the original Expeditionary Force. He had had leg pains, regarded as
due to rheumatism or neuritis. He was invalided home after exhaustion
on the great retreat. He was now found to be suffering from a severe
tabes. He improved greatly under rest and antisyphilitic treatment. He
has now returned to duty.
=Case 5.= (BEATON, May, 1915.)
An apparently healthy man, serving on an English battle-ship, severed
a tendon in a finger. The injury was regarded as minor. The tendon was
sutured and the wound healed. During the man’s convalescence he was
accidentally discovered to have an Argyll-Robertson pupil and some
excess reflexes. Neurosyphilis had probably antedated the accident. But
from the moment of this trivial injury, the disease advanced rapidly.
Overwork in service; several months exacting work well performed:
General paresis.
=Case 6.= (BOUCHEROT, 1915.)
A lieutenant of Territorials, aged 41 (heredity good, anal fistula at
30, with ulceration of penis of an unknown nature at the same period).
In 1907 when off service and married, his wife gave birth to a child;
no miscarriages. Had been a good soldier in service before the war. The
lieutenant was called to the colors August 2, 1914, and was detached
for special duty, for the performance of which he was much praised by
the commanding officers. The work, however, was too much for him and
on April 1 he had to be evacuated to the hospital with a ticket saying
“Nervous depression following overwork in service.” On April 14 he
seemed well enough for a convalescent camp, but, apparently through
red tape, was sent to a hospital at Orléans. On June 23 he had to be
evacuated to the Fleury annex. His eyes were dull and features flaccid;
his whole manner suggested fatigue. His pupils were myotic, tongue
tremulous, speech slow and stumbling. Knee-jerks were exaggerated and
gait difficult, the right leg dragging. Headaches. He could not perform
the slightest intellectual work and was the victim of retrograde and
anterograde amnesia. He was aware of the decline of his mental power
and was fain to struggle against it, becoming restless and sad. The
gaps in his memory grew deeper, he became more and more impulsive,
even violent, and had spells of excitement. Dizziness and palpitation
developed. Sometimes there were auditory and visual hallucinations of
such intense character that he tried feebly to commit suicide with a
penknife. He fell into semicoma, and then had a number of apoplectiform
attacks. W. R. +
Apparently the moral and physical situation of the lieutenant was
absolutely normal when the campaign began and, as he fulfilled detail
duties with absolute correctness for a number of months, Boucherot
argues that here is an instance of general paresis _declanché_ by
overwork.
Syphilis contracted before enlistment. Neurosyphilis aggravated by
service.
=Case 7.= (TODD, personal communication, 1917.)
A laboring man, 42, who always strenuously denied syphilitic infection,
proceeded to France eight months after enlistment. He had not been
in France three weeks when he dropped unconscious. He regained
consciousness, but remained stupid, dull in expression, and with memory
impaired. His speech was also impaired. There was dizziness and a
right-sided hemiplegia.
He was confined to bed four months and was then “boarded” for discharge.
Physically, his heart was slightly enlarged both right and left; sounds
irregular; extra systoles; aortic systolic murmur transmitted to neck;
blood pressure 140:40. Precordial pain, dyspnoea.
Neurologically, there was a partial spastic paralysis of the right
thigh which could be abducted, could be flexed to 120°, and showed
some power in the quadriceps. There was also a spastic paralysis of
the right arm, but the shoulder girdle movements were not impaired.
There was a slight weakness on the right side of the face. There was no
anesthesia anywhere.
The deep reflexes were increased on the right side, Babinski on right,
flexor contractures of right hand, extensor contractures of right
leg, abdominal and epigastric reflexes absent, pupils active, tongue
protruded in straight line.
Fluid: slight increase in protein. W. R. + + +
The Board of Pension Commissioners ruled that the condition had been
aggravated _by_ service (not “_on_ service”).
_Re_ general paresis, Fearnsides suggested at the Section of Neurology
in the Royal Society of Medicine early in 1916, that in all cases of
suspected Shell-shock the Wassermann reaction of the serum should be
determined, and went on to say that cases of so-called Shell-shock with
positive W. R. often improve rapidly with antisyphilitic remedies.
Duration of neurosyphilitic process important _re_ compensation.
=Case 8.= (FARRAR, personal communication, 1917.)
A Canadian of 36 enlisted in 1915, served in England, and was returned
to Canada in February, 1917, clearly suffering from some form of
neurosyphilis (W. R. positive in serum and fluid, globulin, pleocytosis
108).
There is no record of any disability or symptom of nervous or mental
disease at enlistment. The first symptoms were noted by the patient in
May, 1916, six months or more after enlistment. The case was reviewed
at a Canadian Special Hospital, October 11, 1916, by a board which
reported:
“The condition could only come from syphilitic infection of three
years’ standing” (a decision bearing on compensation); but the general
diagnosis remained:
“Cerebrospinal lues, =aggravated by service=.”
The picture which the medical board regarded as of at least three
years’ standing was as follows:
History of incontinence, shooting pains, attacks of syncope, general
weakness, facial tremor, exaggerated knee-jerks, pupils react with
small excursion. Speech and writing disorder, perception dull, lapses
of attention, memory defect, defective insight into nature of disorder,
emotional apathy.
1. Was the conclusion “aggravated by service” sound? On
humanitarian grounds the victim is naturally conceded the
benefit of the doubt. But it is questionable how scientifically
sound the conclusion really was.
2. Could the condition come only from syphilitic infection of
at least three years’ standing? Hardly any single symptom in
this case need be of so long a standing; yet the combination
of symptoms seems by very weight of numbers to justify the
conclusion of the medical board.
Farrar’s case and thirteen others of “Neurosyphilis and the War” were
included in a general work on Neurosyphilis (Case History Series,
1917, Southard and Solomon). For military syphilis in general, see
Thibierge’s _Syphilis dans l’Armée_ (also in translation).
General paresis lighted up by the stress of military service without
injury or disease?
=Case 9.= (MARIE, CHATELIN, PATRIKIOS, January, 1917.)
In apparently good health a French soldier repaired to the colors, in
August, 1914, being then 23 years old.
Two years later, August, 1916, symptoms appeared: speech disorder
with stammering, change of character (had become easily excitable),
stumbling gait. He became more and more preoccupied with his own
affairs, grew worse, and was sent to hospital in October, 1916.
He was then foolish and overhappy, especially when interviewed.
There was marked rapid tremor of face and tongue. Speech hesitant,
monotonous, and stammering to the point of unintelligibility. His
memory, at first preserved, became impaired so that half of a test
phrase was forgotten. Simple addition was impossible and fantastic sums
would be given instead of right answers. Handwriting tremulous, letters
often missed, others irregular, unequal, and misshapen.
Excitable from onset, the patient now became at times suddenly violent,
striking his wife without provocation. After visit at home, he would
forget to return to hospital. Often he would leave hospital without
permission (of course the more surprising in a disciplined soldier). No
delusions.
Serum and fluid W. R. positive; albumin; lymphocytosis.
Neurological examination: Unequal pupils, slight right-side mydriasis,
pupils stiff to light, weakly responsive in accommodation, reflexes
lively, fingers tremulous on extension of arms.
The patient had, December 5, 1916, an epileptiform attack with head
rotation, limb-contractions and clonic movements. Should this soldier
recover for disability obtained in service? Marie was inclined to
think military service in part responsible for the development of
the paresis. Laignel-Lavastine thought so also, but that the amount
assigned should be 5%-10% of the maximum assignable.
SYPHILITIC ROOT-SCIATICA (lumbosacral radiculitis) in a fireworks man
with a French artillery regiment.
=Case 10.= (LONG (DEJERINE’S clinic), February, 1916.)
No direct relation of this example of root-sciatica to the war is
claimed nor was there a question of financial reparation.
There was no prior injury. At the end of March, 1915, the workman was
taken with acute pains in lumbar region and thighs, and with urgent but
retarded micturition.
Unfit for work, he remained, however, five months with the regiment,
and was then retired for two months to a hospital behind the lines.
He reached the Salpêtrière October 12, 1915, with “double sciatica,
intractable.”
There was no demonstrable paralysis but the legs seemed to have “melted
away,” _fondu_, as the patient said. Pains were spontaneously felt in
the lumbar plexus and sciatic nerve regions, not passing, however,
beyond the thighs. These pains were more intense with movements of
legs; but coughing did not intensify the pains. Neuralgic points could
be demonstrated by the finger in lumbar and gluteal regions and above
and below the iliac crests (corresponding with rami of first lumbar
nerves). The inguinal region was involved and the painful zone reached
the sciatic notch and the upper part of the posterior surface of the
thigh.
The sensory disorder had another distribution, objectively tested. The
sacral and perineal regions were free. Anesthesia of inner surfaces of
thighs, hypesthesia of the anterior surfaces of thighs and lower legs.
The anesthesia grew more and more marked lower down and was maximal in
the feet, which were practically insensible to all tests, including
those for bone sensation. There was a longitudinal strip of skin of
lower leg which retained sensation.
Position sense of toes, except great toes, was poor. There was a
slight ataxia attributable to the sensory disorder--reflexes of upper
extremities, abdominal, and cremasteric preserved, knee-jerks, Achilles
and plantar reactions absent.
The vesical sphincter shortly regained its function, though its
disorder had been an initial symptom. Pupils normal.
The “sciatica” here affects the lumbosacral plexus.
As to the syphilitic nature of this affection, there had been at
eighteen (22 years before) a colorless small induration of the penis,
lasting about three weeks. There was now evident a small oval pigmented
scar. The patient had married at 20 and had had three healthy children.
The lumbar puncture fluid yielded pleocytosis (120 per cmm.). Mercurial
treatment was instituted.
The treatment has not reduced the pains. Long thinks it was undertaken
too long (six months) after onset. The warning for early diagnosis is
manifest. There was somehow a delay under the medical conditions of the
army.
_Re_ syphilis in munition-workers Thibierge has much to say of French
conditions. Throughout his work on syphilis in the army, he stresses
the large number of venereal cases in men mobilized for munition-work.
Medical inspections ought, according to Thibierge, imperatively to be
made in the munition-works and upon all mobilized workmen, whether
French or belonging to the Colonial contingents. These men are under
military control in France, but they have more opportunities than the
soldiers for contracting and disseminating syphilis. They are, in point
of fact, very often infected and in a higher proportion than are the
soldiers at the front. The munition-workers should also be obliged to
report their infections to the physician, whether or no they are under
treatment by military or by private physicians.
Thibierge devotes a chapter to syphilis as a national danger. Not
only do available statistics prove that there is more syphilis in
the population since the outbreak of war, but the number of married
women going to special hospitals for syphilis is abnormally high and
entirely out of proportion to the number of married women resorting
to these clinics in peace times. A certain number are contaminated
by their husbands on leave. Thibierge calls attention to the fact of
the extraordinary frequency of syphilis in young men (two or three,
sixteen to eighteen years of age, at Saint-Louis Hospital at each
consultation).
A disciplinary case: Syphilitic?
=Case 11.= (KASTAN, January, 1916.)
Reports varied about a certain German soldier who came up for
discipline. Inferiors thought he was harsh and tricky. A lieutenant
declared that the man always wanted to have proper respect paid to him,
and that he was unduly excited by trifles. The man had become latterly
very nervous on account of battle strain and protracted shelling.
July 28, 1915, the man, who had been drinking with comrades the night
before, was excitedly talking to an officer concerning relief of a
guard. The soldier stated, “As a sergeant on duty with a service record
of 15 years, I think it is my affair.” The lieutenant replied, “So
far as I am concerned, the matter is settled.” The sergeant yelled,
“As far as I am concerned, it is settled also. By the way, my name
is _Mr._ Vice Sergeant …,” and with that the sergeant wrote down the
lieutenant’s words and refused to obey the lieutenant’s order to
“Stop writing.” The lieutenant drew his sword and said, “Take your
hands down.” The sergeant replied, “Surely I am permitted to write.”
Lieutenant: “Subordination; don’t forget yourself, Vice Sergeant.…”
The sergeant jeered, “You forgot yourself anyhow;” whereupon the
lieutenant: “Well, such a thing never happened to me before.” The
sergeant, jeeringly, “Nor to me either. If I were not in undress I
should know what to do.” The lieutenant: “Vice Sergeant …, remain here.
This matter will be settled at once.” The sergeant: “It is _Mr._ Vice
Sergeant …,” whereupon he gave his notebook to a hornblower and said,
“Write.” The lieutenant: “Stay.” The sergeant: “What, stay here. No,
I’ll not stay,” and made off. The lieutenant called after him, “Put
on your service dress and see the captain.” He made ready but said,
“This half-idiot gives an order like that to a sergeant with 15 years’
record.”
The examination showed that the man had a hypalgesia. He complained of
violent headaches. He said that he had had syphilis 10 years before;
there were no bodily stigmata.
Regulations broken: General paresis.
=Case 12.= (KASTAN, January, 1916.)
A German 1st-lieutenant, on active service before the war, had left
the service because there was not enough for him to do in peace times.
During his war service, he became drunk and had two soldiers bound to
a doorpost, with coats unbuttoned and without their caps--a process
quite _verboten_. While in Königsberg, he reported himself ill, and
failed to go to a designated hospital. He was accordingly treated as
a deserter. He ran up bills with landlady and servant girls, saying
that he was going to receive money from his wife. Under hospital
examination, he said he was only a Baden man with a lively temperament.
He got angry at the phrase _test feeding_, refused food, got excited
when asked to help in the care of other patients, and wrote a letter
saying, “If it is the idea to make me nervous by removing the air from
me, by prescribing rest in bed--a punishment only suitable for a boy
who cannot keep himself neat--and such chicaneries, these philanthropic
attempts are bound to fail on my robust peasant nerves. Of course I
know that money considerations make the stay of every paying patient
desirable, but I am really too good for that. [The expenses were being
borne by the state.] I have openly stated what is being here done with
me is foolery, and I stick to that phrase. The food, already poor
enough, is no better, when the meat of a half-rotten cow comes twice to
the table.” This patient was, according to Kastan, a victim of general
paresis.
_Re_ general paresis and delinquency, Gilles de la Tourette long ago
maintained that there was a medicolegal period in paresis. Lépine in
his work on _Troubles Mentales de la Guerre_ speaks of the unexpected
frequency of general paresis in the army, and calls attention at the
outset to the medicolegal period. The danger of overt delinquency
is, in fact, greater under military than under civilian conditions
on account of the closer surveillance of the soldier. Desertion and
thievery are the main forms.
Unfit for service: General paresis.
=Case 13.= (KASTAN, January, 1916.)
Kastan describes a non-commissioned officer, who came voluntarily
into the clinic. It seems that he had absented himself (?) from the
army in the suburbs of Königsberg, September 3, 1914. He was arrested
October 7th. Once before he had been brought to Kastan’s clinic on the
suspicion of general paresis, but had been dismissed as non-paretic.
Brought in again in a condition of marked fear, he declared that he had
to fall behind his company while he was on the march on account of a
feeling of weakness. He had been taken to a hospital and then carried
to the suburbs of Königsberg, examined, and found unfit for service.
He had in his 20th year become infected with syphilis, and had recently
become forgetful, subject to fears, and easily excitable. He had been
very unhappily married with a woman who was hysterical and threatened
to shoot and poison him. He lived in a condition of continual quarrels
with her. The symptoms that he felt on the march were numbness of the
legs and a rush of blood to the head. In the clinic, he was subject
to much dreaming and raving about the war. There was excessive
perspiration.
1. As to the proper interpretation of this case, details
are lacking as to the physical and laboratory side. In
fact, it would appear that the suspicion of paresis at his
first reception in a clinic was dismissed without resort to
laboratory findings.
There are no neurological symptoms in the case clearly
suggestive of neurosyphilis, except perhaps the numbness of
the legs. The remainder of the picture appears to be entirely
psychic. Sensory and intellectual symptoms are missing unless
we count the war dreams and mania as intellectual. It appears
wiser to count these as emotional in the sense that they were
roused by emotion-laden memories. The fear, perspiration, and
feelings of head flush are perhaps to be best interpreted as
satellites about an emotional nucleus.
Hysterical chorea versus neurosyphilis.
=Case 14.= (DE MASSARY and DU SONICH, April, 1917.)
There were various complications in the case of a lieutenant (nervous
tic in childhood; travel 23 to 30), who was at Antwerp during the
period of mobilization. He was taken there by the Germans; was a
prisoner in their hands for 55 days; and succeeded under great strain
in escaping.
He then entered his regiment, and, passing the examinations, was
made an adjutant, and went to the front, March, 1915. He stayed ten
months in the Verdun region, under heavy bombardment, and in June was
bowled over and buried by a 210. He seemed to be fearless, getting no
sensation from shell-bursts except a griping sensation in the bowels.
However, his character had altered in the direction of irritability;
and by the end of January, 1916, he had to be evacuated for the
first time from the front, for general weakness, with the diagnoses:
neurasthenia, neuralgia, dyspeptic troubles, great general fatigue,
marked depression. In fact, at Narbonne he was asked no questions
for several days on account of his obvious depression. He was given
ice-bags for violent headaches, complete rest in bed, cacodylate and
sodium nucleinate. In two weeks he was up and about.
At this time appeared choreiform movements, which reached their maximum
in two or three days, whereupon he was sent, March 4, 1916, to the
neurological centre at Montpellier. Here W. R. positive! Neosalvarsan
on the second injection (0.45 and 0.60) yielded a strong reaction, with
fever, delirium, vomiting, and then jaundice.
About a month later, he was given twenty more intravenous injections,
whereupon the choreic movements now decreased, and July 15 he was given
convalescence for three months. October 15 he went back to his dépôt
cured; and October 20, on request, went to the front. He was potted
and under machine-gun fire at times during the next three months, but
the choreic movements did not reappear. January 1 he left the trenches
as the division went into billets. January 8, suddenly, without
any emotional cause, he began to “dance” again. Accordingly, he was
evacuated for the second time, January 10, 1917, with the diagnosis:
choreic movements, especially on left; evacuate to special centre.
At Royallieu, a lumbar puncture showed a slight lymphocytosis.
The headache improved. He was evacuated January 24, 1917, to
Val-de-Grâce, with a diagnosis: Recurrent chorea; first attack followed
commotio cerebri, nervous depression, inequality of pupils, various
pains, contracted in the army. Another W. R. was positive. Twelve
intramuscular injections of oxygen cyanide were given, besides baths.
He was then sent to Issy-les-Moulineaux with a diagnosis of tic. He
showed choreiform movements affecting the legs alone. When sitting,
legs extended and flexed, the knees would abduct, then adduct;
the thighs flexed. When standing, flexor movements were produced
alternately on the left and the right, the knee being raised high,
sometimes striking the patient’s hand. In walking, the thigh and lower
leg flexion was always out of proportion to the required step. There
was thus a sort of saltatory chorea limited to the legs. The reflexes
so far as they could be tested were normal save that the left pupil
was fixed to light and accommodation; the right pupil was sluggish to
light but accommodated normally. Leucoplakia of the cheeks; nocturnal
headaches; and pains resembling lightning pains in arms and legs.
Lumbar puncture, March 26, showed blood-stained fluid, and the puncture
was followed by headache, vomiting, and slow pulse. The fluid showed a
slight lymphocytosis; W. R. negative.
It is clear that a diagnosis limiting itself to the leg trouble would
probably content itself with “hysterical chorea.” The lieutenant said
that when he saw people “dance” he did have a tendency to imitate
them; and when he was cured of that, he did not want to go to Lamalou
because he would see the ataxic patients there and might fall back
into his “dancing.” However, in view of the pupillary inequality, the
lymphocytosis, the leucoplakia, the W. R., and the initial neurasthenia
and depression found in the very first hospital in which he was
examined, we probably should be entitled to consider that general
paresis played a part in the chorea.
Shrapnel fragment driven through skull: General paresis.
=Case 15.= (HURST, April, 1917.)
A private, 31, was wounded December 7, 1916, by a shrapnel fragment
which entered the skull above the left ear and lodged in the brain,
an inch above and 2½ inches below the middle of the right orbital
margin. At Netley, December 30, he proved to show a complete internal
and external left sided ophthalmoplegia, with the exception of the
external rectus. On the right side, there was a complete paralysis of
the superior rectus and a partial paralysis of the inferior rectus and
levator palpebrae superioris. There was a paresis of the left side of
the face. The right plantar reflex was said to have been extensor at
the clearing station, but at Netley it and the other reflexes proved
to be normal, as were the optic. The patient was stuporous and had
incontinence of urine and feces for two days. Shortly after admission,
slurring of speech with a long latent period occurred. It was clear
that the shrapnel fragment must have passed far above the crus, and
it was not plain how isolated lesions of the third and seventh nerve
nuclei could have been brought about without injury of the long tracts
of the crus.
The Wassermann reaction of the serum was negative, but that of the
spinal fluid was positive. Iodide and mercury secured considerable
improvement in the mental condition and some diminution in the
paralysis. The patient is now extremely pleased with himself and has a
speech suggestive of paresis.
Head trauma: Shell-shock effects, over in a few months.
Manic-depressive (?) attack more than two years later. X-ray evidence
suggesting brain lesion. Serum Wassermann reaction positive.
=Case 16.= (BABONNEIX and DAVID, June, 1917.)
A bullet glancing from his gun barrel November 28, 1914, wounded a
man in the head, whereupon he lost consciousness and was carried to a
hospital and trephined. On coming to, he found that he could not hear
and felt pains; but the latter disappeared in a few months. He was
given sedentary employment and did his work properly until February,
1917, when he suddenly became sad, wept, slept poorly, stopped eating,
had an absent air, and began to complain of his head. He passed whole
days without moving, in a sort of stupor, which was then followed by a
hypomaniacal agitation in which he walked furiously up and down in the
room and threw objects about.
He was found subject to a generalized tremor and he was distinctly
weaker on the right side. The tendon reflexes were excessive. The
bony sensibility, as well as the pain and temperature sense, and
the position and stereognostic senses were completely abolished on
the right side. The scar lay on the left side. It was deep and very
sensitive to pressure, so that if it was touched ever so slightly
the patient began to weep. X-ray indicated loss of substance in the
posterior part of the left parietal region. Remains of the projectile
were found subcutaneously in the right supraorbital region. The W. R.
of the serum was positive. There was no lymphocytosis in the spinal
fluid.
Interpretation of this case is manifestly difficult. Four possibilities
exist: Syphilis, manic depressive psychosis, traumatic brain disease,
and functional shock effects. More than two years had passed between
the trauma and the change of character.
Skull trauma in a syphilitic.
=Case 17.= (BABONNEIX and DAVID, June, 1917.)
A soldier, 31, sustained fracture of the occiput from shell-burst,
and thereafter showed confusion and total loss of memory. Operation
November 11 withdrew bony fragments and clots, whereupon the man
returned practically to normal. He developed, however, a few seizures,
in which he struggled, fell, and lost consciousness, afterward
suffering from headache. The tendon reflexes were increased. The
occipital cicatrix was a little depressed and slightly painful on
pressure.
Lumbar puncture showed a very slight lymphocytosis (5 to 6 cells),
practically negative globulin reaction, and a low albumin titer. There
were no signs of syphilis in the eyes. The W. R. in the serum was
strongly positive. Very possibly the traumatic phenomena in this case
can be safely disengaged from the syphilitic phenomena.
_Re_ the mechanism by which trauma evokes or accelerates the course of
neurosyphilis, it is probable that most neuropathologists believe that
the _commotio cerebri_ causes sundry chemical or physical effects in
the nerve tissues such that spirochetes are moved into new and more
dangerous places, or such that more appropriate food is supplied to the
organisms, which then begin to multiply. Whether the organisms live in
a kind of symbiosis in the tissues under ordinary circumstances in the
pre-paretic period of the development of neurosyphilis, is unknown.
Possibly fat embolism should be added to the list of possible causes
of the hastening of the neurosyphilitic process. Fat embolism in the
brain has been shown by various authors to be accompanied by minute
hemorrhages, in the midst of which by proper stains the fat embolism
can be made out.
Shell-wound in battle: General paresis.
=Case 18.= (BOUCHEROT, 1915.)
A soldier in the Territorial Infantry, 42, a gardener who went to
taverns, as he said, “like everybody else,” a widower with two
children, a good worker though irascible, had had syphilis as a youth.
He was called to the colors at the outbreak of the war and got on well
despite tremendous strain. March 9, 1915, he was in a bayonet charge
with his regiment and was bowled over by a shell of which a fragment
wounded him above the knee and several fragments in the thorax. All
these fragments were extracted at a temporary hospital, March 11.
The man now became strange, refused to obey orders and did a number
of peculiar things so that he was sent to Orléans temporary hospital
whence he was evacuated to Fleury Asylum, March 19. He refused to give
up his things because he was the master. He did not want to go to bed
and wanted to keep on walking constantly. He was without sense of
shame, satisfied with himself, grandiose as to his millions in bank and
the thirty-six decorations he believed had been awarded him. He mistook
the identity of the landscape and of the people about him.
Tongue tremulous; pupils unequal; knee-jerks exaggerated; dysarthria;
gaps in memory. In May occurred a number of violent reactions.
In June, however, there was a remission; the ideas of grandeur
disappeared first, then the tremors and reflex disorder and finally the
speech disorder. There was a slight seizure at this point and the man
said he had had another such just before he came to the army. July 20
he was invalided out much improved.
In this case of general paresis there is, besides the syphilis, also
alcoholism to consider, so that it is not entirely plain that the
exertions of campaign liberated the paresis.
_Re_ wounds and paresis, see also Case 5 (Beaton), in which
neurosyphilis advanced rapidly from the time of a trivial injury.
Shell-explosion: Syphilitic ocular palsy.
=Case 19.= (SCHUSTER, November, 1915.)
Schuster notes briefly a curious result of the explosion of a shell,
which caused the patient in question to lose consciousness. Shortly
after the explosion, the patient came to his senses again, but a
surprising paresis of the eye muscles had developed. This paresis
looked precisely like a syphilitic paresis clinically.
Examination of the blood serum yielded a strongly positive Wassermann
reaction.
According to Schuster, the explosion of the shell had brought about
hemorrhage in vessels supplying the region of the eye muscle nerves or
nuclei. The reason for the selection of these vessels for rupture due
to shell explosion is, according to Schuster, that the vessels were
probably already syphilitically diseased.
_Re_ hemorrhages in the neighborhood of the oculomotor nuclei, the
phenomena of polioencephalitis may be recalled. In that disease, the
predisposition to hemorrhage is presumed to be alcoholic, as the cases
of ophthalmoplegia of this group almost always appear in alcoholics.
However, the first case of hemorrhagic superior polioencephalitis was a
non-alcoholic one of Gayet (1875), in which the symptoms followed three
days after a boiler explosion.
A tabetic lieutenant “shell-shocked” into paresis?
=Case 20.= (DONATH, July, 1915.)
An apparently competent German professor in an intermediate school,
a lieutenant of infantry reserves, 33 years old, on the 17th August,
1914, was stunned for a while by the shock of a cannon-firing 25 feet
away. Urination became difficult. Headaches and limb pains ensued, with
paralysis of fingers, gastric troubles, forgetfulness, especially for
names, insomnia, and general scattering of mental faculties.
Neurologically, the pupils were irregular, left larger than right;
Argyll-Robertson reaction. Right knee-jerk livelier than left. Achilles
reactions absent. Slow and dissociated pain reactions in feet, lower
thighs and lower quarter of upper thighs, with hypalgesia or analgesia.
Station good; gait steady. Mentally depressed, slow of thought. Speech
poor and of indistinct construction (mild dementia). Calculation
ability poor. No pleasure in work.
Wassermann reaction of serum weakly positive.
It seems that for a year the patient had been subject to spells of
anger. He was irritated by his wife who had been nervous since an
earthquake.
_On the occasion of the earthquake_, 1911, the patient himself had had
a spell of _difficulty with urination_. The spell had lasted two or
three months. The patient had had a chancre in 1902, “cured” in four or
five weeks with xeroform. In 1908, when about to marry, he had had six
mercurial inunctions.
_Re_ tabes, Lépine shows that tabetics are numerous. They are numerous
among officers and also in the auxiliary service, in which latter
tabetics are maintained on desk duty. Perhaps they had been admitted
to such work as unable to march or fight, on the basis of having had
so-called “rheumatism.”
Shell-explosion may precipitate neurosyphilis in the form of tabes
dorsalis.
=Case 21.= (LOGRE, March, 1917.)
An artilleryman, 38, had a large calibre shell explode very near
him and afterward could not hear the whistle of a shell without
falling down in a generalized tremor, sweating profusely, urinating
involuntarily, in a mental state approaching stupidity. Here was a case
that might be regarded as one of morbid cowardice in a psychopath,
following violent emotion.
The artilleryman proved to be a victim of tabes and of general paresis.
The incontinence of urine under the influence of emotion was nothing
but an effect of tabetic sphincter disorder. The crisis of cowardice
proved nothing but an initial symptom of general paresis.
Shell-explosion; burial: Tabes dorsalis incipiens.
=Case 22.= (DUCO and BLUM, 1917.)
A French soldier was buried by effects of shell explosion September 8,
1914. He sustained no wound or fracture.
Incontinence of urine developed. Anesthesia of penis and scrotum.
Reflexes absent; pupils sluggish. Wassermann reactions suspicious.
The diagnosis =tabes dorsalis incipiens= was made (hematomyelia of
conus terminalis eliminated).
The patient was estimated to be “40% incapacitated,” according to the
French “_échelle de gravité_” of conditions. A full pension would not
be justified in the opinion of the French authors.
SHELL-SHOCK PSEUDOTABES (non-syphilitic, serum W. R. positive).
Improvement.
=Case 23.= (PITRES and MARCHAND, November, 1916.)
Innkeeper B., 36, a shell-shock and burial victim June 20, 1915, was
looked on by a number of physicians as a case of genuine tabes.
Even eight months after the episode, he still showed (when observed
by Pitres and Marchand, February 3, 1916) absence of knee-jerks and
Achilles jerks, a slight swaying in the Romberg position, pupils
sluggish to light, incoördination, delayed sensations. There was also
a history of pains in the legs, compared by the patient to those of
sciatica. These pains came in crises, the longest of which had lasted
30 hours.
It seems that this soldier’s troubles began the day after his shock
with a feeling of swollen feet and of cotton wool under them. He stayed
on service, however, walking with increasing difficulty.
At the time of his evacuation, July 10, he could walk with great
difficulty. “Strips of lead were between his legs.” He could hardly
control movements in the dark, or descend stairs. Often his legs would
bend under him. Vesical function sluggish.
After a few months the patient could walk better. In February, 1916,
he walked thrusting his legs forward trembling, and dragging toes a
little. He could not support himself on either leg. Jerkiness and
incoördination in extension or flexion of leg on thigh.
The muscular weakness was decidedly against tabes or at all events
a pure tabes. The incoördination proved to be due, not to loss
of position sense (which was intact) but to unsteady muscular
contractions. Deep sensibility was intact.
There were no mental symptoms. There was a slight hesitation in speech
and doubling of syllables, but nothing demonstrable with test phrases.
The serum W. R. was positive.
Shell explosion; unconsciousness: Neurosyphilis.
=Case 24.= (HURST, April, 1917.)
A private, 31, was in the retreat from Mons, was blown up by a shell
and buried in May, 1915, went back to the front after two months leave,
was knocked unconscious by a shell December, 1916. He came to himself
two days later in the hospital, but remained confused and lethargic.
In England, December 21, his legs were still weak and walking was
unsteady. The right pupil reacted neither to light nor to accommodation
and was irregular, eccentric, and dilated. The left pupil showed the
Argyll-Robertson reaction. There was early primary optic atrophy.
The right knee-jerk was slightly exaggerated. The vibration sense
was reduced over sacrum and malleoli. At this time the man’s mental
condition was practically normal.
The Wassermann reaction of the serum and spinal fluid proved positive.
Improvement followed rest, iodide, mercury, and seven injections of
salvarsan. By the middle of February he was able to walk well. The
right pupil regained its power to react to accommodation, but remained
inactive to light. Meanwhile, the left pupil had regained a slight
power to react to light.
_Re_ treatment of syphilis, both Thibierge and Lépine give warning
of some bad results with arsenobenzol treatment, though Thibierge
states that the number of serious accidents and especially of deaths
has diminished more and more now that no arsenobenzol (drug No.
914) is given. Encephalitis is the gravest of the untoward results
of injection, sometimes appearing in young and vigorous subjects.
Hemorrhagic encephalitis appears to occur more frequently after the
second injection than after the first, and according to Thibierge may
be especially suspected in subjects who after the first injection
present much fever, congestion of face, and cutaneous eruptions.
Treatment in these cases should be suspended or given in moderate
doses.
Shell-explosion: Neurosyphilis. Fit for light duty.
=Case 25.= (HURST, April, 1917.)
A corporal, 26, blown up by a shell December 7, 1916, was admitted
to the hospital on the 13th, dazed and with symptoms of a left-sided
hemiplegia of organic origin. The right pupil was larger than the left.
There was a bruise of the scalp in the right parietal region. The
man had had syphilis at 16. The Wassermann reaction of the serum was
strongly positive. Rest, salvarsan, mercury, and iodides were given,
and the general symptoms and hemiplegia gradually disappeared, until
on December 12 there was only a moderate weakness of the left side,
with knee-jerks in excess, abdominal reflexes absent, and the Babinski
reaction.
The Wassermann reaction was still strongly positive. Salvarsan,
mercury, and iodide were continued. January 6, 1917, the plantar reflex
had become flexor. The abdominal reflex returned. Babinski’s second
sign (combined flexion of thigh and pelvis) was now the only evidence
of organic disease. Further antisyphilitic treatment removed this sign
also. February 28, the man was discharged fit for light duty, with
unequal pupils and positive Wassermann reaction, and a complete amnesia
for the four weeks following his blowing up in the trenches.
_Re_ fitness for light duty, see remarks on Case 20 concerning desk
duty for certain tabetics.
_Re_ the premature or unexpectedly early appearance of neurosyphilis
under war conditions, the early claims of some authors have not been
maintained. In the above instance, the infection was at 16 and the
shell explosion occurred at 26, namely, at about the right interval for
the development of neurosyphilitic signs. Gerver states that military
service brings out the lesions of paresis earlier than they would
otherwise come. Bonhoeffer has been unable to show that cerebrospinal
syphilis is favored in its development by the exhaustion factor.
SHELL-SHOCK PSEUDOPARESIS (non-syphilitic). Recovery.
=Case 26.= (PITRES and MARCHAND, November, 1916.)
June 19, 1915, a shell exploded some distance from Lieutenant R. He
remembers the gaseous smell, the bursting of several shells nearby
and a sensation of being lifted into the air. When he recovered
consciousness, he was in hospital at Paris-Plage, covered with bruises
and scratches. They told him he had been delirious and had vomited and
spat blood.
June 24, his wife came to see him, but this visit he could not
remember. Nor could his wife at first recognize him, he was so thin. He
roused a few moments and recognized his wife, but relapsed into torpor
again. Speech was difficult and ideas confused.
A few days later he was able to rise; but his mental status grew worse,
especially as to speech and writing, the latter quite illegible. There
was insomnia, or, if he slept, war dreams.
August 7, he began a period of five months’ convalescence passed with
his family, depressed, given to spells of weeping, confined to bed or
couch, unable to “find words,” conscious of his state and troubled
about it, speaking of nothing but the war, and afraid to go out for
fear of ambuscade. There was at first a slight lameness of the right
leg. Although he could walk, he felt pain in the knee on flexing the
right leg on the thigh. He walked holding this leg in extension.
On going back to the colors, he was immediately evacuated to the
_Centre Neurologique_ at Bordeaux, January 20, 1916.
Examination found a bored, impatient, irritated man, vexed that a man
who was not sick should be sent up “_comme fou_.”
Omitting negative details, neurological examination showed slight
lameness as above, body stiff and movements jerky, difficult, unsteady
gait. The lieutenant could stand for some time on either leg. Tongue
and face tremulous during speech. Limbs moderately tremulous,
especially in the performance of test movements.
Knee-jerks and Achilles jerks absent. Other reflexes, including
pupillary, normal. Segmentary hypalgesia of right leg, especially
about knee. Tremulous speech and writing. Patient would stop short in
speaking for lack of words.
Malnutrition. Appetite good, but a bursting feeling after meals.
Skin dry, scaly on legs, fissured on fingers.
Serum W. R. negative. Fluid not examined.
=Mental examination.= Conscious and complaining of his troubles,
Lieutenant R. claimed persistently that he was not sick. Memory for
recent events was in general poor. Errands easily forgotten. Lost in
the street. Complaint of corpse odors round him. Everybody is looking
at him and making fun of him. He was apt to insult bystanders. He was
afraid of German spies. Things in shops angered him as they seemed to
him to be of German manufacture.
There were frequent periods of depression, with pallor and no
spontaneous speech for some hours to a half-day. Headaches coming on
and stopping suddenly.
As to diagnosis, the first impression, say Pitres and Marchand, was
that of general paresis. The progress of symptoms after the shock was
consistent with this diagnosis. The mental state and the physical
findings seemed consistent, although the pupils were normal. His
partial insight into his symptoms was not inconsistent with the
diagnosis. He had a characteristic self-confidence. There had been four
stillbirths (two twins); two children are alive, 11 and 13. Typhoid
fever at 30. Syphilis denied. No mental disease in the family.
The patient had never done military duty, having been invalided for
“right apex.” But he had volunteered and been accepted in September,
1914.
How was Lieutenant R. cured? Apparently by rest in the _Centre
Neurologique_. Pitres and Marchand do not speak of the subtle
relation between mental state and the idea of non-return
to military service. This motive might still work even if
Lieutenant R. kept protesting sincerely that he wanted to go
back into military service.
War strain; shell explosion; unconsciousness. Sensory and motor
disorders. Subject an old syphilitic.
=Case 27.= (KARPLUS, February, 1915.)
A captain, 34, was under much stress and strain in the field and gave
himself over to excesses of alcohol and tobacco. August 25, 1914, at
the Krasnik battle he suddenly saw at his right a gleam of fire and was
afterward able to remember very distinctly the words of a lieutenant
standing near by, “The man is dead.” Three or four hours later he came
to himself at a relief post, vomited and bled a good deal from nose and
mouth. He heard later that he had been thrown on his back.
Manual tremors and general pains developed in the next few days. Two
weeks after the accident a slight nystagmus on looking to the left
appeared, but there was otherwise no disorder of head or extremities.
He was able to sit up, supported by his arms, and he was able to
contract his abdominal muscles normally. As for his legs, active
movements were limited and weak. He could not lift his legs. The
paralysis was more marked distally. He could walk with the support of
two persons, but was unable to lift his feet from the ground. The right
upper abdominal reflex was elicited, and both patellar reflexes were
tolerably active. Cremasteric and plantar reflexes were absent. Neither
of the Achilles jerks could be produced. There was hypesthesia and
hypalgesia of the lower extremities, and of the back up to a horizontal
line corresponding with the ninth dorsal segment; thermo-hyperesthesia
and disorder of vibration sense in the lower legs. Both the motor and
the sensory disorders were more marked on the right than the left.
Insomnia and battle dreams.
The gait disorder and paresis gradually improved. There was no
alimentary glycosuria and adrenalin produced no mydriasis. In the
course of several weeks the patient gained seven kilograms, began to
sleep well and showed gradual improvement in his gait and in the
execution of various movements with his feet. The abdominal reflexes
were now both present, but there were no plantar reflexes and the
Achilles were still both absent. The sensory disorder remained
unchanged, so far as the skin was concerned, but the deep sensibility
improved. Both legs from the knee down were somewhat cold.
This man had had syphilis at twenty-two, had gone through an inunction
cure, and repeated W. R.’s came through negative. He had suffered from
vomiting spells and anxiety feelings for a number of years which had
been diagnosed by physicians as cardiac neurosis. Yet for a year before
going into the war he had felt absolutely well.
Shell-explosion: Amnesia; syphilitic hemiplegia. Recovery except for
amnesia as to brief period and loss of occupational skill.
=Case 28.= (MAIRET and PIÉRON, July, 1915.)
A man of 40 underwent shell shock June 15, 1915, and had no remembrance
of what happened up to July, 1915, when in hospital at Tunis he felt
“born again.”
Examined in January, 1916, it was found that he had a left hemiplegia
(in fact, he had a syphilitic hemiplegia on that side, several years
before, which had disappeared under antisyphilitic treatment). This
hemiplegia passed, but he then had crises of depression due to his
despair at not being able to know who he was and what he was doing.
He could speak French and Spanish, and knew from the hospital ticket
that he was born in Spain; but he had no idea what had happened to
his relatives or what he was doing in France. He had, however, a very
correct idea of what happened during six months after July, 1915.
One morning in April, 1916, his old memories came back all of a sudden
on waking. The gap was filled up to the moment of the shock. There was
no gap left except for a period of about 25 days following the shock.
He now found that he knew a little English but that he had lost his
stenography as well as his professional skill at typewriting.
_Re_ French statistics for the occurrence of general paresis, Lautier
found 27 cases in 426. Early in the war, Boucherot at Fleury received
four cases of paresis among 107 cases; the majority of these, however,
had not left the interior. Consiglio in Italy received two cases out of
270.
_Re_ hemiplegia in this case, it may be inquired whether the hemiplegia
which developed after the shell explosion on the same side of the body
on which the patient had a true syphilitic hemiplegia, was really
syphilitic or not. Was it not, perhaps, in some sense psychogenic? A
similar question may be raised concerning cases in which the _locus
minoris resistentiae_ becomes the site of symptoms. See Cases 409-414.
Shell-shock: Hysterical blindness. Signs of cerebrospinal syphilis:
Nevertheless, amaurosis functional.
=Case 29.= (LAIGNEL-LAVASTINE and COURBON, March, 1916.)
A soldier of the class of 1906 underwent shell-shock August 13, 1914,
regaining consciousness 20 days later, but blind. The light of the
shellburst, he said, was the last thing he had seen.
For sixteen months, he was transferred from hospital to hospital,
looked on sometimes as blinded; sometimes as feigning. Finally, on the
isolation service of Maison-Blanche, December 15, 1915, he received
an ophthalmologist’s diagnosis namely, hysterical amaurosis. At this
time there were found: stereotyped winking, with slight lachrymation,
a slight left external strabismus, limitation in movement of all
the extrinsic muscles of both eyes, especially to the right and in
convergence and elevation; pupils slightly smaller than normal--and
the general impression of a genuinely blinded or amblyopic subject. He
seemed to be able to distinguish faint whitish spots, without contour
or color, in objects brought to a distance of at least 40 cm.
He also complained of bad feelings inside his head on the left side,
and he proved to have a left-sided hemianesthesia of hysterical nature.
There were no other sensory disorders and no reflex disorders.
The nasolabial fold on the left side was flattened out, and there
was also on the same side a slight diminution in the lower abdominal
skin reflexes, and no response to plantar stimulation. Examination
of the mouth showed leucoplakia, and the history showed that the
man’s fifth child was born before term and died at two months. Lumbar
puncture yielded lymphocytosis (55 cells) and an excess of albumin. The
fundus examination showed a slight papillary disorder, suggesting a
retrobulbar affection of the optic nerves.
However, the preservation of the pupil reflexes seemed to indicate
that nine-tenths, at least, of the amaurosis was functional. After
mercurial treatment the headache grew less and the man was able to see
somewhat better with his right eye.
Laignel-Lavastine and Courbon suggest that there was a dynamic disorder
in this case, bearing the same relation to vision as mental confusion
bears to the process of ideation. Analogous phenomena have been found
in the sense of hearing, in such wise that the victims can, as it were,
passively hear but do not listen.
_Re_ functional eye cases, see below, especially Cases 432-437.
Shell shock (functional) phenomena in a syphilitic.
=Case 30.= (BABONNEIX and DAVID, June, 1917.)
A marine, 26, on land service March, 1916, was buried by the explosion
of a large calibre shell which killed most of his comrades. He remained
for a time in a sort of lethargy. Coming to, he found himself victim
of a right hemiplegia and deafmutism, which phenomena vanished under
electricity.
In July, however, he had to be sent to a hospital on account of his
sufferings, which received the diagnoses _commotio cerebri_, disorder
of consciousness, disorientation, delirium, amnesia, over-emotionality.
He was sent back to the front in December, 1916, but promptly reported
sick, with headaches and insomnia.
Examination showed nonorganic nervous disorders, consisting in
a variable and patchy anesthesia of the legs, anesthesia of the
conjunctiva and pharynx, and over-reaction, with sighing, during the
course of the examination. The organic signs were: exaggeration of
tendon reflexes, equilibration disorder, and incapacity to stand on
one foot or execute a half turn or to stand still with eyes closed,
and disorder of position sense. The lumbar puncture showed no cells,
a slight globulin reaction, and an albumin titer within the normal.
There was a leucoplakia and a positive W. R. The man was emaciated,
febrile, and showed signs, with the X-ray, of bronchial lymph node
disease. According to Babonneix and David, the normality of the fluid
indicates that the phenomena here were Shell-shock phenomena, despite
the indisputable syphilis of the blood serum.
_Re_ occurrence of functional phenomena in syphilitics, Freud’s remark
may be recalled to the effect that a large proportion of his hysterics
and other psychoneurotics are the offspring of syphilitics.
Consider in this connection also Case 28: an old syphilitic hemiplegia
was followed by a probably psychogenic or hysterical hemiplegia on the
same side.
Vestibular symptoms in a neurosyphilitic.
=Case 31.= (GUILLAIN and BARRÉ, April, 1916.)
A soldier, Colonial, 29, was twice in the 6th Army neurological
centre. The first time, February, 1916, he was under observation for
astasia-abasia, having been invalided twice for this disease,--once
in 1915. This man had had syphilis at 21, and was then taken care of
at Saint-Louis Hospital and at Cochin. A volunteer for the duration
of war, September, 1914, he had intermittent disorders of station and
walking, which caused his invaliding January, 1915. As the trouble
stopped, he asked to go back to the front in September, but the same
difficulty reappeared with fatigue, and he was sent to the army
neurological centre. When standing, there was a ceaseless trembling of
the whole body but especially of the legs, with tendency to propulsion.
In walking also, there was a trepidant abasia, sometimes dizziness, and
even a sudden fall. Standing on one foot he trembled and fell.
Examined on his back, muscular strength was found intact in all limbs,
and there was no trembling or incoördination or intention tremor in
the performance of any movements, though there was a slight trembling
of the raised fingers and hand. Reflexes were normal. The right pupil
was dilated; the left pupil reacted sluggishly. There were lateral
nystagmiform movements to the left. Caloric nystagmus appeared from
the right ear in 15 seconds, from the left in 30. Rotatory nystagmus
appeared in 35 seconds on both sides. Lumbar puncture yielded a fluid
with a slight lymphocytosis; albumin, .3 grams; chloride, 7.30; sugar
normal.
Rest in bed improved the astasia-abasia, and the man was sent back to
his corps, February 20, 1916. He came back March 16, having had a dizzy
spell, with suffocation feeling and a fall, whereupon the trepidant
astasia-abasia had reappeared. There were none of the so-called
defensive reflexes. The neuromuscular excitability of gastrocnemii was
less on the right than on the left. A von Graefe sign was sometimes
found; no diplopia save on looking far to right.
Lay reflections on syphilis: Suicidal attempts.
=Case 32.= (COLIN and LAUTIER, July, 1917.)
A man was called to the auxiliaries at the outbreak of the war, and
served as stretcher-bearer at the Marne. He then became an attendant at
the Grand-Palais. Acquiring gonorrhoea, he was cared for but he grew
depressed. The blood was examined and the W. R. found positive. The
physician immediately made known the result without circumlocution,
and knowing vaguely that the W. R. meant syphilis, the patient felt an
irresistible impulse to suicide, and cut his throat. It seems that he
had often before said that if he got syphilis he would kill himself.
Recovering from his wound, he was invalided to Villejuif, Sept. 19,
1916, breathing through a cannula and responding to questions in
writing. He had always been a nervous and emotional man, a farmer in
Auvergne; he was married and the father of several children.
Examination showed that the recurrent nerves had been cut and that the
man must needs always breathe through the cannula. In point of fact,
the W. R., only partially positive at the outset, did not indicate
syphilis, and the gonorrhoea was now cured. But though the patient
knew these facts, his hypochondria persisted, basing itself upon the
suicidal wound. He said that his larynx had been stolen and he wondered
why. He said that he had violent crises of suffocation, though there
was, as a matter of fact, no difficulty with his breathing. Verdigris,
he said, was forming on his cannula. Self-accusations about the suicide
developed. On being transferred to his department asylum, he made a
suicidal attempt on the trip.
Of course the gonorrhoea may have served as a partial factor in the
genesis of the case, and his own mental attitude toward the contraction
of syphilis may have been another factor.
The imitation of chancre.
=Case 33.= (PICK, July, 1916.)
A married German farmer, 32, was in Prague hospital in 1908 during his
period of military service and was then treated by inunction for a
local chancre. He was given mercurial injections a year later for rash.
In 1912, he had signs of syphilis in the mouth.
He was sent home from service in 1913, with ulcers of hand.
At the beginning of the war he was found to have ulcers on the knee,
legs, and mouth, and was sent home for six months.
Again called up in 1915, the ulcers were still in evidence; he got
inunctions in a military hospital four months.
He was sent to his corps in July and had no relapse until July, 1916,
when he was detailed for active service. Thereupon, ulcers began on the
left hand and right leg. He reported sick, but was sent nevertheless
to the front. In hospital he was found to have several scars about
one inch across on each leg, on the dorsum of the left hand, at the
right of the left index finger, and elsewhere. These scars were deeply
pigmented. _One of them was square!_ There were other recent ulcers
that closely resembled tertiary ulcers. The most recent of these ulcers
was angular, intensely red, and showed remains of a collapsed vesicle.
There was a deep dark scab on the mucous membrane of the left cheek.
There is no doubt that these ulcers were produced by some caustic, the
nature of which remains unknown. The patient had, however, been able to
evade military obligation during peace time and for two years during
war time.
_Re_ simulation, according to Pick, some 5 to 7 per cent venereal
diseases in the German army have been simulations. Gonorrhoea is
simulated by soap, balanitis by cantharides, soft chancre by soap
and mercuric or mercurous chloride mixed, hard chancre by a fluid or
powder containing NaOH, Na_{2}CO, and NaCl. Secondary syphilitic signs
are imitated by cantharides or garlic, producing scrotal dermatitis.
Tertiaries are imitated with caustics.
Ramón to Rosina: a soldier’s letter to his fiancée.
=Case 34.= (BUSCAINO and COPPOLA, January, 1916.)
“I am here to stay a month. Believe me, it is better here than
in the army. There is a rule that we may eat as much as we can
and everything is of the very best. The servants treat us like
brothers. Do not think it is a nuisance to be inside four walls
with a wee bit of a garden. No, indeed! But I have got to act
the fool and from the very first day I began to play and act
crazy with a kitten, so that if you had seen me you would say:
“Ramón is really crazy.” Rosina, dear, to avoid paying taxes
you have got to be a smuggler. And now that I am at the ball I
have got to dance. I want to see if after all the suffering I
cannot get something better. I am better off here than at the
regiment. I sleep in a fine warm bed, and they have only cold
straw; I have good food and drink and plenty of milk, and they
have poor food and drink and so little.
“I expect to go home in about three weeks. I would have been
there before if some fool of a spy at our place had held his
tongue and minded his own business. At the same time, Rosina,
dear, remember what I told you at Leghorn: that they had some
officers sent there to get information and instead of going
home they asked somebody else and were told that I had never
been sick and had never had neurasthenia. When this information
was got from the officers I was called to the office and they
read to me that all that I had said and done was not true. I
kept on acting the fool, and as they were still doubtful they
sent me here, where there is a professor who passes me every
morning in the garden and says: “How are you?” I always say:
“I am the same,” acting like a crazy man. Let me tell you,
Rosina dear, not to say anything contrary to this in your
letters because they open and read everything in order to find
out everything that happens and everything that is said. Now
what you must do is to ask me how I am feeling, and whether my
headaches are gone, and whether I have them all the time as
formerly, and any other trifle that will help me.”
Rosina’s fiancé had a strongly positive W. R. in the serum. It was
negative in the fluid. He was returned to the front.
II. HYPOPHRENOSES
(THE FEEBLE-MINDED GROUP)
Moron of use at front (alienist’s report).
=Case 35.= (PRUVOST, 1915.)
Vigouroux reports concerning a tanner of 19 who could not read, write
or calculate (3 plus 8 equals 14) and had been of the 1916 class in an
infantry regiment at Brest, on the occasion of his asking to be sent to
the front more speedily:
Mental weakness, with insufficient school and theoretical knowledge but
with the ability to assimilate practical ideas, though not knowing how
to read, write or calculate; seems to have earned his living in several
lines. “As a soldier, he does not know the insignia of the different
ranks but understands how to obey a superior officer. Understands a gun
and can tell a _chargeur_ from a _Le Bel_ gun. Moreover he seems to be
perfectly stable, fixed in his wishes, persistently and intelligently
wants to go to the front and kill Boches. He appears to be well
disciplined and educable. Although feebleminded, he appears to us able
to be useful at the front, though he should not be employed in any
undertaking requiring initiative or foresight.”
An imbecile, superbrave.
=Case 36.= (PRUVOST, 1915.)
A loquacious, active fellow, 22, with very slight school knowledge and
no idea of military ranks (treated his superiors like his comrades),
was often punished in the barracks. He did not get on well with his
instructors. His activities were never interrupted by any obstacles or
by derision. He kept singing and talking enthusiastically during the
mobilization. He was the butt of his section.
At Dinant he did very well; though his section was losing a good many
men he remained calm. He was careless of danger and remained at his
post firing ceaselessly at the enemy and giving a magnificent example
to the few comrades who remained with him. In fact, he remained so long
in his shelter that he was surrounded and taken prisoner. He escaped,
swam the Meuse and got back to his regiment.
An imbecile of service in barracks work.
=Case 37.= (PRUVOST, 1915.)
A farmer, 36 (father alcoholic, mother always sick, two brothers at the
front; patient had typhoid at an unknown age; had gone to school at
13 but “learned nothing”; worked in fields with his brother who gave
him some pennies on Sunday), was put into the auxiliary service by the
Council at 20. Patient said he was not strong enough for this service.
In 1914 the Council reconsidered the case and put him into a regiment
of infantry. He could not be given military instruction or execute the
most simple drilling manual. He said that 4 plus 2 equalled 7; 4 plus
3 equalled 5. He was of an excellent character, very docile and easily
directed. He did all his comrades’ barracks work and was very proud
because, as he said, “I do everything they tell me to do.” He was happy
in working, everybody was good to him, but he had no comrades. He had
no general knowledge and knew nothing about the war but that they were
fighting the Boche.
_Re_ imbeciles, Colin, Lautier and Magnac found amongst 1000 soldiers
entering Villejuif, 53 imbeciles. Twenty-four of them had been either
exempt or retired at the outset of the war, when military surgeons had
reviewed them and considered them fit for service. Several of the 29
others also had shown previous evidence of imbecility.
Of course, French military surgeons may have felt that a number of
these men would be of just such service in barracks and otherwise as
Case 37 (Pruvost). But for one or two cases like Cases 37 and 41 of
Pruvost, there are great numbers of other imbeciles who prove quite
useless in the army. Two of the Villejuif cases had been volunteers:
one volunteer declared that, if he had been intelligent, he never would
have enlisted! Ten cases proved unable to use a gun; one turned his gun
upon his mates. One regularly forgot the password. One (see Case 42
of Lautier) thought the war too long and tried to take command of the
company in order to finish the war one way or the other. Three of the
imbeciles had to be evacuated for desertion (unmotivated fugues); two
of them cursed their officers. Some of the imbeciles had an emotional
diarrhoea throughout their service.
Colin suggests that line officers and military surgeons ought to agree
that these men are not fit for service, and that the civil authorities
of the home towns should advise the review boards about known imbeciles
and criminals. In point of fact, previous knowledge of imbecility could
have been obtained quite readily in 27 of the 53 cases observed by
Colin.
A feeble-minded inventor.
=Case 38.= (LAIGNEL-LAVASTINE and BALLET, 1917.)
A jockey of Nîmes, 31, entered the service May 15, 1917. He
retired before the war. He was in the auxiliaries at the moment of
mobilization. Nothing is known as to any pathological episodes in his
past. He said he had been a poor scholar, had left the primary school
at eleven hardly knowing how to write or spell, but he had a lively
imagination and was a happy-go-lucky youth, playing many tricks on
the trades people. He tried a variety of ideas in the industrial or
commercial world with very varying success. He had a mechanical taste.
The Colonial Exposition at Marseilles caused him to float a variety of
projects, from that of having the visitors photographed on a camel to
the sale of lemonade. He said he had been a jockey and then a trainer
and had finally become a valet de jockey at Maisons Laffitte. He was a
gambler and invented a “system.” He made various inventions in relation
to horses. At the end of 1914 he had plans for a bomb thrower and
placed his discovery at the service of the War Minister. He was not
discouraged by the lack of success of the bomb thrower. He now made an
aerial torpedo carrier. He had the idea of the tanks. However, he found
the secret of his torpedo carrier printed in a magazine. There was a
slight difference between the German apparatus and his own.
From this time he began to be mistrustful, and now he jealously avoided
entering into any details about his inventions and he did not let
his officers see his plans. The Commandant offered to give a place
in the safe to his documents, but he could not embrace the offer. He
now invented a counter-torpedo machine. He went on leave to Paris,
asked an audience of the Minister of Marine, who put him in relation
to the Committee on Inventions, who put him off, desiring that he
should forward all his plans. He emerged from one of his interviews so
excited that there was a scandal on the public street and the police
commissary evacuated him to Val-de-Grâce, but the patient says he does
not remember this incident. He came on service of Laignel-Lavastine
May 15. He shortly wrote again to the Minister, who again referred
him to the Committee on Inventions. He protested to the President of
the Republic and wrote directly to the King of England, who referred
him to the Military Administration. He is now occupied in creating a
machine to destroy the first line trenches and continues to write to
the Ministry. He has documents buried underground in a secret place. He
still talks with great vivacity of his discoveries.
According to Laignel-Lavastine, we deal with a feeble-minded person who
has for many years had a _délire raisonnant_ of the inventing group.
_Re_ feeblemindedness in the British Army, Shuttleworth found 70 who
had joined from special schools for the feeble-minded in London, and
100 from Birmingham in the year 1915. The institutional “children” were
in general good at drilling and obeying. One of them, given to lying
and stealing, got into constant trouble in Flanders.
Sir George Savage stated that he had sometimes run the risk of allowing
enlistment of men who had shown earlier in life a weakness for lying
and pilfering, and remarked that such men might make good soldiers.
A case like the above (38) would run counter to this view. On this
matter, see below Case 183 (Henderson), one of pathological lying.
An imbecile who walked lame.
=Case 39.= (PRUVOST, 1915.)
A soldier, 20, eight days after being called to the colors, complained
of pain in the knee and hip. He was observed for 18 days in hospital
and then sent back to his company; but he continued to complain of the
pains, and the regimental surgeon sent him to a neurological center
where the joints were found to be normal and where no sensory, motor or
reflex disorders were in evidence. The man continued to walk lame and
insisted he could not get about without a cane. He also complained of
his mouth and his belly and, though he was very ruddy, said he was _á
bout de forces_.
It was a question of simulation. The man, however, was a feebleminded
person who could not read, write or calculate. He was invalided as such.
Enlistment to improve character.
=Case 40.= (BRIAND, February, 1915.)
A village boy had passed for simple ever since typhoid fever at 8.
He had learned to read and write, but had always been impulsive
and subject to fugues, running to see his grandmother, or off as a
truant. It was decided that he, at 19, should enlist to improve his
character. But one fine day, even before the war, he deserted. He said,
in explanation, that he had lost his way, and he was being examined
mentally when mobilization began.
He looked ape-like, with spread ears; had a low forehead, a head
flattened behind, an asymmetrical face, prognathous jaws, an arched
palate, and defective teeth. He talked freely of homosexual relations,
and said he wandered off because it occurred to him to do so. He was
determined to be unfit for service.
An imbecile who may be sent to the front.
=Case 41.= (PRUVOST, 1915.)
A Parisian sandwichman, 25, of unknown parentage and a state ward,
placed out with a farmer at 12, escaping with a friend to Bordeaux at
14, thence leading a wild, improvident life at Lyons, Marseilles and
Paris, sleeping in fields and hedges, earning 22 sous a day but in no
case mixing with the police, was examined for physical inefficiency
at 20 years. He wanted to enlist but was refused. He insisted and was
very proud of the fact that he got in as the Major said to them, “Let
him go in.” He could hardly read, write or calculate but was by reason
of his adventurous life full of practical resources. He was irascible
and frequently _crimed_, whereupon he would cry under the Captain’s
window, “Robber band, idiots, I shall write to the Minister.” He was
passionately fond of military life, though he had but the vaguest
notions about the commands, the names of generals and the like. He
wanted to drill. His comrades played practical jokes upon him asking
him to look for a trajectory, for the squad’s umbrella and the key
to the drill ground. They also told him he had been proposed to be
corporal, whereupon he was greatly overjoyed and immediately sewed
stripes on his sleeve and began to give commands. He said if they put
him among the auxiliaries he would throw the adjutant in the water. He
sang and swung his gun with joy when he went to the front. He thought
there were stripes hanging to the barbed wire and wanted to pick as
many as possible. Such a man may be safely sent to the front although
he will bear watching. At the date of report this man had been at the
front two months doing very well.
_Re_ the comparative success of the Germans in the matter of excluding
imbeciles, Meyer found that 8 per cent of the mental cases in the army
were cases of mental defect.
Imbecile with sudden initiative.
=Case 42.= (LAUTIER, 1915.)
A soldier, 41, a farmer, from the Department of the Marne, married,
childless, was called to the colors August 31, 1914. He was on guard
duty until May, 1915, watched prisoners until October and was finally
sent to the front, February, 1916, where he fell sick.
“He was tired in his head.” “His commanding officer made him drill
without rhyme or reason; he would have been able himself to have
commanded with greater intelligence.” He once attempted to put himself
at the head of the company to lead them against the Boche; this idea
arrived to him all of a sudden in a phase of perfect confidence and
_sang froid_. He thought his comrades would follow him and that the
officers would do likewise. He hoped thus to be able to end the war
one way or the other. He was getting tired of the war and regretted
his family life and kept saying that this was no existence for family
men. “We ought to attack or ask for peace.” No one followed him and his
comrades said he was _un peu fou_ but he did not share this opinion.
In point of fact he hardly knew how to read or write and at home lived
with his relatives, submitting himself entirely to their guidance. He
was much afraid of being punished and often feared that he had done
badly as he had _trop de conscience_. He was non-alcoholic and without
hereditary or acquired neuropathic taint. He had no pronounced stigmata
of degeneration. He was rather reticent about certain mystical ideas of
a political tinge. At Villejuif, whither he was brought February 17,
1916, he received a diagnosis of imbecility.
Emotional fugue in a subnormal subject.
=Case 43.= (BRIAND, February, 1915.)
A soldier in the Territorial Army, 40, appeared before the examining
board in a depressed, dejected-looking state, speaking slowly but
collectedly and lucidly. Mobilized the second day, this man was much
afraid that he could not get through the marches, and asked for a
special examination to determine whether his feet did not make him
unsuitable for fatigue. Two physicians thought he was unsuitable for
marching, and another thought he put it on. A trial march was not
executed well. He was kept in barracks but jumped the wall, put on
civilian clothes, and made off for Paris. But a relative, warned by his
wife, finally got him to go to the authorities. He was told that he
ought to return in the afternoon, when suddenly he was arrested.
It seems that the man relied on the opinion of the two physicians
and discounted that of the third. He thought himself the victim of
an injustice, and not knowing how to get on, it occurred to him that
he would abandon the regiment and get out of the difficulty. It was
without resistance, however, that he gave himself up as a prisoner.
This fugue was neither unconscious nor amnestic, nor was it due to
an irresistible impulse; nor can we say that it was due to a genuine
intellectual disorder. It was an emotional fugue, and partly due to
the man’s long-standing depression. It seems that he had inherited
this character from his father. He was below normal intelligence,
had a very poor education, lost his wife, and grew more and more
sombre. He married again, but this time a neuropath. He began to be
preoccupied with his health and he had even some ideas of suicide. At
the time of his leaving the regiment, he had passed through a phase of
depression of about 6 months’ duration, and at this time had a number
of hypochondriacal ideas with poor appetite and loss of weight.
Diagnostic dispute between regimental surgeon and alienist.
=Case 44.= (KASTAN, January, 1916.)
Julius Q. was sent on guard April 14, 1915, with orders to remain
there. While on guard he made a noise and made a movement as if to take
a knife from his pocket. Ordered to empty his pockets, he attacked the
other guards. The witnesses said that he was drunk.
Upon examination, it appeared that he had recognized and called by name
those present in the guardhouse, despite his supposed intoxication.
There were red spots on the skin and a certain amount of analgesia. His
powers of computation and reasoning were poor. He was unable to explain
the meaning of a picture shown him. He maintained that he had an
indomitable desire for drink. A diagnostic draught of alcohol yielded
no reaction. Upon dismissal, he got drunk at once again, and had again
to be imprisoned in a state of excitement. What the outcome in this
case was is not stated by Kastan.
The previous history seems important. Julius Q. had been a state ward.
He had escaped several times from the institution but had always to be
brought back again because he could not be trained at home. He had once
attacked a supervisor in the state institution with a knife. It seems
that he had at this time been drunk, having been brought back drunk to
the institution.
Two years before the war he had been taken to the Breslau Hospital
for the Insane on account of fits of insanity. In 1913 he had been a
patient in Wuhlgarten on similar grounds. The diagnosis there had been
epileptoid degeneration, psychopathic constitution, imbecility, or
epilepsy(?). He had been convicted of crimes a number of times and put
to labor. He had been given to cruelty in childhood.
Despite this, he was _declared perfectly healthy in mind and body by
the regimental surgeon_.
In 1914, Q. fell suddenly ill in prison (he was presumably in prison
for a military offence), and smeared the cell with feces, saying that
he was able to do that as he could pay for anything. He stared at
the floor and failed to answer questions. He remarked, however, that
he had frequently been convicted for breach of the peace and assault
and battery, and he said his father had been a drunkard, and he
acknowledged hallucinations to the extent of saying that he heard his
name called when he was alone.
The story of this case warrants our inquiring why such a patient was
kept in the army. He was kept there clearly on account of the report of
the regimental surgeon, who could not have taken seriously the previous
history of the case, or else thought the patient perfectly good cannon
fodder.
The hypothesis of syphilis apparently need not be entertained. That of
feeblemindedness is possibly the fundamental diagnosis, yet epilepsy
was considered by the German diagnosticians, doubtless on account of
the sudden violent attacks and breaches of peace on the part of the
patient. There is clearly something behind mere alcoholism in the
entire story of this state ward. On the whole, the periodicity of the
attacks is equally consistent with the picture presented by numerous
feeble-minded persons, and the institutions that had to deal with Q.
regarded him rather as epileptoid. There seems to be evidence of actual
intellectual defect. Accordingly it seems wiser to consider the case
of Julius Q. one of feeblemindedness, possibly of the moron group. We
should then consider the epileptoid features as part and parcel of the
feeblemindedness. We should consider the intellectual defect a part
of the process; and the uncontrollable impulse to drink, the sudden
violent attacks, and the cruelty in childhood would then be regarded
as merely symptomatic of the feeblemindedness. It seems clear that
either mental tests by the regimental surgeon or an examination of the
patient’s previous history would tend to exclude such a patient from
the army.
How can a rifleman be an imbecile?
=Case 45.= (KASTAN, January, 1916.)
Anton K. was down in the list as “missing.” He was found at home. He
said his feet had become sore from the marching. He had lain down and
become unconscious. Coming to his senses, he was possessed only of
trousers and a shirt but he got a civilian suit in a village. He had
gone home part way by train, part way on foot. It seems that he did not
tell his father any details about his coming back although he expressly
denied deserting.
It seems no mental weakness had been noticed in the army. It had been
observed, however, that after seeing the first corpses he was deeply
impressed and did not want to see any more. On examination in the
hospital he gave the impression of indifference and low spirits. He had
to be urged to eat and work. No great amount of intelligence defect
could be determined, though his knowledge and capacity were below the
average. The physician examining him thought his depression was either
caused by or increased by his imprisonment; but this examiner thought
that the protection of Section 51 did not extend to the patient at the
time of his desertion. The examiner thought that an examination by a
psychiatrist was not necessary, though both judge and prosecutor urged
it.
When examined in the clinic, he seemed to be disoriented for time. He
claimed to have been able to stand the shooting and the sight of the
corpses. After becoming unconscious, he had wakened and eaten cucumbers
and carrots in the fields, wandering on for a period of three or four
weeks, until he came to a place where he had formerly worked. The
reason he had thrown away his uniform was because Russians had been
about. He had not known that it was his duty to report to the army
again.
It was found that the patient’s father was poorly developed as to mind,
that his brother was subject to periodic mental disturbance so that he
had to be watched. It was found also that K. himself had had a similar
mental disturbance, lasting a week, two years before. Moreover he was
not considered mentally right in his home town. In fact, no one there
wondered really at his desertion because he was so stupid. His school
work had been poor and limited.