He himself said that his people were of sound mind; that during school

days he had felt bad in his head, once running into the woods after

being told something. He was able to give the names of his former

superiors. His calculations were only partly correct. He was poor at

reasoning and at simple distinctions; for example, asked the difference

between a bird and a butterfly, he replied that a butterfly was a bird

too. He did not know the difference between a river and a lake. He

thought Russia, England, and Austria were the enemies of Germany.

He sat about or lay on the floor, motionless and indifferent, with

a newspaper stuffed into his trousers, unoccupied although saying

that he wanted to work, and even allowing his fingers to be burned by

cigarettes he was smoking.

He was tried once more and the first medical expert still adhered to

his former opinion, pointing out that K. was a rifleman and that _only

an intelligent man could be a rifleman_. The court, however, accepted

Kastan’s opinion and granted K. the protection of Section 51.

In comment upon this case, it seems clear that ever so slight a

knowledge of K’s home town reputation would have naturally excluded him

from the army. However, what is to be said “when doctors disagree,”

as noted by Kastan in this very case? It seems impossible, also, that

his comrades should not have noticed something odd about him (over

and above the deep impression on seeing the first dead) which might

have given occasion to the regimental surgeon for a special mental

examination. However, to the military mind, mayhap the man seemed to be

sufficiently “effective.”

_Re_ imbecility in a rifleman, the compiler has studied somewhat

elaborately the brain of a feeble-minded murderer with some North

American Indian blood in him. This man was a crack shot despite his

subnormality. It would seem that the German regimental surgeons

castigated by Kastan as above were very properly so castigated.

Hypomania in an imbecile.

=Case 46.= (HAURY, August, 1915.)

A brusque little man, of a somewhat bold and talkative disposition,

though giving a good first impression, was evidently a bit

feebleminded, though (as Haury says) of the active group. He had a

sister like himself, whose children were taken care of by the State,

and at home he had had a number of fugues, about which details were

lacking. It was soon evident what sort of soldier he would make, and

he was put in one of the Territorial regiments, but it was not noted

that he had a genuine mental disorder, as he was thought to be just a

peculiar person.

His new relations caused him to do a number of eccentric things.

He shortly proved to be in a sort of rudimentary maniacal state;

talkative, restless, scheming rather feebly to go back to his village.

He said that he couldn’t walk on account of corns, and that these corns

required a certain drug, which he wanted to get from home. He said that

he had been struck by lightning twice; that he had fires in his body,

etc. He wanted only to be retired on a pension of one or two hundred

francs so he could take care of his farm, his hay and his fields. There

was no need of trying to get land by means of bullets, he said, since

he had enough.

The mental disorder of this man was much deeper than appeared, and in

fact, he did a number of dangerous things compromising the security of

the entire regiment.

_Re_ the dangerous tendencies of Case 46, see the remarks above drawn

from Colin, under Case 37.

Insubordinate desire to remain at the front.

=Case 47.= (KASTAN, January, 1916.)

Friedrich L., on March 4, 1915, was ordered to go back to the

baggage-train. He did not obey. He said to the non-commissioned officer

who then came to him, “I am not going; you have nothing to say anyhow,

you ox-tender!” He stood with his hands in his pockets, and, when the

officer seized him angrily by the collar, L. struck the officer’s face.

He stated at his hearing that no one had the right to send him back.

At that time even he conveyed the impression of being not quite normal

and was let off with his arrest only. Later he refused again to go on

guard duty, saying, “You have nothing to say at all. Perhaps you will

find out that we shall meet each other again in hell tomorrow morning.”

He was taken before the physician, who considered him mentally inferior

and not entirely appreciative of the nature of his acts. He was told

that the death penalty would meet such behavior, whereupon he remarked,

“I am not afraid of the death penalty,” staring excitedly at the

officer and trembling throughout his body. It seems that he had already

made an impression of mental inferiority in the troop, and had once

before said to an officer who wanted to send him to the front, that he

would not go; this had been regarded as almost a breach of discipline.

He had been in the habit of not reacting to the calls of his superiors,

and had smiled at their reproaches. He seemed to hold the opinion

that not even a company commander had power to order him to go back.

Examined in the clinic he held to the same opinion, that there was no

need of his going back; that they took volunteers; and that he wanted

to remain at the front. On the day of the deed, he had drunk a rye

whiskey. He had shaken off the non-commissioned officer because the

leader had seized him by the throat. In the clinic he often smiled and

wrinkled his forehead. He gave evasive and inadequate answers. Asked

about oaths and perjury, he remarked, “I prefer to remain silent.”

He said that one of his sisters was a little stupid. Study of his

previous history indicates that Friedrich L. had formerly been a quiet

and steady man, although he often had attacks of rage, breaking out

upon sudden excitements. As to his capacity in school, nothing could be

learned, since the Russians had taken the school registers away.

The analysis of this case seems to reduce to the question of

feeblemindedness and schizophrenia, unless some form of inborn

qualitative inferiority of mind be preferred as the diagnosis. On the

whole, possibly, the diagnosis of feeblemindedness seems preferable.

The entire symptom picture seems to relate to the patient’s one mental

attitude about sticking at the front, _ruat coelum_.

A French soldier who admired Germans.

=Case 48.= (LAUTIER, 1915.)

A man with the extraordinary first name of _Agapithe_ (Laurent insists

on the frequency of strange first names in degenerate families) came

from Val-de-Grâce to Villejuif June 5, 1916, with the diagnosis

of mental weakness, interpretative ideas of persecution, mental

excitement, recrimination, logorrhoea, and a tendency to revengeful

reactions.

On arrival the patient said he must be in an insane asylum because he

heard _spiritiques_ talking together. He, however, was “not insane”

and began expounding his plans for revenge with the words “Kill,”

“Cut-throat.”

This man had been placed in the auxiliary service by the Council,

called to the colors December 13, 1914, and finally sent to the front

in May, 1915. In July he was made prisoner in a brush. He said, “I

cried out, ‘Comrades, what difference does it make to me whether I am

German or French? My officers are imbeciles that drink the blood of us

unlucky ones!’” He was interned in some camp whose name he could not

exactly give and reported that the Germans were very gentle with him,

that his real enemies were the French, for the French were against

him night and day. “As a matter of fact, among Germans the French are

nothing but _cochons malades_. The Germans are fine types.”

He was repatriated in May, 1916. He kept making verbose and neologistic

eulogia of the Germans. He had been a farm boy in Brittany, where he

had had headaches. He had been at Quimper Asylum in 1910. In fact, he

said his parents had tried to poison him and to have him assassinated;

they had charged him with setting fire to their house. His mother was

an imbecile, he said, who believed she was the Queen of France. His

recriminations did not stop short of himself. He had been accused of

kissing a girl and stealing apples; as a matter of fact he knew what to

do with girls.

He had a coarse face and a number of stigmata besides his name

_Agapithe_. He was kept at Villejuif as an imbecile.

Unfit for service: Question of feeblemindedness.

=Case 49.= (KASTAN, January, 1916.)

Walter N. was declared unfit for military service in 1912, on the

ground of mental incapacity. He had shown this clearly during his

period of training. He committed a number of slight offences secretly,

but not so secretly but that they were immediately discovered and

punishment meted out therefor. He could do nothing without aid. It

appears that his mental weakness had not been noticed in school, but

that his employers had thought him both feebleminded and irresponsible.

Nevertheless he always executed orders properly. While in hospital in

1912, he had occupied himself very little, sitting indifferently, quiet

and dreaming. At that time, he had shown poor calculating ability and

decreased power of perception. It also appears that he did not grasp

the nature of simple orders, the requisite associations being disturbed.

Despite this history, on September 11, 1914, he found himself being

transported. He claimed to be very tired. Upon reaching the city,

he picked up a large stone and raised his arm as if to strike the

transport leader. While N. was being bound by the transport leader in

consequence, he kicked at his leader’s shins.

In the clinic he resisted examination, moving his legs without

speaking, staring at the floor, moaning frequently, sitting motionless

with head hanging, answering monotonously repeated questions, but

turning his head at a loud noise. He felt ill. It appeared that he

was oriented and that his knowledge was well preserved although his

calculation ability was poor.

It would seem that psychiatric examination, possibly with the aid of

psychological work, would have excluded Walter N. from the army.

Oniric delirium (Régis) in a somewhat feebleminded Esthonian.

=Case 50.= (SOUKHANOFF, November, 1915.)

An Esthonian, 21, a soldier in a reserve regiment, came to a

psychiatric section towards the close of 1914. He was negativistic,

mumbling, restless, fugacious; later more tranquil. One day he entered

the physician’s office, walking up and down, mute, looking at articles

and attempting to take them away.

February 21, 1915, he was evacuated to the Notre Dame Hospital for the

insane at Petrograd,--a tall, healthy, agitated-looking youth with a

rapid pulse. He explained in poor Russian how he was now among Germans

and feared that they were going to hurt him. At first in the hospital

he was seclusive and morose. March 9 he became excited, and tried

to break through the door. He was placed in the bath, agitated and

yelling. An Esthonian interpreter did not quiet him. The Germans were

going to make a martyr of him. After an hour of this he grew quieter,

and next day complained only of head weakness and malaise, was in good

humour, smiling, and reading an Esthonian paper, and well behaved in

church, though tired and pale.

He now got better, began to work and wrote letters. It seemed as if he

had waked up from a painful dream. He explained how he thought he had

been in captivity; that he was going to be hanged. He had thought that

the Germans could talk Russian. He had had hard work in his regiment,

as he did not understand Russian and had never before left his little

village in Livonia. His mental disorder had started in the autumn,

but all that was now like a dream. He said that he had had a mental

disorder of short duration following some bodily disease, at the age of

thirteen. According to Soukhanoff, this is a case of Meynert’s amentia,

in a somewhat feebleminded person. The twilight state might well

receive (according to Soukhanoff) the term “oniric delirium” invented

by Régis.

Shell-shock; burial: Incapacity to rationalize the situation.

=Case 51.= (DUPRAT, October, 1917.)

A soldier, 39, a herdsman, was shell-shocked at Hill 304 May 23, 1916,

buried twice, slightly wounded in right eye, and carried unconscious

to Bar-le-Duc. He was then forty days in a semi-confusional state with

headaches and dreams of the Boches wanting to behead him. Some of these

dreams came in the waking state, in which state he could recognize them

as imaginary. In April, 1917, he said he had always been afraid, even

in daytime, that he would be hurt and had been especially troubled by

the fear of shells. He was also bothered by nocturnal enuresis which

might become an incurable disease and bring impairment of memory and

attention. Although not feebleminded the man was of but moderate

intelligence, and his emotions, according to Duprat, were such as to

defeat any complete resolution of his plight by the intellect.

An affective complex, passing from the surprise of the shell-shock over

to a fright based on clear though wrong ideas of what might happen to

him, had left him without sufficient power of _autocritique_.

Weakling, twice buried by shell explosions in one day: Change of

character; fear; three fugues (“It is stronger than I am”).

=Case 52.= (PACTET and BONHOMME, July, 1917.)

An infantryman, Class of 1913, at the front from September, 1914, had a

somewhat infantile build physically but was intellectually of average

powers, having been a type-setter (three years in a job). However, the

confined life had borne hard upon him and his father put him on a farm.

He passed through his military service successfully, though he was

given two weeks in the guardhouse for overstaying Easter leave. He was

suggestible enough at this time to think that he would not be punished

very severely, since there were other men whose leaves did not expire

at the same time as his own.

He was buried twice in the same morning, March, 1915, at Bois Le

Prêtre, spent four or five days in hospital, and went back to his

battalion. But now there was a change in his character. Formerly

indifferent to danger, he was now apprehensive every time he went to

the line and felt an almost irresistible impulse to make for the rear.

He was condemned to five years in prison, June, 1915, but was finally

sent back to the front.

However, in July he left his company a second time as it was going into

the trenches, and this time the captain simply asked him to do better.

A third fugue, a few weeks later, sent him back to court-martial, and

thence to be examined by alienists. He was perfectly conscious at the

time of the fugues and understood his duties and possible punishments.

All he would say was, “_It is stronger than I am._” Fear outweighed

every consideration after the episode of the shell burials.

The man may be regarded as a hypobulic, somewhat feebleminded person,

able to get on in civil life but thrown out of gear by war. Of course,

the concept of fear as a disease can easily be overdone; however,

here was a case in which three desertions occurred; the third after

severe punishment. In the differential diagnosis, epilepsy, alcoholism,

impulsive poriomania, must be considered, as well as feeblemindedness.

III. EPILEPTOSES

(THE EPILEPTIC GROUP)

Diagnosis “epilepsy” revised to neurosyphilis.

=Case 53.= (HEWAT, March, 1917.)

A Scotch soldier, in the Royal Navy, 43, was admitted to the Royal

Victoria Hospital at Netley, as major epilepsy. He had been 12 years

a stoker, and 16 years before admission had suffered from syphilis, a

chancre locally treated with black wash, without secondary rash.

After leaving the Navy, he had worked in a fire-brigade and as dock

laborer. He had been very alcoholic when funds permitted, although

never “primed.” His first convulsive seizures came at 40, while working

at the docks, following a night on which he had drunk a bottle of

whiskey. He thought he had been about half an hour in the fit.

He joined the A. S. C., January, 1915; served in France; later at

Salonica. He had eight convulsive seizures, some in France, and others

at Salonica, always after much rum.

The man was tall, powerfully built, without visceral disease, speech

defect, or other symptoms except that both pupils showed the typical

Argyll-Robertson phenomenon. The deep reflexes of arms and lower legs

were increased. The superficial reflexes were diminished, and the

Wassermann reaction strongly positive. A seizure was observed by Hewat

and the diagnosis of major epilepsy was revised. The diagnosis of

cerebrospinal syphilis, non-paretic, was preferred to that of paresis

on account of the absence of all the ordinary symptoms of paresis and

of tremor. It might be asked whether these fits were chiefly alcoholic

in origin. However, the patient had two or three fits while in hospital

during a period of eight teetotal weeks. Hewat remarks that the case

suggests that the serum of any patient developing epileptiform seizures

for the first time say between 35 and 50 years of age, should be given

the Wassermann test.

Syphilis may bring out epilepsy in a subject having taint.

=Case 54.= (BONHOEFFER, July, 1915.)

A man of 35 in the _Landwehr_ acquired syphilis some time in the summer

of 1914. He was a good soldier, passed through several clashes, and was

promoted to _Unteroffizier_.

To understand what followed it must be stated that he had been a

bed-wetter to 11, had been practically a teetotaler (Bonhoeffer’s point

is perhaps that otherwise epilepsy might have developed sooner?), and,

when he did drink, vomited almost at once, and had amnesia for the

period of drunkenness. His father drank. His sister had fits as a child.

February, 1915, the _Unteroffizier_ lost appetite, got headaches,

and went to hospital for a time. Upon getting better, he was sent on

service to Berlin. In a Berlin hotel he had his first convulsions and

unconsciousness, biting his tongue. He was confused for several days,

and, when he had become clear, had a pronounced retrograde amnesia

together with a tendency to fabricate a filling of events for the lost

period.

This retrograde amnesia is uncommon in epilepsy and suggests organic

disease. No sign of such was found, or signs of the epileptic make-up.

The serum W. R. was negative. On the whole, Bonhoeffer regards the

epilepsy as “reactive” to the syphilis, as a syphilogenic epilepsy.

Alcoholism caused amnesia in this man in the same way as the syphilitic

epilepsy now did.

_Re_ epilepsy and syphilis, Bonhoeffer states that he has repeatedly

seen syphilis giving no other symptoms than epilepsy develop in

the campaign. At the same time, Bonhoeffer does not find that the

incubation period in paresis can be shortened by war factors; at all

events, by the exhaustion factor in war (see Case 25). It might be

questioned whether the above case (54) was not psychogenic; that is,

whether the syphilis did not act in combination with being sent to

Berlin on service as a psychic factor. However, this epilepsy on the

whole seemed not psychogenic.

Syphilis in a psychopathic subject. Convulsions 5 days after Dixmude.

=Case 55.= (BONHOEFFER, July, 1915.)

A soldier in the reserves, 23, was, subsequently to his being brought

to hospital, described by his wife as a rather over-sensitive fellow,

who could hardly look at blood and was meticulous about the household.

He had always been subject to headaches, especially after hard work.

However, he had passed through his military training well in 1910, not

even having been _bestraft_.

He began service in October and fought at Dixmude on the 19th. On

the 24th in the trench and while being carried back, he had several

spells of pallor, falling stiff, and then having convulsions. Brought

finally to the Charité in Berlin, he had more spells of sudden pallor,

collapse with brief convulsions, tossings in bed, as well as absences,

post-convulsive headaches, and mild bad humor.

There were numerous attacks several days apart in the first seven

weeks. The patient was not of an “epileptic” disposition, though

readily dissatisfied and headachey.

The serum W. R. was positive. Treatment by mercurial inunctions. No

further convulsions. Prognosis doubtful.

_Re_ epilepsy and the war, during the first six months Bonhoeffer

observed 33 cases in the Charité Clinic in Berlin. Twenty of these 33

cases, unlike Case 55, had attacks before the war, although ten of

these had become epileptic rather late, namely, after the period of

active military service, at ages from 22 to 27. The development of

epilepsy like Case 55’s is not without frequent precedent.

Bonhoeffer states that aside from epilepsy directly due to brain

injury by shells, there has been no certain case in which we have the

right to regard the war itself as the total cause of the epilepsy.

Some, like Case 55, are of syphilitic origin. No subject with a severe

long-standing epilepsy has been able to get into the field, according

to Bonhoeffer; when they do, they prove constitutional subjects.

An epileptic imbecile, court-martialed.

=Case 56.= (LAUTIER, 1916.)

A Belgian soldier was condemned by court-martial February 27, 1915, to

five years imprisonment for leaving his post in the presence of the

enemy. It seems that he was mounting guard with two of his comrades and

all three left to eat as no food had been brought to them.

A physician examined the Belgian soldier and declared him responsible,

although a little sick. All three were condemned to imprisonment. The

Belgian attracted attention in prison through crises of anxiety and

agitation; he had terrible nightmares, seeing Germans in his cell and

hearing gunshots. He was accordingly sent to a special infirmary of

the dépôt, whence July 24 to Sainte-Anne, July 26 to Villejuif. He

talked Flemish, hardly understanding French, and spoke slowly and with

difficulty. He hardly knew how to read or write. He had been a truckman.

At 18, this soldier, according to his own account, began to have

nervous crises in which he fell, lost consciousness, bit his tongue,

foamed at the mouth and urinated involuntarily. The attacks were

somewhat rare. His father sent him in 1910 to Gheel where he stayed two

years. Returning home he helped his father in the trucking work.

When the Germans came the family fled to France and, about the end of

1914, he was put into the military service and sent to the front after

a very short period of instruction.

The man had followed the example of his two comrades without taking

the slightest thought. He did not understand the gravity of his act.

He was not remorseful, regretful or angry against his judges. He was

well oriented but quite indifferent. He was a tall, intelligent looking

man with adherent lobules, slight facial asymmetry and evidence of

tongue biting. He wrote like a child and read slowly, spelling out the

complicated words. He was employed at various manual tasks during his

sojourn at the asylum and had no epileptic attack. He was given over to

the Belgian military authorities October 5, 1915.

Seizures in a feebleminded subject--psychogenic components.

=Case 57.= (BONHOEFFER, July, 1915.)

A 21-year old tailor, unused to marching, went into the field in

August. A month later, after a period of long standing, he was

nauseated and fell in a faint. Upon waking, his fingers were stiff

and he had pains in his legs. He got better in the reserve hospital

and was sent back to the line. On the way he had a similar seizure,

with nausea and fainting. On the way back to Berlin, he had a seizure

in the railway station, and was carried to the Charité Clinic. At the

clinic he stated that he could feel an attack come on; that he first

had _Angst_ all over his body, and that it was hot inside of his head.

Latterly he had been able to stop an attack by clenching his teeth,

after which the attack would not proceed except that all became black

before his eyes.

He was observed for four weeks but no seizure appeared. He was

somatically negative; his Wassermann reaction was negative. There was

nothing hysterical about his make-up; he was somewhat surly and of low

mental grade. He was unwilling to walk alone for fear of attacks.

As to the heredity of this soldier nothing is known. He had been

an illegitimate child; he was a sleep-walker in childhood; he had

sometimes spoken out loudly in sleep as a boy. At school he had been

somewhat backward, fought readily with his mates, and often complained

of dizziness and headaches. He could not stand smoking or drinking

well, getting drunk upon two glasses of beer. He had not held positions

well. He became a _pionier_ in 1914, working chiefly as a tailor.

Early in his time as a soldier he had obtained an ulcer of the glans,

which had been excised and burned. There had been no secondary symptoms.

According to Bonhoeffer, this is an example of a not infrequent

condition. Although the attack itself and the habitus of the patient

did not look hysterical, the manner in which the attacks repeated

themselves speaks for psychogenic components. Just as genuine

hysterical attacks may be looked on as reactions to unpleasant

situations, so may these attacks. In fact, we are probably dealing

with an hysterical fixation of the symptoms of emotional fright like

those in the true hysterias following shell explosion. A great many of

the phenomena of Shell-shock, to use the English phrase, are not in

and of themselves of a psychogenic nature, but they are, according to

Bonhoeffer, psychogenically liberated under the influence of unpleasant

ideas.

_Re_ reactive epilepsies, Bonhoeffer considers that there is a group

of reactive epilepsies in which the war process plays an important

part. The prognosis of these cases ought to be relatively favorable. In

point of fact, Case 57, although a feebleminded subject, seems to have

had a relatively favorable prognosis: at all events, no new seizures

appeared under prolonged medical observation. These reactive seizures

may occur in cases with a labile vasomotor system. They are, according

to Bonhoeffer, aligned rather more with hysteria than with genuine

epilepsy. Genuine epilepsy has not been developed in the war cases

observed by Bonhoeffer except where an endogenous factor was clearly

in evidence; or else where there was the requisite antebellum soil for

the development of an epilepsy. In short, genuine epilepsies developing

in the war are all, according to Bonhoeffer, predispositional. The

antebellum soil was clearly in evidence in Case 57. Even before the

war, according to Bonhoeffer, many German soldiers during the period

of military service gave evidence of their epileptic soil by sundry

suspicious phenomena. Among these were fainting spells during hard

drilling and other exercises, spells of enuresis, abnormally deep

sleep, and even phenomena of somnambulism. One of the Bonhoeffer

epileptics had been released during his reservist practice as unfit for

military service, and had only been put into the line at his own urgent

request at the outbreak of the war. Three volunteers concealed their

epileptic history. One man, who had had merely petit mal attacks before

the war, regarded them as of little consequence, entered the service,

and developed epilepsy.

Responsibility of a drunken epileptic.

=Case 58.= (JUQUELIER, March, 1917.)

The question of responsibility arose in the case of a soldier who left

his camp the morning of October 23, 1916, and went to a neighboring

place, where he drank, with four others, two quarts of wine. At about

three o’clock in the afternoon, his captain met him on the street,

lost, and looking drunk. He told him that he would send him to the

trenches in the evening. The man lay down and went to sleep. At about

six o’clock, it was found that he could not put on his equipment alone,

and in fact threatened the other men with his bayonet, and then went

to sleep. He woke up and explained that he had had one of his nervous

crises. He remembered the matter of the bayonet but had forgotten

everything else about the struggle.

This soldier was 29 years old, the son of an alcoholic, and the ninth

child of a mother who died shortly after her tenth pregnancy. He had

had measles and bronchitis as a child, and in childhood had had bad

dreams; at the age of ten he had swooning spells. He became a quarryman

and a habitual drinker, subject to dyspepsia, nightmares, and nocturnal

cramps. There had never been any crises, however, up to wartime.

January, 1916, when a shell burst near him, the first sharply-defined

epileptoid crisis came, and was followed by a number of others,

either on leave or on service, March 8, June 2, and July 13. These

attacks showed a sudden fall without warning, loss of consciousness,

convulsions, tongue biting, incontinence of urine, a period of more or

less coördinate agitation at the time consciousness was reappearing,

sometimes a fugue, and often amnesia for the whole. He had a scar on

the left border of the tongue.

Should this epilepsy be regarded as entailing irresponsibility? He

left camp before the crisis, accordingly in a period when he was in

full possession of consciousness and will, and he had gotten into

an irregular situation by drunkenness before his epileptic crisis

started in. His struggle with his comrades, however, appears to be

a portion of a post-critical dazed state. The medicolegal decision,

therefore, was that he was guilty of leaving his command but not of

the other misdemeanor. Considering the general nature of epilepsy, the

responsibility of this man for the whole adventure is rather slight.

The Council, however, condemned the man to five years of labor, without

admitting that the crisis following so soon the actual misdemeanor

should argue a diminution of responsibility.

_Re_ epilepsy in the army, Lépine notes the serious theoretical and

practical problems to which it gives rise. In the first place, epilepsy

occurs in the army more frequently than in the same number of men in

civilian life. Consequently, the diagnosis as to the really epileptic

nature of the attacks observed is not too easy. Again, the situation

affords much opportunity for simulation (see, for example, the case

of sham fits (Case 78, Hurst), and the case of epileptoid attacks

controllable by the will (Case 79 of Russell)). Wounds may produce it,

and even wounds which do not affect the brain; besides which, a variety

of war conditions, short of trauma, may produce it. When the ordinary

impulsiveness of the epileptic turns into automatism and to epileptic

equivalents (_états seconds_), much of medicolegal interest may

happen. Case 58 was just short of a murderer. Cases of actual murder

in epileptic equivalents have been known under military conditions.

Fugues with amnesia for the phenomena (which look to the military man

like intentional desertions) form another group of epileptic events;

but aside from the manias and the fugues, there are still more dubious

epileptoid phenomena of a delusional and confusional nature, such that

the proof of epilepsy comes only afterward, when frank convulsions

supervene. _Re_ fugues and desertion (the most frequent of military

delinquencies according to Régis), we may think of the fugue reaction,

according to Lépine, as a natural reaction on the part of both the true

delinquent and the mentally sick subject. The loss of liberty, alcohol,

fatigue, minor phenomena of _commotio cerebri_, may lead to states

of mental depression that favor the fugue. It is an affair of the

greatest delicacy for the expert to build up again the exact plight of

the soldier at the time of his desertion. Special inquiry must be made

of the man’s mates. Only in this way can the wheat be separated from

the chaff and punishment allotted to those only who deserve it.

According to Lépine, there are fewer guilty fugitives than there are

innocent ones, or at least partially innocent ones. In the decision,

one takes account of the duration, the course, and the peculiarities

in the termination of the suspicious flight. According to the military

code, there are cases like Case 58 in which the fugue itself was

carried out in an unconscious state, and yet in which the martial

responsibility of the man was absolute. Drunkenness is no excuse for

the fugue, even if the latter is automatically carried out. Of course,

the paretic is not responsible for his fugue any more than the organic

dement, the delirious uremic, or the chronic alcoholic, who is already

severely demented. For a case of this sort, see Case 1 (Briand).

In the differential diagnosis, we must also consider that fugues may be

carried out in confused states as well as at times in various paranoid

states, and even in melancholia.

A disciplinary case: Epilepsy.

=Case 59.= (PELLACANI, March, 1917.)

A Milanese workman, 28, was exposed to the sun on sentry-go and had

an attack of convulsions, on awaking from which he found himself in

hospital. He always had attacks in reaction to emotion. One day, in a

quarrel provoked by jealousy concerning a prostitute, he apparently

lost his mind, whipped out a hunting-knife, and wounded a comrade.

Thereafter he lay unconscious until the next day. The court-martial

decided that he was not fully responsible.

Eventually, he was sent from the front for having insulted and

struck a superior officer. The report read also that he was a prey

to delirium and had frothed at the mouth. In the interior he had

convulsive attacks, with falling and loss of consciousness. He told

of arguing with a sergeant about a bicycle, of seeing darkness before

his eyes like a veil, and of subsequent amnesia. In hospital he had

intense headaches at times, with spells of sullenness, hostility, and

complaints concerning nurses and attendants and other patients. At

other times, he was quiet and comfortable. One day he went into an

excitement and wept, asking to be sent back to the army, striking the

table with his fist and head. He then screamed, flew into a passion,

and fell to the ground in semi-stupor, shaking his body and trying to

kick and knock away those who intervened. He was placed in bed but

remained agitated and unconscious, with anesthesia and frothing at the

mouth. The abdominal and cremaster reflexes were absent in this attack,

and the pupils were rigid and myotic. The pulse was rapid and the

blood pressure high. Afterwards he was sleepy, stupid and weary, and

showed fine rapid tremors of hands, tongue, and eyelids. The abdominal

reflexes now returned in excess, and a marked dermatographia developed.

Upon investigation, it was found that the patient’s father was also an

epileptic and was alcoholic; that one paternal uncle had died in an

asylum; another of apoplexy; that two maternal uncles were chronic

alcoholics (one in an institution); that an alcoholic brother had been

six times convicted of assault and battery; that a sister had howling,

crying, and hair-pulling spells, throwing herself to the ground. The

patient himself had had an early Bright’s disease and had always been

an undisciplined, excitable, and impulsive boy, sometimes kept out of

school. His first conviction was at 18, for assaulting a policeman, and

he had been arrested four further times for assault and battery. He

stated that his convulsive attacks with the veil before the eyes came

on when he was irritated or had taken cold, or had drunk to excess, or

had over-exerted himself. He said he suffered from intense headache,

weariness, and sleepiness after an attack. He always bit his tongue at

the same period. Irritation and exertion sometimes caused attacks of

dizziness and vertigo without unconsciousness. Alcoholism; ulcer in an

inguinal gland. He had been confined in an asylum 40 days for epilepsy,

attacks of which had become more frequent after he had heard of his

father’s death.

_Re_ violence and epilepsy, Lépine remarks that a pure epilepsy

unclouded by alcoholism may occasionally give rise to acts of extreme

violence, but these pure epileptic violences are infinitely rarer than

the alcoholic ones. The Milanese was in point of fact alcoholic, and

in his ancestry were a number of alcoholics as well as epileptics.

According to Lépine, when subjects are “out for blood,” they are almost

always either, like this Milanese, hereditary alcoholics, or else

strongly predisposed subjects, or even the offspring of the insane.

A disciplinary case: Epileptic attacks with amnesia.

=Case 60.= (PELLACANI, March, 1917.)

A Veronese, 23, quarrelled with his comrades, and one day wounded one.

Another time, when reproved by a superior, he struck him with a shoe;

and at still another time, hurled himself upon his superior officer and

bore him to the ground. Yet he seemed to have a perfect amnesia for all

these violent acts. At other times, he had convulsive attacks with a

mental state which seemed to combine anger and depression, after which

he would fall to the ground, lose consciousness, go into clonic spasms,

spit bloody saliva, and cause wounds and abrasions upon his body. Once,

after such an attack, he passed into a brief excited spell. Finally

he was so insubordinate and violent to superior officers, that he was

brought under hospital observation, having been excited and confused

for a day.

Next day he was lucid, oriented, and tranquil; entirely amnestic

for what happened the day before, though his acts were sufficiently

unusual. He had threatened his superior officer and been reproved and

sent to prison to think it over. In prison he had suddenly thrown

himself against another innocent person and clutched him tightly about

the neck. He threw another violently to the ground and then ran to help

the previous victim! Bound fast, he had succeeded in freeing himself

and thrown himself furiously against the prison door, whereupon he had

fallen to the ground in an epileptic fit. He had tachycardia (120) and

a generalized hypalgesia. The vasomotor reactions were excessive.

Upon investigation it proved that his mother had been subnormal and

that the patient had been constitutionally excitable and unstable,

given to attacks of anger and impulsiveness from youth up. In fact, he

had been in prison several times for violence. He described himself

in his restless spells as feeling a trembling all over his body as if

his blood were boiling in his heart and his head, whereupon he would

lose knowledge of what he was doing. He had been a quarrelsome boy,

pursuing his mates with knives and stones. Once, after arguing with

a car conductor, he had broken the car windows, turned everything

upside-down, and thrown the conductor into the street.

Case 60 is clearly in the same group as Case 59. The Veronese falls

into the same frame with the Milanese except that he appears not

to have been alcoholic. The insubordinations of the Veronese were

apparently carried out in a state of unconsciousness. The majority of

insubordinates appear not to be epileptics. Some authors have called

attention to pathological politeness as an occasional symptom in

epilepsy. Perhaps the majority of insubordinate cases are feebleminded

or schizophrenic.

Desertion in epileptic fugue.

=Case 61.= (VERGER, February, 1916.)

A blacksmith from the Rochefort Arsenal, 27 (nothing known as to

grandparents; father, now in the fifties, for 30 years in an asylum

with frequent attacks of furor; mother, 45, well and apparently

well-balanced; brother with the colors, wounded and decorated with the

military medal; a cousin-german, who has had a typical epilepsy--in

the patient himself enuresis up to 13 or 14, later, less frequently;

apparently no tongue-biting; no information as to infectious diseases;

graduate from primary school, apprenticed to a blacksmith; an unskilful

worker; never able to rise to the level of a _frappeur_), in 1909 had

passed the board of review and been put in the sixth division of the

line. Antebellum there was a history that one night at supper, he had

slipped away from quarters and gone 30 kilometres, home. His astonished

mother sent him back to the military post by railway.

Upon the night of May 26-27, 1915, this soldier found himself in the

position of a sentry, opposite the enemy. He told his comrade that he

had to go away for a time, leaned his gun against a tree, disappeared,

and did not return. It was then one o’clock in the morning. At six

o’clock, he was found two kilometres away from the lines, in a village.

He was in front of a barn where his company had been quartered before

taking possession of the advanced posts.

He was brought up before the military authorities; but upon stating

that in civil life he had wandered off several times without knowing

where he was going, he was submitted to neurological examination.

There was available a letter from his family physician relative to his

antebellum military service. It appeared that he had committed a number

of breaches of discipline, and that he was regarded by the physicians

as a _déséquilibré_. He had lived with his mother a very quiet and good

life; there was no history of sexual irregularity, and no history of

illness except a slight catarrhal jaundice. He had frequently suffered

from headaches; there had been slight attacks of vertigo of very brief

duration. He had never fallen in these fits. From his story it was

elicited that he had had absences; his comrades had noticed that he

sometimes stopped stock-still with vague eyes, then shortly regained

his wits and continued upon his task. Sometimes he would not work

without being able to explain why he went away. He would go off for a

period and, upon coming to, discover that he had not eaten his meals.

There were never, however, any convulsive crises by day or night. He

sometimes felt sick, and although there was no medical treatment, from

time to time he took bromides upon his own authority, saying he had

been ordered to do so by his father. Although habitually of a gentle

demeanor, nevertheless he was subject to excessive anger upon slight

occasion.

During the mobilizing and first months of the war, both in quarters and

at the front, however, his conduct had been that of a good soldier.

Suddenly, about March or April, 1915, the nocturnal enuresis began

to be frequent again, occurring twice or three times a week; but the

patient hid this misfortune as far as possible from his comrades. The

captain thought he looked tired and depressed sometimes. Upon the

days following the nights with enuresis, there was intense headache

and marked moral and physical depression. There was no proof of

nocturnal convulsions, and it is very problematical whether there was

tongue-biting.

Another odd feature was that the patient, who had been sober in civil

life, had become intoxicated several times after going into the

army. Physically, he was of low stature, but otherwise well built.

Neurologically, he was entirely negative. There was no sign of venereal

disease. There were a few stigmata of degeneration; for instance, there

was very little hair upon the face, the ears were unequal in size, and

the teeth were somewhat anomalously set. Mentally, he was below par;

for instance, he could not add mentally two numbers of two digits.

As to his desertion, the patient says he does not know what he did;

that he learned of his act only from his comrades in the morning; that

he remembered having left his duty _pour aller satisfaire un besoin_.

A specialist in escapes (epileptic fugues).

=Case 62.= (LOGRE, March, 1917.)

An epileptic fugue with recidivism is described by Logre. He described

himself as a specialist in escapes. As a schoolboy, he had practised

escapes and run away without purpose, and without remembering fully

what he had done. His father would bring him back to school. At first

they had punished him and then would pardon him. These escapades in

his work as a shoemaker caused him to lose various places, but he had

been kept by one employer for a long time nevertheless. From 11 years

on, this patient had never ceased living either in foreign parts or in

prison.

The fugues on military service began to multiply. The military chiefs

did not abide the escapades like the schoolmaster or the employer.

Every punishment he received had to do with some fugue. Three times

he gave himself up to the military authorities. Three times after a

few more days’ service or a week in prison, he left the barracks or

escaped. There had never been any appeal throughout this history to an

alienist. On the declaration of war, he had returned to Belgium and

was put into the army; whereupon in January, he carried out a fugue of

a few hours which was rewarded with eight days in prison. There was a

five-days fugue in July, whereupon he was taken before the council.

Upon investigation, these fugues seemed to have the classical features

of epileptic fugues. They were sudden, unconscious, blindly automatic,

almost completely forgotten afterwards and of a stereotyped and

recidivistic nature. Most of the fugues had been preceded by a slight

excess in drinking. An investigation was made to see if there were any

convulsive antecedents; none were found. This mental epilepsy, then,

it was thought, must be an isolated symptom, free from every motor

symptom. But his mother and one of his brothers had also shown a number

of attacks of some sort of epilepsy. In all three cases there was

impulsivity, unconsciousness, absurdity, recidivism, and refractoriness

to treatment. On these grounds the fugue was regarded as pathological

and as epileptic probably. The patient himself thought that these

_coups-de-tête_ and this mania for running away without knowing where,

made really a very ugly fault, particularly in a soldier.

_Re_ such specialists in escapes as Case 62, Lépine speaks of a type of

military delinquent which he calls _Ceux qui sautent le mur_. Some of

the fugue subjects, as well as other types of imbalance can apparently

be held by no possible kind or degree of discipline. They jump any

guardhouse or any other form of imprisonment through what amounts to

a wild instinct for liberty. In some cases, this instinct appears in

a relatively pure form; that is, without any combined tendency to

dipsomania and without any sexual factor. Some of them are, in fact,

very good soldiers, especially in shock troops. They, in fact, belong

to what one might call the good element among delinquents. In the

French Army some of them have been old legionaries and have even been,

as in Case 62, previously condemned for desertion. They form a curious

minority among the wall jumpers. Wall-jumping makes, so to say, the

entire pathological phenomenon, and the recidivism is a part of the

disease.

A disciplinary case: Epilepsy and other factors.

=Case 63.= (CONSIGLIO, 1917.)

An Italian private in the artillery (father dead of general paresis)

had been a victim of infantile convulsions and of convulsions with loss

of consciousness up to 18 (convulsions with shouts and violence in the

streets of Rome; had to be put in a straight-jacket at the municipal

hospital).

He developed more convulsions during antisyphilitic treatment in the

military hospital. He was a very poor soldier, of the rough and violent

sort, and after eight months of service had to be assigned to a special

disciplinary company, with which he remained for fifteen months. Here

also he was punished frequently, and was given a period of four months’

imprisonment for refusal to obey the officers. Then for a period of

several years he had no convulsions whatever.

During the war he was given to alcoholism, and one day in June, 1916,

he struck an officer and ran away to arm himself. He was at this time

observed by psychiatrists and declared sane. He was regarded as an

emotional and alcoholic epileptic but not as neurotic or psychopathic.

He was again placed in a special disciplinary corps.

_Re_ the convulsions which this Italian developed during antisyphilitic

treatment, it would be interesting to know whether intravenous

injections were used. In case they were used, one might compare

the case of this Italian with Bonhoeffer’s volunteer who developed

epileptic convulsions after antityphoid inoculation.

_Re_ the insubordination and violence of this Italian, compare remarks

of Lépine noted under Cases 59 and 60. _Re_ the “other factors,”

compare remarks of Bonhoeffer noted under Case 57.

An epileptic goes through Mons and two years fighting without symptoms.

Then strange conduct with amnesia.

=Case 64.= (HURST, March, 1917.)

A private, 26, epileptic from 11 to 18 (mother also epileptic) entered

the army at 20, attempted to commit suicide in 1912 (amnestic for this

attempt), and went to France with the expeditionary force in August,

1914. The retreat from Mons and further fighting caused no recurrence

of the symptoms. September, 1916, he was in fact put in charge of eight

men doing guard duty. At this time he was able to get to bed only every

other night. The charge of the telephone worried him, as he had never

before been made to assume responsibility. After two months of this,

he was found one night arresting civilians without cause and driving

them before him with fixed bayonet. He was let off court-martial on the

medical evidence, and at hospital remained confused and suspicious.

November 16, he was seen by a medical officer in a typical attack of

petit mal. Of all this, on reaching England December 19, he had no

recollection, and was keen to return to duty.

_Re_ the remarkable delay in the return of epilepsy to this soldier of

Mons, Bonhoeffer remarks that one of the epileptics observed by him at

the Charité Clinic had passed through nine battles, and another through

18 battles before the first attack of epilepsy. Bonhoeffer regarded the

strenuous marching as a liberating factor of epilepsy in five cases,

actual fighting in seven cases, shell explosions in two cases, and

bullet wounds in three.

_Re_ the apparently psychogenic factor in Hurst’s case (epilepsy coming

on after assumption of too great responsibilities), compare remarks of

Bonhoeffer under Case 57 concerning psychogenic factors. Sir George

Savage has called attention to a form of functional epilepsy following

shock or injury, in which recovery occurs after removal from the

strain, but in which there is a relapse if the men go back to duty.

Therapeutic (antityphoid inoculation) epilepsy.

=Case 65.= (BONHOEFFER, July, 1915.)

A volunteer without psychopathic signs except a slight stuttering, and

without psychopathic history of any sort, went into service at 17.

After he had been a short time in the field, a shell fragment injured

him in the upper part of the thigh. He lay up in hospital four weeks.

He then spent four weeks in the reserve.

He was then given antityphoid inoculation, and a half hour afterward

had epileptic convulsions. These appeared four times more during the

next fortnight, as a rule followed by a delirious excitement. No fever

was reported. After the fourth attack, he was transferred to the

Charité Clinic.

At the clinic there were no attacks, and there was nothing epileptic to

discern in the make-up of the patient. His nervous system was normal

to examination. There was, however, one fact in the family history of

note, namely, that an older brother of the patient, 20 years of age,

suffered from convulsions.

What is the relation of the antityphoid inoculation to the epilepsy?

According to Bonhoeffer, we must not forget the family history even

if we regard the inoculation as the liberating factor. Curiously

enough, the shell injury did not itself serve apparently to bring out

the epilepsy. Bonhoeffer has seen three other instances of epileptic

attacks or epileptoid phenomena following antityphoid inoculation.

However, in the hundreds of thousands of inoculations, it is not to

be wondered at perhaps that there should be a number of instances of

epileptic attacks. One was a man with severe epileptic taint; in the

others, there was a question of pathological intoxication.

_Re_ antityphoid inoculations, a French observer--Paris--remarks that

these inoculations may occasionally start up the symptoms of general

paresis. Compare in this connection also Case 63, in which a syphilitic

developed convulsions during antisyphilitic treatment. The psychogenic

factor of intravenous injection itself, with its possible effect upon

glands of internal secretion, can hardly be distinguished from purely

serological effects. Paris goes so far as to state that he regards it

as imprudent to vaccinate a syphilitic subject. He thinks it might be

better for a syphilitic subject to contract typhoid or paratyphoid

fever than to run the risk of developing paresis. If the soldier

happened to be not only syphilitic but alcoholic, then the danger would

be larger. Possibly, however, both Bonhoeffer’s case of antityphoid

inoculation epilepsy and the cases alluded to by Paris of antityphoid

inoculation, are merely statistical accidents.

Shell-shock; (apparently slight) scalp wound: Jacksonian seizures.

Operation, decompressing the edematous upper Rolandic region. Recovery.

=Case 66.= (LERICHE, September, 1915.)

A Moroccan of the Seventh Tirailleurs was thrown to the ground by the

explosion very near him of a large calibre shell, lost consciousness,

and woke up with a slight contusion of the right side of the head. The

date of this injury is unknown. He was evacuated to the interior, but

stopped May 25, 1915, at the evacuation hospital because his pulse

in the train stood at 51. An hour later in the hospital he had a

Jacksonian epileptic attack, followed by a left-sided flaccid, brachial

monoplegia, and after a quarter of an hour a second crisis, and then

a third,--a sort of epileptic status occupying an hour. The attack

seemed to start in the left hand. After the crisis, hand and arm became

flaccid and inert.

Lumbar puncture in the crisis gave fluid under small tension in a few

absolutely limpid drops. The wound was a superficial skin wound as big

as a 25-centime piece, near the middle line, roughly corresponding with

the upper Rolandic region. It was hardly a wound--a mild abrasion not

passing the epidermis; periosteum and bone intact.

The patient was trephined and a thin layer of clot was found over the

dura mater. The clot was removed and a crucial incision was made into

the dura mater. The brain seemed a little edematous, hemorrhagic and

bruised. It soon began to beat and was tamponed.

May 26, complete brachial monoplegia without seizure.

May 27, seizure at 2 in the afternoon, starting in left arm.

The wound was going well and from this time forward no more seizures.

May 28, a cast was made for the hand.

June 4, lumbar puncture yielded a clear liquid under the pressure of

58. That evening an hour after the puncture, the brachial monoplegia

disappeared. The arm was still a little weak June 5. June 8 the man was

evacuated to the auxiliary hospital at Laversine. June 18, complete

recovery.

Fall and blow to head: Hysterical convulsions. Cure by studied neglect.

=Case 67.= (CLARKE, July, 1916.)

Clarke had seen in the war but one case of hysterical convulsions,

though this particular patient had severe hystero-epileptic fits

occurring in series. The man had never suffered from epilepsy and was

20 years of age. He received a slight wound and fell back into the

trench a distance of six feet, striking but not contusing the back of

his head.

On admission to the hospital he was found drowsy and dull. Fits

occurred a week later, following one another at brief intervals in

series that lasted one or two hours. The arms would be raised and

extended in clonic spasm; the patient would resist violently if held,

and then turn to his right side with rigid extension of legs and back

in opisthotonos. The eyeballs underwent irregular movements, and

there was a well marked hippus. Though the tongue was protruded in

these attacks, it was never bitten. It was doubtful whether there was

a complete loss of consciousness. Between attacks, the patient was

morose and sullen, and showed a varying incoördination of the movements

of the left leg, which was anesthetic to the knee. There was also a

glove anesthesia of the right forearm and hand. Fields of vision were

contracted.

The fits recurred with intervals of a day or two, for a fortnight. The

patient was then strictly isolated in a small room with an observation

window. His bed was made up on the floor. He then had very slight

attacks, as a rule when the nurse came into the ward; no notice was

taken of these attacks and in a fortnight they ceased. The paresis

of the leg and the anesthesia also cleared up without treatment. He

remained in the general ward three weeks longer, at first dull and

listless, but later cheerful and active. Clarke suggests that this

patient was below normal intelligence.

Shell injury with unconsciousness; delayed attacks of epilepsy:

superposed hysterical hemihypesthesia. Previous history consistent with

the hypothesis that a genuine epilepsy had been developed.

=Case 68.= (BONHOEFFER, July, 1915.)

An excellent soldier, of good build, 29 years, a member of the

_Landwehr_, passed unscathed through eleven battles in the 1914

campaign, but finally succumbed to fragments of shell which struck his

chest and the lower part of his thigh. He fell down, nauseated, and

lost consciousness. He is said to have struck about him with his arm

and to have voided urine. There was a second attack three weeks later,

in which he fell upon his face.

In the Charité Clinic he had three attacks, two of them nocturnal, one

in the daytime, followed by a long period of somnolence. He once cried

out suddenly in the night as if warding off an attack. He complained of

headaches, and was often irritated and out of humor. Somatically, there

was a hemihypesthesia on the side of the injury.

The history indicates that this patient up to his sixteenth year had

been a victim of occasional enuresis, often cried out in his sleep or

even rose from bed. Occasionally he suffered from such violent sudden

headaches that he would have to sit down. He was easily irritated, and

had once been arrested for assault. As a soldier, however, he had never

been guilty of any breach of discipline. Mild headaches would follow

drinking. These phenomena in the history pointed in the direction of

epilepsy. According to Bonhoeffer, we cannot entirely exclude contusion

of the brain from the shell injury. However, there were no cerebral

symptoms, and the interval before the occurrence of the attacks rather

indicates that we are dealing with a genuine epilepsy. As for the

hemihypesthesia, this is a hysterical “_superposition_,” which does

not interfere, according to Bonhoeffer, with the genuineness of the

epilepsy.

Shell-wound; musculocutaneous neuritis: Brown-Séquard’s epilepsy.

=Case 69.= (MAIRET and PIÉRON, January, 1916.)

An infantryman, 30, a gardener, was wounded in the right forearm by

a shell fragment, which fractured the ulna, September 7, 1914, at

Revercourt. Despite much fragmentation of the bone and suppuration, the

wound healed with two cicatrices, where the fragments had gone in and

had come out. The scarring process was over in December.

However, in the middle of January, 1915, this man began to suffer from

headaches and insomnia, with vertigo and buzzing in the head, “as if

an airplane inside.” Sometimes arms and legs would stiffen, and the

man would tremble, have to lie down, and even lose consciousness for

a quarter of an hour, waking up tired, wandering, and with feelings

in his head. These crises, at first occurring every week, later grew

frequent. Finally there was a very complete attack, in which he fell

out of bed, got up, made several turns about the room, and went back to

bed; and in the morning, was dull and disoriented. Accordingly, he was

sent to the central military neuropsychiatric service of the general

hospital at Montpellier, November 10.

Besides the two extensive cicatrices, there were motor disorders.

Pronation and supination were almost impossible, as well as extension

of the hand and fingers and abduction of the thumb. There was a radial

paralysis without R. D. Electrical excitability of the extensors

was diminished on the right. The hand was weak. The right thumb was

atrophic. There was a hypertrichosis as well as redness, heat and

perspiration of the right hand. There was a hypesthesia for all forms

of stimulation in the hand, especially in the radial region; less in

the ulnar region. This hypesthesia rose along the posterior surface

of the forearm and covered all the territory of the ulnar nerve;

but there was a corresponding hyperesthesia in the musculocutaneous

distribution, as well as in the internal cutaneous distribution. Above

the scar there was a region of complete anesthesia. The hyperesthesia

rose higher along the circumflex nerve and the posterior branches of

the cervical nerves and included the great occipital distribution, even

involving the superficial cervical plexus, though not the territory

of the trigemini. There was some hyperesthesia of areas governed by a

few dorsal intercostal nerves. There were also spontaneous pains in

these hyperalgesic regions. The _musculocutaneous nerve_ could be felt

to be _thick and swollen_, indicating a perineuritis. There were no

neuropathic stigmata, but the knee-jerks were exaggerated a little more

on the right side.

The convulsions appeared two or three times a day, the pain would get

worse along the arm, rise to the head, following the hyperesthetic

zone, then invade the interior of the head, whereupon objects

would appear to turn and the ears would buzz. The right leg, and

especially the right arm, would begin to tremble. The man would have

to support himself to avoid falling. He saw shadows moving, colored

trees, occasionally persons. When the vertigo got stronger, he lost

consciousness. The extremities of the right side stiffened and carried

on jerky movements. These sometimes extended to the left side. The

seizure lasted from five to fifteen minutes, and sometimes occurred

in the middle of the night. Fatigue followed but headache disappeared

after an attack.

The diagnosis of Brown-Séquard’s epilepsy was made. If the

musculocutaneous trunk was compressed, a crisis was produced with

pain radiating to the head, obscuration of vision, numbness in the

arm, and tremors. Electrical treatment was resorted to for analgesic

effect. There was a certain improvement during May, so that the diurnal

dizziness disappeared. May 19 he had a period of 24 hours without any

vertigo. In June no further improvement occurred.

An operation was performed June 23, 1915. The two cicatrices were

excised, and some fragments of cloth were removed. Three Jacksonian

crises followed the operation, and there was another seizure next day.

Frequent headaches followed without crises. More seizures appeared in

the night during July, and their frequency increased. Pains persisted

along the arm and in the back of the head; the musculocutaneous

perineuritis was still intense. Prolonged baths for the arm were begun

August 4, two baths of two hours each, at 40 deg. each day. Following

August 10 there was an improvement, which stopped as soon as the baths

were omitted, with diminution of the vertigo and the hyperesthesia.

This improvement continued; the baths were made to last three hours.

There were no attacks from August 21 to 26 whereupon they then returned

for two days. The pains had much diminished in the arm but persisted in

the occiput. A few night attacks occurred August 30 and 31, September 5

and 6, as well as September 19 and 20, 25 and 26, and 27.

The occipital pain had now become less; the musculocutaneous nerve

was not so large. Only a few headaches followed during the months

of October, November, and December. After November 3 the baths were

stopped and the arm was kept wrapped in a warm compress. There

was still a certain hyperesthesia, the knee-jerks had become less

exaggerated. Massage and mechanotherapeutic exercises were begun. There

were no more attacks after September 27.

_Re_ Brown-Séquard’s epilepsy, Lépine remarks that besides the case

of Mairet and Piéron, Hurst and Souques have published cases. Lépine

himself has observed two cases: one followed a nerve wound in the

foot; another, a penetrating wound of the chest. As a rule, such

Brown-Séquard epilepsies appear a number of months after trauma; as

a result of irritation in the scar. Lépine’s subjects were taken for

simulators because they had not received any _cranial_ wound. The

prognosis should be guarded, though the outcome in Case 69 appears to

have been favorable.

Epileptic episode at 24 years following bullet-wound of hand, in a

soldier who had had convulsions in childhood (sister epileptic).

Reactive epilepsy? Epilepsia tarda?

=Case 70.= (BONHOEFFER, July, 1915.)

A man in the reserve, 24, bore the stresses of the war very well

in the campaign in East Prussia until he was shot in the hand at

Deutsch-Eylau. He had always been well aside from rheumatism, and was

discharged with a good record from his military service.

Sent to the reserve hospital for his hand injury, he had, two or three

times in the night, convulsions with loss of consciousness and dilated

pupils; after which there was a thirty-six hour period of depression

with refusal of food. Thereafter this soldier had amnesia for both

the seizures and the subsequent depression. He was observed six weeks

longer in the Charité Clinic but had no more attacks, and indeed

nothing more of note either mentally or somatically.

The history showed that there had been convulsions in the third and

fourth years of the patient’s life. There had been, however, nothing

epileptoid in the later childhood or developmental years of the

patient. However, a sister of the patient had suffered since childhood

from convulsions. It remains a question whether this episode is to be

regarded as reactive epilepsy--reactive, namely, to experiences in the

war--or whether we are dealing with a true epilepsia tarda.

_Re_ this episode following bullet wound, the compiler has placed

it after Mairet and Piéron’s case of Brown-Séquard epilepsy, but

apparently Bonhoeffer regards his case as probably a reactive one.

Unlike the case of Mairet and Piéron, Bonhoeffer’s case had an

epileptic soil (convulsions in childhood and epileptic sister). _Re_

the so-called reactive epilepsies, see remarks by Bonhoeffer under Case

57.

Epilepsia tarda in a lance-corporal without hereditary taint or

previous history save dizzy spells and excitability.

=Case 71.= (BONHOEFFER, July, 1915.)

A reserve lance-corporal, 24 years--a soldier from 1911 to 1913

without disciplinary record, and in his second year becoming

lance-corporal--was in the campaigns in Belgium, East Prussia, and

Poland, making long marches and going through several battles. In the

middle of October, 1914, he fell from a horse and suffered a contusion

of the thorax, after which blood appeared in the sputum. In November he

was brought to the reserve hospital in Berlin, and there had convulsive

seizures. Before transfer to the Charité Clinic, a seizure occurred,

and he was brought into the clinic in a characteristic dazed state.

Thereafter he was clear but often out of humor and irritated. Three

weeks later came a brief attack, probably epileptic in nature, with

restless half-delirious sleep following.

There was nothing in childhood or in the family history to indicate

epilepsy. However, the patient himself stated that from 1913 onward,

after his period of military service, he had from time to time felt

attacks of dizziness after exertion, and that he had become more easily

excitable than before.

The attacks in the lance-corporal are probably not to be attributed to

the thoracic contusion, according to Bonhoeffer, because of the long

period that elapsed after the thoracic injury, and their development

nocturnally without special occasion. According to Bonhoeffer, we are

probably here dealing with a late epilepsy.

_Re_ late epilepsy, see also under Case 57. Bonhoeffer makes a

considerable point of the lateness in attacks of epilepsy in some of

the military cases, pointing out their beginning at the ages of 22 to

27 in the period of peace practice undergone by soldiers. The theory

is that cases of severe and long-standing epilepsy are known to the

authorities, so that they would not ordinarily be in military service

except under conditions of concealment or in case of error. The present

case (71) appears to be the nearest that Bonhoeffer has found to a case

of epilepsy without heredity and without acquired soil. All that can be

regarded as evidence of soil is the dizzy spells and excitability.

_Re_ thoracic contusion, compare remarks of Lépine under Case 69, on

Brown-Séquard epilepsy following thoracic wound.

Convulsions by autosuggestion.

=Case 72.= (HURST, November, 1916.)

A private, 27, is described as a typical martial misfit--in private

life a music hall falsetto singer, and afterward a valet. He joined

the army in 1915 and proceeded to France, and worked in a canteen.

A week later, men broke in and threw a mallet at him, whereupon he

immediately had a fit, and was dazed, dumb, and unable to walk for two

days. Thereafter occasional further fits occurred, with nervousness

and insomnia. He was sent home in September, 1916. Discharged to duty,

he again in December returned to France, had six fits in the first

week--three in hospital, two on the boat, and between two and four for

four days after admission. The diagnosis of genuine epilepsy was made

in France by a medical officer who had seen one of the convulsions.

However, he had never passed urine or bitten his tongue, had no family

history, and had never had fits before going to France.

He was hypnotized and given the suggestion that he would have a fit.

In the convulsion which followed the plantar reflexes remained flexor,

but otherwise the convulsion was quite like the genuine epilepsy. He

was told that he would not have any more convulsions, nor did he have

any more except on Feb. 16, 1917, when some talk was made to him about

returning to duty. Bromides used in France did not help the epilepsy

at all. This patient developed a gait and speech defect copied from

two patients in the wards. These symptoms, due to autosuggestion,

disappeared on persuasion.

_Re_ autosuggestion, Bernheim has returned to the fray (1917) in a

book on automatism and suggestion, dealing only in small part with war

problems. The most general formula for suggestion appears to be that

it is an _idea accepted_. A suggestion offered but not accepted is

in effect not a suggestion at all. Any accepted idea, says Bernheim,

is from the psychological point of view as well as from the medical

point of view, a suggestion. A suggestion may be direct or indirect,

reasonable or unreasonable, brought about by

(_a_) mere verbal assertion,

(_b_) hypnotic state,

(_c_) persuasive explanation, rational or emotional,

(_d_) emotion (that is, emotion not the effect of any form of

suggestion offered by the physician, but emotion brought about by some

event affecting the sentiments of the subject).

Epilepsy of emotional origin.

=Case 73.= (WESTPHAL and HÜBNER, April, 1915.)

A lieutenant without neuropathic tendencies (except that his mother

was in a hospital for the insane) was under shell fire for some time.

Finally, a shell burst near him, whereupon headaches and transient

spells of confusion followed. Shortly upon the news of the death of

his Major, he had a spell of violent excitement and confusion, dancing

about on the ground and breaking things up. He passed into a stuporous

condition with a suggestion of catatonia. There were a few isolated

delusions to the effect that he was poisoned. After sleeping a long

time, he suddenly cleared up. There was an extensive amnesia covering

a period of weeks. He had forgotten the Major’s death and everything

thereafter. He complained of headache, difficulty of thinking, and

forgetfulness. An agoraphobia developed, as well as great sensitivity

to sounds, and a feeling as if the bed and surrounding barracks were

moving. There were a few illusions of a visual nature. He had complete

insight into his condition. Conduct was normal. There was general

hyperesthesia and ageusia.

According to Westphal, this case of deep disorder of consciousness of

some duration in a healthy person is probably one of a dazed state

following the so-called “affect epilepsy.”

Is Case 73 Shell-shock? Note that, in Case 73, the shell explosion

at first occasioned mere headaches and confusional spells. The true

occasion of the convulsions appears to have been the news of the death

of a superior officer. It is, of course, possible that the transient

spells of confusion were actually epileptic equivalents. Lépine

remarks that Pierret and others, observing such spells of confusion

often accompanied by agitation, have inquired whether manic depressive

psychosis is not a kind of epilepsy. This question remains unresolved.

These phenomena of epilepsia larvata (see also Case 81 of Juquelier and

Quellien) are to be sharply distinguished from attacks of confusion

occurring in pronounced epileptics. These latter attacks often follow a

crisis and suggest exhaustion; sometimes they last several days.

Fatigue; fear; hysterical convulsions. Visual aura (approaching fire

wheel) built up after the third crisis (scotoma after look at sun).

=Case 74.= (LAIGNEL-LAVASTINE and FAY, July, 1917.)

A sapper, 23, with his company under heavy bombardment, October, 1916,

was overcome by weariness and fear (he had always been of a timorous

disposition). The order for the rear came, but the convoy was hardly en

route when the sapper felt a griping in the pit of the stomach and the

blood going to his head; whereupon he lost consciousness and went into

convulsions.

This incident seems to have made a powerful impression upon the

sapper. A fortnight later, while working in the trenches, he had more

epigastric sensations with vague discomfort. He thought about the

earlier crisis and about his wounded comrades, and again fell down

and had more convulsions lasting a quarter of an hour. The tongue may

have been slightly bitten in this seizure. In the genesis of this

second seizure we may consider that the feeling of discomfort and the

epigastric sensations served to recall the first seizure, so that

the second one may be regarded as due to autosuggestion--that is, as

hysterical.

A little later, on a hot day in the trench, while working, the sapper

turned to a comrade and saw a great black spot on his face. He turned

toward another and saw another great black spot on this face also.

He was frightened, felt strange sensations, fell, and had a third

convulsive crisis. The black spots that he saw were due to a scotoma,

the result of a transient glance at the sun.

After this scotomatous episode, his crises always had a visual aura.

He would feel rather uncomfortable, leave the supper table, feel a

gastric sensation, warmth in the face, and oppression. He would go out

in the cold for the air, look about for something, appear frightened,

fix his gaze upon a certain point, and cease to reply to questions. His

head would jerk back suddenly, and he would utter strangled cries of

fear. He was now evidently prey to a terrifying hallucination. In ten

minutes, everything had gone again, leaving him trembling with emotion.

He would then relate how, after the epigastric sensation had begun,

he tried to see if he could make out something abnormal; whereupon a

little fiery wheel would appear and roll up nearer and nearer, so as to

almost touch his eyelids. He could see his comrades to the right and to

the left of the wheel; he could hear questions but could not answer.

Just as the fire wheel was about to blast him, consciousness was lost

and the fits came on.

War strain; anxiety; confusion; fugue. Demotion and detail to the

interior.

=Case 75.= (BARAT, November, 1914.)

A lieutenant, 25, an officer in a regiment on active duty near the

front, was called before a special board charged with desertion in

the face of the enemy. He had been assigned to a certain position but

not only had not complied with the order, but had wandered off to the

British sector and been arrested there as a spy.

The prisoner was well developed, without stigmata; heredity, negative.

His career in the army had been courageous and he had been advanced

several ranks and was about to be given a medal for bravery. He said

that he had been under a severe strain for several days.

One evening he had been given the order to attack. The artillery opened

fire. He found that the Germans had erected barbed wire defences. The

loss of men was terrific. His order was to shoot all who held back. A

poor territorial crouched down and would not go forward--supplicating

the prisoner not to shoot him. The prisoner spared him.

The next night the order to attack the German trenches was again given.

This time he was overcome with anxiety and discouragement. The last

he remembers was the order to attack. Next day he felt sick and his

mind was foggy. He remembered leaving his regiment and wandering round

for several days until he fell into the hands of the British and was

arrested. Then he understood what he had done.

The prisoner asked to be allowed to return to the front. The testimony

of one of the lieutenant’s men verified his statements. On the day

before he left the front he had been anxious, had cried often, and

would speak to no one. On the day he left the trenches without

permission, he was nervous and disoriented.

There was no doubt that simulation could be ruled out; the differential

diagnosis lay between a “confused state of emotional origin” and an

“epileptic dazed state.”

For epilepsy there was a history of attacks with falling to the ground

and loss of consciousness, without involuntary micturition or biting of

tongue, during the time when he was a sergeant. Moreover, irritability

and unwarranted suspiciousness had been present at these periods.

However, there were no other epileptic symptoms; these two attacks were

isolated and of quite long duration, leaving no headache or malaise

after them. Also there was no basis for the diagnosis “epileptic

dazed state,” since there was no abrupt commencement; the loss of

consciousness was never complete (the subject was able to converse with

persons while the attacks were on); and some remembrance was present of

incidents during the attacks.

For Barat, the important points are that the attacks were preceded by

long periods of anxiety and the disturbances resulted more from moral

than physiological causes.

The importance of the psychological factors lead the author and his

colleagues to the diagnosis “Mental confusion of emotional origin.”

The board decided to return him to the interior and give him a barracks

position at the reduced rank of drill sergeant.

A solitary epileptic episode in an artillery officer (slight concussion

of the brain two years before) following extraordinary campaign stress

(38 artillery battles in two months).

=Case 76.= (BONHOEFFER, July, 1915.)

A first lieutenant of artillery, 35, was able to count 38 artillery

clashes in which he had taken part in two months of very strenuous,

almost daily fighting. Then appeared headaches, anxiety, dizzy

feelings, insomnia. Finally one day suddenly, after eating, the

lieutenant sustained a loss of consciousness with convulsions, which

sent him to his home reserve hospital. The officer had felt nothing

before his convulsions came on. The medical report, however, yields no

doubt of the epileptic character of the attack.

When he was examined, there was a slight psychopathic depression

with a feeling of insufficiency, anxiety, insomnia, restless dreams,

over-sensitiveness, and a pessimistic outlook on the future. There were

no epileptic traits whatever. There was nothing alcoholic, luetic, or

arteriosclerotic about the officer. There was nothing in the childhood

or youth of the patient, though there had been a fall two years before,

with phenomena of concussion without sequelae. In fact, this fall with

concussion had led to no medical examination.

As to the relation of the concussion two years before to the epileptic

attack, Bonhoeffer is inclined to interpret the case as one of genuine

“reactive” epilepsy on the basis of continuous overstrenuous work for

a period of weeks. He regards the previous concussion as soil for this

epilepsy.

_Re_ amount of stress occasionally required to bring out epilepsy,

compare Hurst’s Cases 64 and 80. It may be recalled that Bonhoeffer

is decidedly of the belief that exhaustion has not brought about

any actual psychoses, calling attention to the remarkable absence

of psychoses among the Serbians after their exhausting campaigns. A

general review of war experience indicates, according to Bonhoeffer,

the marked power of resistance of the healthy brain.

Nocturnal narcoleptic seizures accompanied by spells of somnolence in

the day, both to be regarded as due to the “brain fag” of trench life.

=Case 77.= (FRIEDMANN, July, 1915.)

A tradesman, 23, had been in the German infantry since the beginning

of the war. Never sick, he had been, in a general way, nervous; and

a brother had had, at the age of 30 years, some sort of severe brain

disease, in which he became blind, dying a year later.

The man was for a long time in the trenches and proved himself a

courageous and stalwart soldier. He went to hospital after a slight

bullet wound of the leg, with a benign paralysis of the peroneus.

In the hospital he began to show a somewhat pronounced emotional

depression, with a nervous tachycardia.

Friedmann reports the case on account of certain peculiar seizures

which, upon the man’s own story, had begun five weeks before, in

the field, although he had told no one about them. He had never

felt anything like them before. At first, they came three to five

times almost every night. He would suddenly wake and find himself

unable to move, to speak, or even to think. These seizures, however,

were not accompanied by any feeling of anxiety or any respiratory

distress. Consciousness remained clear, and after 10 or 15 seconds,

he could begin to think normally again. It was clearly a question of

psychopathic absences of a mild narcoleptic type, occurring, however,

only at night.

Daytimes, also, throughout the whole period in which the nocturnal

absences occurred, there were seizures of another description. During

the many hours in which he had to sit in the trench, about twice a

day for half an hour long, he would plunge suddenly into a sort of

irresistible lethargy. Without any external occasion whatever, there

would be a feeling of great fatigue. In the spell he could not move or

think, would lean his head upon his hand. He was unable to overcome the

feeling of weariness and became convinced that he was ill, and that

the fatigue could not be natural. However, he did his work like the

rest. Friedmann interprets these spells as a kind of imperfect sleep.

The patient was physically healthy and stalwart, mentally not

excitable, and tolerably tranquil in the midst of shell fire. He would

never have been reported sick had it not been for his wound. Aside

from the tachycardia, of which he himself complained little, nothing

wrong was found in the hospital. There was, to be sure, a feeling of

discomfort without any hysterical tinge, and sleep was restless. Aside

from the peroneus palsy, the injury made a good recovery. The nocturnal

attacks persisted; bromides and even luminal failed of effect. There

was, however, no longer any somnolence by day. In fact, for the five

weeks of observation, there was no change in his condition.

Friedmann states that mild emotional alterations are not infrequent in

the trenches with minds disposed thereto, although emotional shock,

especially in shell fire, is the most frequent cause. However, these

particular seizures are quite unusual. The stresses of field service

lead to a sometimes complete paralysis of mental power, interfering

transiently with service. There is no evidence of sudden circulatory

disturbances such as would bring about dizziness, pallor, nausea,

or fainting spells. According to Friedmann, the regulative brain

functions, especially those that maintain consciousness, become weak

on account of a condition which he terms _Gehirnmüdigkeit_, or, as we

should say in English, brain fag. The situation forbids due completion

of sleep. Thus, the explanation of the daytime attacks follows rather

obvious lines of brain fag. The accidental awakening it is, which at

night produces the absences; the wakenings are due to the general

restlessness of the patient. The general weakening of cerebral function

produces the disorder at the moment of wakening, since the regulative

factors of consciousness are already out of order. The condition in

the absence rather closely resembles the state of consciousness just

before going to sleep, and also perhaps the state of consciousness

during the process of awakening. It is as if the process of waking were

somehow delayed a few moments. Friedmann is interested to show the

relation of such absences to the so-called _gehäuften kleinen Anfälle_,

originally described by him in 1906 as occurring in children, and

distinguished from epileptic attacks. These attacks, after lasting for

years, finally disappeared completely. The same sort of thing in adults

was symptomatic of some other disease, such as neurasthenia, and was

not a true entity. In children these attacks failed to be attended with

any mental injury, nor were there any pronounced epileptic phenomena.

Bromides had no effect upon them, and they already showed a somewhat

striking and peculiar appearance, involving interruptions ten seconds

long of capacity to think, speak, or move, without disturbance of

consciousness or automatic movements. Sometimes the attacks occurred

from six to 100 times in the day, without in any respect interfering

with the general condition of the child. The occurrence of such series

of mild seizures is nothing but a syndrome. To be sure, some cases

turn out to be cases of genuine epilepsy with an eventual degenerative

process. Some forms belong in the spasmophilia group, and some among

the hysterias. However, according to Friedmann, there is a narcoleptic

_petit mal_ that is an entity by itself, proceeding after a period

of years to complete recovery without complications. It is this form

which may be regarded as a peculiar kind of brain fag. The case of the

soldier may be supposed to be one which will prove to have this benign

outcome.

Sham fits.

=Case 78.= (HURST, March, 1917.)

An unwilling conscript developed numerous fits on board ship coming

from Jersey, three days after enlisting. _Fifty_ more developed during

two days in hospital. He was sent to Netley.

On the hypothesis of hysteria or malingering, he was hypnotized. A fit

was suggested to him, but did not come off. The Sister was informed

in the patient’s hearing that the man was clearly shamming, as in all

genuine cases a fit would occur after this treatment. A fit with marked

opisthotonos immediately occurred. This fit immediately stopped when he

was ordered to stop it and to wake up.

The man after waking promised to have no more fits.

Epileptoid attacks, controllable by will.

=Case 79.= (RUSSEL, August, 1917.)

A man was received in No. 3, General Hospital: Diagnosis, epilepsy. He

was shortly sent to the convalescent camp and then returned, having had

two attacks. Russel watched for another attack, felt it was not genuine

and “put the situation up to” the soldier whose story was as follows:

He had been at the front without leave for twelve months since the

German retreat. Leave was due him. A sister’s letter said his brother

was severely wounded and his mother was praying for his return. When he

thought these things over an attack came. He could, however, control

the attacks. Russel told him, if he would play the game, he would be

sent to the base with a recommendation for leave. In ten days the man

was remarkably changed and had no further attacks.

Hereditary epileptic taint brought out by two years service with

eventual shell-shock and burial thrice in one day.

=Case 80.= (HURST, March, 1917.)

A private, 24, in the army from 16, never epileptic (sisters

epileptic), was wounded four times in the war from September, 1914.

Shell fire did not worry the man, but he gradually became depressed

after his father and five brothers had died in active service. He

was blown up and buried three times in one day in July, 1916. He was

unconscious for two hours after the second blowing up, but carried on

for two hours more until blown up for the third time.

After this, he became nervous and shaky, and began to sleep badly, and

a month later had a typical attack of major epilepsy. Fits occurred

with increasing frequency. As many as 19 occurred in a single day. Rest

and bromides caused the fits to cease, and there had been none for six

weeks at the time of his discharge.

_Re_ the extraordinary delay in the bringing out of this epileptic’s

taint, refer back to Case 76 of Bonhoeffer, with its discussion, and to

another case of Hurst (64).

_Re_ Shell-shock and its relations to epilepsy, see below, discussion

under Cases 82-84 of Ballard, who has erected a theory of Shell-shock

as in some sense epileptic.

Shell-shock: Epilepsia larvata.

=Case 81.= (JUQUELIER and QUELLIEN, May, 1917.)

A soldier, 29 (father alcoholic, died in hospital for the insane),

a decorative painter without plumbic history, non-alcoholic,

non-syphilitic, was wounded once, September, 1914, but returned to the

front in 1915.

May, 1915, a shell burst near him. He lost consciousness, regained it a

few days later at Brest, and was so far recovered that he could go on

leave in seven days. While on leave, he had short attacks of delirium,

followed by a total amnesia; there was, however, no crisis, fall, or

convulsion. After the first attack, he had for 24 hours malaise and

headache, but got well and went back to his dépôt. Shortly afterward

more attacks of this sort recurred, and he went to hospital and thence

to the neurological centre at Tours. Whence, August 9, 1915, he got a

two-months’ leave for “mental disorder post-confusional, _second état_,

probably hysterical (_commotio cerebri_), and organic hemiparesis.”

November, 1915, after returning to the dépôt, there were more spells

and he went again to hospital. Invalided December, 1915, he passed a

year at home, but the spells continued. Although the epileptic nature

of these attacks was maintained by Francais at Évreux, he was placed in

the auxiliaries, December, 1916, but had to go to hospital almost at

once, and, February 28, 1917, entered the neurological centre of the

9th Region for the second time. Here, when called to be examined two

days after admission, he was observed in an attack. He suddenly rose

from the bench, made a few steps, seemed to be listening and anxious,

as if he ought to be on guard. He looked up, seemed to be looking for

something whose noise was approaching, lowered his head, made a slight

jerking movement, and said, “Poum!” as if to express the noise of an

explosion. He took a few more steps, the same movements were repeated,

and the same “Poum!” was uttered. This lasted for about a quarter of

an hour, during which the patient was unaware of his surroundings. He

could be guided all about the hall without resistance, but did not

respond to orders, commands, noises, or contact. In short, the patient

was in the midst of a hallucinatory dream at his post in the trenches,

undergoing a bombardment. He was placed in a chair; remained motionless

for a few seconds, woke up, and answered questions. “Where am I? Oh,

yes; I must have been sick because my head feels bad.” In answer to

the question. “What did you see; what was there?”, he said, “I don’t

remember anything. I never remember. I don’t know.” The patient was

dull and weak after the spell.

These spells varied in number but occurred once a week. The patient was

able to tell of certain attacks that had occurred while he was out of

doors at home.

Now and then, there was another theme in the hallucinatory delirium,

namely, a pencil drawing of a woman’s picture, of no great artistic

worth but carefully done, at which the patient was much astonished on

awaking.

It seems as if auto- and hetero-suggestion can be eliminated from the

genesis of these attacks. Neither hysterical nor epileptic crises have

preceded or ever alternated with these seizures. Nevertheless, on the

organic side, the patient had a general increase of tendon reflexes on

the left side, most marked in the knee-jerk, and fell to the left in

voltaic vertigo. There was a left hemiparesis, apparently of organic

origin, which had been determined as far back as July, 1915.

There was no true dementia. Past memories were but slowly recalled,

and inattention interfered with the fixation of recent memory. He

complained of troubles in his sleep and dreamed of war experiences

somewhat analogous to those in his attack of amnestic delirium. After

the seizure, there was a marked hebetude and mental inactivity, torpor,

and a severe headache. The case was presented to a special commission

as one of epilepsia larvata in a person hereditarily predisposed who

had never before presented epileptic signs, suffering from a disease

characterized by frequent short attacks of hallucinatory and delirious

automatism, following shell explosion which had at the same time

produced a slight left-sided hemiparesis and mental inhibition.

To illustrate an epileptic theory of Shell-shock; three cases:

1. Fugue; minor symptoms: later, epilepsy.

2. Epileptic confusion eight months after explosion.

3. Mine explosion: stammering replaced by mutism; mutism

replaced by epilepsy.

=Case 82.= (BALLARD, 1917.)

Atmospheric concussion from shell explosion, October, 1915, was

followed by unconsciousness in a soldier described by Ballard.

Blindness for a month followed recovery of consciousness.

“Neurasthenia” (anxiety neurosis) after return of sight. Apparently

nearly complete recovery after latent period of a few weeks. Return of

blindness in one eye in December. Five days automatic wandering (the

man was found in a west country town five days after leaving home to

rejoin his dépôt and seen by a medical officer who reported that he

was dazed and amnestic for that period); admission to second Eastern

General Hospital, December 15.

On admission he proved to be suffering from minor hysterical symptoms

such as an inability to open his eyes and to see clearly when the

lids were raised. The symptoms rapidly cleared up under suggestive

conversation and did not return except for amnesia and slight emotional

depression. He remained well until December 25. On that day he began

for the first time to have definite epileptic fits and nocturnal

epileptic delirium. In January he was discharged as an epileptic. There

was no epileptic temperament or feeblemindedness. Finally, there had

never been any personal or family neuropathic or psychopathic history.

=Case 83.= (BALLARD, 1917.)

A soldier was blown up, April, 1915, and had a spell of

unconsciousness. Later, pains in the head, slight amnesia and a

condition of asthenia developed.

He was eventually admitted to the second Eastern General Hospital at

Brighton, January, 1916. At the time of admission he was semiconscious,

stuporous, confused, disoriented, anxious in a dull sort of way,

talking about his expectation of “a sailor with a card.” Speech was

intelligible, though fragmentary and infrequent. The man obeyed

commands but gave no replies to questions. The mental processes were

slow and impaired.

According to Ballard, we have here a case of epileptic confusion, eight

months after the initial concussion. This particular attack ceased

three days later, leaving amnesia for the attack and a certain amount

of mental retardation. The man was not epileptic in temperament and his

personal and family history proved negative.

=Case 84.= (BALLARD, 1917.)

A soldier was buried in a mine explosion, October, 1915, and for

several days thereafter was unconscious or semi-conscious. He emerged

deaf and subject to stammering and a condition termed “neurasthenic.”

The stammering was soon replaced by mutism, which lasted several weeks.

The mutism was then supplanted by epileptic fits.

He was observed by Ballard in a dreamlike, disoriented and inaccessible

state, in which he was anesthetic to pin pricks, lay awestruck, dumbly

following with his finger hallucinatory airplanes. Flexibilitas cerea

was also shown at this time.

Next day he emerged from the dreamlike state with mental processes

somewhat slowed, disorientation for time, amnesia for the attack,

memory disturbance and a return of the stammer. On the next day

following, all these symptoms had disappeared except amnesia for the

attack. Another spell of epileptic fits occurred later. It seems that

the man had had a convulsion thirteen years before and occasional

convulsions since. In fact, he, seven years before, had had what

was called “a stroke” and residuals of a slight hemiplegia were

still present. (There is no statement in the case report relative to

syphilis.)

Emotion; shell fire: Epileptic equivalents.

=Case 85.= (MOTT, January, 1916.)

A man, 19, suffered from shock due to emotional stress and shell fire.

He had terrifying dreams. After a short time, he developed paroxysmal

attacks of maniacal excitement. Just before the first attack he had

been helping in the kitchen, lay down on his bed, went to sleep, woke,

startled, flushed, and sweating, and made for the door as if terrified.

He remained in this state as if suffering from hallucinations of sight

and hearing, and without ability to recognize his wife, the doctors, or

the Sisters. When two strangers in uniform came in to observe him, the

adjutant became violent, as if the uniforms had started terror anew.

The attacks lasted from a few hours to a few days, coming on suddenly,

without apparent cause. One day he tried to get over the wall of the

playground. He came back and buried his head in his hands. Major Mott

spoke to him, whereupon he got up, looking terrified, made for the

door, and four orderlies were required for his restraint. At Napsbury

Hospital, to which he was sent, he made a complete recovery.

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

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

IV. PHARMACOPSYCHOSES

(THE ALCOHOL, DRUG, AND POISON GROUP)

Pathological intoxication.

=Case 86.= (BOUCHEROT, 1915-6.)

A Territorial infantryman, aged 37, was in the habit of drinking a good

deal without getting drunk, and at the front drank a good deal of bad

brandy. He had just taken a considerable quantity when his regiment got

the order to charge. The charge was hardly over when the man became

greatly excited and hallucinated. He thought he was surrounded by

Germans and tried to transfix his comrades with the bayonet. Howling

and struggling he was carried to the rear.

He was soon brought to the asylum at Fleury after howling all night

and seeing the Boches and animals fighting among themselves. His hands

and tongue were tremulous and there were cramps in the calves of his

legs. On the 6th he expressed astonishment to find himself in hospital

and was found to have but slight memory of what had happened. He

remembered, however, that he had tried to kill his comrades. With the

deprivation of alcohol he became rapidly normal and was sent back to

the dépôt in a few days.

_Re_ alcoholism under army conditions, Lépine remarks that alcohol

has played in this war a rôle analogous to that of malaria in the

epidemiology of some countries. Many of the victims are, to start with,

unbalanced subjects and _détraqués_ who are hereditary alcoholics.

Alcoholism, according to Lépine, dominates the pathology of the

interior and has a marked bearing upon conditions at the front. In

fact, alcoholism would have been disastrous in France had not measures

been taken against it; measures still insufficient (1917). More than

one-third of 6000 cases studied by Lépine during three years have

shown alcohol as a sole or, at all events, principal cause of the

difficulty. It would be within reason to state, according to Lépine,

that if we throw in cases in which alcoholism was a partial factor,

more than half, or even more than two-thirds, of the mental cases

had been strongly influenced by alcohol. Lépine thinks there may be

effects like those of anaphylaxis. Certainly, the startling and sudden

effects in so-called pathological intoxication, as in Case 86, suggest

the critical and vehement effects seen in the sensitized anaphylactic

subject.

CHART 4

PHASES OF WAR PSYCHIATRY IN FRANCE

I. Antebellum phase of PSYCHIATRIC NEGLECT: Groundless fear

that recruiting would be disorganized by psychiatric

sifting processes.

II. Phase of ALCOHOLISM OF MOBILIZATION: Hospitals unprepared.

III. Phase of the MARNE: Alcoholism restrained by law;

psychoses few; psychiatrists optimistic.

IV. Phase of TRENCH WARFARE: Overemotionality; and of HIGH

EXPLOSIVES (January, 1915); now psychiatric services were

systematically established along evacuation lines.

V. Phase of SYSTEMATIC WAR PSYCHIATRY: Filterwise system of

management (_a_) near trenches, (_b_) in main body of

army, (_c_) on evacuation lines, (_d_) special hospitals.

Chiefly from data of Chavigny, 1915.

Pathological intoxication: criminal prosecution stopped.

=Case 87.= (LOEWY, 1915.)

An orderly, in private life a teacher, one day about _noon-time_, when

going on duty, called the commanding officer to account because he (the

orderly) had had to wait. He said he had been ordered to come at _two_

o’clock and it was already long thereafter! He was severely reprimanded

but addressed a number of the officers present with questions having

no relation to military service. In fact, he seemed to have forgotten

entirely that he was on military service.

This was the more remarkable as the teacher-orderly had many times

distinguished himself upon dangerous patrol expeditions and in critical

situations, winning the confidence of his superiors and the likelihood

of promotion to corporal. He had been a discreet, earnest, and clever

soldier.

Loewy observed him during this affair and noticed that he did not

by language or movement suggest intoxication or hilarity but merely

a certain excitement. He was entirely oriented for time, place and

person, and his outward behavior was correct enough except for his

military rank.

Sent to his quarters near by, he gave the impression to his immediate

superior officer of deep drunkenness. He murmured something and soon

fell into a deep sleep. After waking, he had an almost complete

amnesia, knowing only that something disagreeable had transpired. He

remembered that he had been offered several little glasses of cognac

brandy by a comrade, and that he had drained them off quickly before

going on duty. He said that he had never drunk cognac before, and in

fact had drunk nothing for a long time.

The diagnosis of pathological intoxication was made, and the soldier

was thereby cleared of his dangerous situation; a criminal prosecution

was not instituted. He thereafter behaved with entire sobriety and

modesty, and he achieved his corporalcy and later became file leader.

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

fugue.

=Case 88.= (LOGRE, July, 1916.)

A “deserter” said: “I went because I drank a glass. I just went,

_comme ça_, without any motive.” He was somewhat feebleminded and,

in explaining the impulsivity of his act, he added: “I went like a

broken-down beast. I walked straight ahead, without knowing where I was

going and if I had been going to be killed, it would have been all the

same to me.” He could not that afternoon remember very well; but next

morning, after having slept, he regained full consciousness. He said

that he then found himself in a field near a cemetery. He had carried

his gun and equipment with him, but had lost them somewhere, and from

a military point of view, his desertion was complicated by loss of

effects. On coming to, he said to himself, “Where am I? How foolish

after fifteen months in the line! Probably I have deserted again.”

In fact, he had a month before left his post under exactly the same

conditions in the midst of a period of alcoholic excitement.

This alcoholic fugue is typical: drunkenness, impulsive and

subconscious ambulatory automatism, with partial amnesia,

disorientation, with mislaying of objects, followed by sleep and

immediate return to normality.

_Re_ fugue, see discussion under Cases 58 and 59. The French military

code cannot excuse victims of fugue even though executed in a quite

unconscious state, if the fugue is due to alcohol. There was a certain

procursive suggestion in the fugue of Case 88, who went “like a

broken-down beast,” straight ahead, without knowing where he was going.

Alcoholism: Amnesia experimentally reproduced.

=Case 89.= (KASTAN, January, 1916.)

February 15, 1915, a German soldier drank beer in the canteen and at

roll-call appeared tipsy. He then went to bed, but rose an hour later

to go to town. A quarter of an hour later, he went to a clerk’s house

and asked for paper, on the ground that the next day he was going to

march to Warsaw. The clerk gave him no paper, which he then tried to

get by force. A policeman arrested him and he said, “You just wait,

lame dog!” Upon examination he denied that he had ever been guilty

of any crime but had been in institutions on account of delirium. In

point of fact, this man had grown up in very bad surroundings, amongst

quarrels and disputes of his parents, who kept a disorderly house. At

19 he had been convicted of incest. He finally admitted having been

convicted for rape. It was found that he had once run out into the

front trenches; had been removed by an advance guard to a stable,

and then wondered why he was not in school. He described a number of

attacks of delirium although he had not drunk more than moderately.

He was given an experimental dose of 50 c.c. of alcohol, and in ten

minutes became excited, tried to get out of bed, attacked other

patients without reason, and was able to speak neither spontaneously

nor in response to questions. In a period of two hours he became clear

and asked what the trouble was. He knew only that he had taken alcohol.

_Re_ the experimental excitement produced in Kastan’s case by the

exhibition of alcohol, it is of note that Bérard has been much

impressed by the agitation that surgical cases of alcoholism undergo

when anesthetized. It may be that the anesthetics act similarly to the

experimental alcoholism of Kastan’s case. According to Bérard, these

phenomena of the anesthetized wounded (who are men recently evacuated

from the front and other hospital cases) are of larval alcoholism

brought out by the anesthesia. Bérard wonders whether rum issues at the

front are at all responsible therefor.

Desertion, drunk. Contributory factors.

=Case 90.= (KASTAN, January, 1916.)

Gottlieb S. left the barracks, January 25, 1915, met friends and drank

with them, remaining all night in the railway restaurant and waiting

room. He was promptly arrested.

According to the patient, he had always drunk a good deal and had once

fallen from his horse in the campaign, and become unconscious. After

this fall, he said he had been able to stand less alcohol than before.

There is doubt as to the syphilis of Gottlieb. He said he had been

infected once, but his further statement that he had six relapses is,

of course, questionable. As to the hypothesis of feeblemindedness,

it appears that in childhood he had learned badly and had been a

stammerer. He had been a herdsman, and after that a laborer. He finally

became a travelling man for a specialty photographer.

He had previously been convicted of an embezzlement, brawling, and

breach of the peace.

As to his military crime, he said he had been celebrating the emperor’s

birthday the last three days, being urged on by acquaintances and

drinking whiskey. He was, in fact, on a spree and did not eat properly.

He had met a student in the railway station and had forgotten all about

his military service. He remembered having spoken with the waiter,

remembered telling the student that he was going to commit suicide, and

the student had drunk seltzer with him. January 29, he for some reason

drank no more, and then it occurred to him that he ought to go back to

duty. He remembered that he was easily led astray. He had once thought

of becoming a tanner but had been dissuaded from the trade because of

its bad smell.

The analysis of this case must consider, first, syphilis.

Supposing, however, that this hypothesis is not substantiated

by laboratory findings, the hypothesis of feeblemindedness

might well be raised. It seems possible, if not probable,

that this patient was in the subnormal group, lying between

normality and feeble-mindedness proper. The value of mental

tests would here be extreme. There seems to be no evident

epilepsy, and the majority of the phenomena can perhaps best be

explained by alcoholism. Possibly the case is one of so-called

pathological intoxication. The patient’s own story that,

although he had been always subject to drink, he had been less

tolerant of alcohol since a fall from his horse, seems to be

entirely consistent with the post-traumatic history of numerous

cases, so that it would hardly be wise to consider that alcohol

accounts for the whole story. We must raise then in succession

the hypothesis of syphilis, feeblemindedness, alcoholism, and

coarse brain disease, bearing in mind also early stammering.

As to the utilization of such a man, it would appear that a

supervision of him with absolute countermanding of alcohol in

view of the decrease in tolerance of alcohol since the fall

from his horse might perhaps preserve this man for some form of

military service.

_Re_ German and French war alcoholism, Soukhanoff remarks that the

conditions in these countries were in strong contrast to those in

Russia. In Russia there was a great decrease in the number of cases of

acute alcoholic psychosis; particularly at the time of mobilization,

there were few cases of alcoholic psychosis. He says that during the

Russo-Japanese war, alcoholic psychoses constituted a third of all the

mental cases observed. This figure corresponds with that quoted above

from Lépine (see under Case 86). Soukhanoff, writing in 1915, had not

observed personally a single case of alcoholic psychosis. Incidentally,

the number of cases of psychosis in the Russian army had remained in

general small.

Desertion by mild alcoholic dement.

=Case 91.= (KASTAN, January, 1916.)

Emil S. made a number of statements when he came for examination.

He had once had a treatment by injections. Both his mother and his

grandmother had been insane. He said that his brother was an officer in

the navy, but this statement was found to be false.

According to his story, he had lost touch with his troop at the end

of September, 1914, and had lived in several lodgings in T---- up to

October 19, when he was arrested. He said that he did not know that a

man who had lost touch with his troop had to report.

A week after his arrest, S. entered a shop and asked for coffee, saying

that he had a furlough of 24 hours and wanted cake for his comrades.

He said he was the owner of an estate and would send a roebuck for the

cakes. The shop-man gave him cakes to the value of one mark. Bystanders

said that he had been lodging in T---- for about two weeks. It seems

that he had told his landlady that a city official had quartered him

upon her and that he was on furlough. He went away in the morning and

came back in the evening. He had written to a bank of which he had

once been a representative, asking for money. One night he had lodged

with another landlady, being given a meal, and he had there stated

that he was in the City of T---- on duty and that his horse was in the

barracks. He offered a thousand marks for his board and lodging.

At another lodging he had given himself out as a courier. In fact,

the letter to the above-mentioned bank had been signed “Otto S.,

Land-owner, at present, courier.”

“If I do not revoke this in person or by writing on January

1, 1915, I beg you to pay to Mr. and Mrs. M. of T----, one

thousand marks and deduct it from my balance.

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

Joseph B.”

The letter was addressed “To the direction of Commercial-Counsellor

P----.” There was no stamp on the letter.

A second letter reads:

“Honored Sir, Commercial Counsellor:

I beg you to send by return mail to the address given below

1000 marks, and deduct this amount from my account. I have been

in Russia. Well, things are moving now. Thank God, we have

reached the point we have. Write me please more in detail about

my property and estate and give me your very valuable advice.

With best regards to your esteemed wife, I remain

Sincerely and respectfully yours,

Otto S., at present courier,

otherwise, land-owner.”

As for this Commercial-Counsellor P., P.’s son stated that his father

had been dead for three years and a half.

S. gave himself out in T---- as a land-owner, falsifying his name,

asking for beer to the amount of a mark a day, borrowing from his

landlady ten marks, paying nothing, but remaining on friendly terms

with the landlady and her women lodgers, making a contract with a

superintendent ostensibly for his estate, and borrowing money from him.

Observed in the clinic, he said he was a bank representative and had

been very nervous since being divorced in 1911. The divorce was due to

his wife’s adultery. Sometimes he would not know really what he was

doing, once even tried to shoot himself, and again once threw a burning

lamp into his wife’s face without knowing it.

He had gone to the City of T---- without furlough in October because

others used to, too. Only five days later had he noticed that his troop

was no longer there; and upon inquiring about the troop he could find

nothing as to its whereabouts.

He had been a heavy drinker and was always somewhat intoxicated, which,

according to the patient, made him forget everything. He had drunk 20

glasses of beer and liquor daily. He wrote to P. because he knew his

father.

As for the frauds, he said he knew nothing about them. He did not know

even the baker from whom he had gotten the cakes. In fact, he had been

drunk the whole day long.

He said that he had learned badly in school and had not passed any

examinations. In active service he had already been convicted of

drunkenness once. Referring to his treatment by injections, he said

he would rather be dead. He had only sought diversion in looking

over estates. Both his ability to reckon and his memory had suffered

greatly. He and another patient eloped from the clinic one day but were

captured a few hours later.

Remarks: Details are lacking as to the physical and laboratory

side of this case. On the whole, there appeared to be no

convincing features of paresis or cerebrospinal syphilis.

The phenomena are very possibly in part alcoholic. There

appeared to be no sensory disorders, and in particular no

hallucinations. The intellectual disorder is chiefly amnestic.

There is little or no evidence of emotional abnormality. The

curious conduct seems hardly to indicate a primary disorder of

will. The main feature psychologically appears to be amnesia

coupled with an inability to reckon. To be sure, the letters

are written externally in sufficiently good form; the amnesia

does not appear to extend to details. It is a question of

whether the disorientation which one suspects is not merely

amnestic. On the whole, however, it would appear that there

must have been at various times disorder of consciousness,

as indeed is indicated by the patient’s own account of his

ignorance of the cake-roebuck episode.

Dismissing the hypothesis of a syphilitic dementia, we might

cling to that of alcoholic dementia more or less punctuated

by acute alcoholism. Yet it is also possible that the patient

was actually somewhat feeble-minded; this would be consistent

with his own statement. The question might arise whether

this soldier could have been excluded by careful psychiatric

examination before entering service. It would seem that a

knowledge of the insanity of the mother and grandmother, and an

inspection of school records, if available,--to say nothing of

the episodes which may or may not have been accurately related,

between himself and his afterwards divorced wife--would have

sufficed to throw doubt upon the military effectiveness of

this man. We know also that he had already been convicted of

drunkenness on military service before the episodes mentioned.

Desertion by alcoholic. Contributory factors.

=Case 92.= (KASTAN, January, 1916.)

Carl B. was a soldier about whom the captain thought that his

intellectual power had been weakened by drink. An inquiry after

arrest showed that he had been odd also at home. He had once been

sued for perjury, but the suit had been stopped for lack of evidence.

He had been several times convicted of drunkenness. It appears that

on March 30, 1915, after mounting guard, he said nothing and went

home, remaining at home until the next day and then returned to

the guardhouse in the street-car. He declared, this time, that the

non-commissioned officer had given him permission to leave, although

this statement was not correct.

Again, on April 6, B. was about to leave the quarters, but the surgeon,

finding him drunk, kept him back. He did not go home that night, and

the next day when he was wanted at the hearing, he could be found only

in the afternoon. He replied confusedly and somewhat irrelevantly to

the questions asked. On arrival at the clinic he was in tears and much

depressed. Given 50 grams of alcohol, he became somewhat livelier.

Upon examination, his perceptions were found diminished; he felt, he

stated, a cracking and crackling in his neck. In his cell he had felt

as if sparrows were roosting in his face; he had heard voices and

seen pictures, and had not known what he was doing. He asserted his

innocence, blaming his imprisonment for all his troubles. He had been

in the habit of drinking three liqueurs and two glasses of beer a day.

He had been drawing a pension since a fall from a scaffold.

A sister had suffered from continual headaches. The patient himself had

three sickly children and ten of his children were dead; there were

also two premature births.

The analysis of this case would clearly show the benefit of

considering, first, the hypothesis of syphilis. Not only is the history

of his children suggestive, but the impairment of mind noted by the

captain as due to alcohol may very possibly be syphilitic in origin.

Examples in division he could not solve, and it is a question whether

his leaving guardmount is not in part related to disorientation for

time. There appears to be no evidence of feeblemindedness and none of

epilepsy (though a sister suffered from continual headaches). Alcohol

may account possibly for the entire picture and is particularly

consistent with the false voices and figures, the sparrows in the

face, and the sensations in neck and the tickling in the ears. It is

possible, also, that intolerance to alcohol had set in since the fall

from the scaffolding for which a pension was being received. It does

not appear necessary to consider any further of the groups of mental

disease. Syphilis, alcohol, and a post-traumatic brain condition, all

may play a part. Alcohol is able probably by itself to produce a number

of these symptoms, and these alcoholic symptoms would be probably the

more readily produced in virtue of the post-traumatic intolerance that

we may assume.

A disciplinary case: Alcoholism.

=Case 93.= (KASTAN, January, 1916.)

A German soldier, brought up for examination for disobedience and

insubordination with intoxication, was found already to have been

convicted 33 times of a variety of crimes. Once he had drunk a bottle

of shoemaker’s polish, evidently with suicidal intent.

In the canteen he had assaulted superior officers and tried to strike a

sergeant. He said he had been attacked by the sergeant and pushed into

a cell, whereupon he had lost his mind.

He came from a family of drunkards, and had been himself very alcoholic

formerly. On the day in question, however, he had drunk very little.

According to his account, he had fits of this sort if any one injured

him. He was amnestic and had forgotten his previous convictions.

Anything he might have done, he said, had happened a long time ago, in

his youth. For example, concerning a theft, he said that it was merely

that he had fallen into some Christmas trees and stuck fast there, and

no one wanted to be paid. Tremors of hands, feet, head. Analgesia of

thorax.