Whenever any other voluntary movement was carried out (even slight

finger movements of the left hand or of the right or left foot

while lying in bed) this right-sided convulsive tremor immediately

disappeared. The movements could also be made to disappear by slight

turning movements of the head or of the tongue. Moreover, when the

mind was diverted, as in reading, the tremors ceased. When the patient

thought intensely of some mathematical problem, he could bring his

shaking to a stop. The left grip was stronger than the right. In the

Romberg position there was a marked swaying to the left and backwards.

Subjectively, the patient complained of nothing but a circumscribed

headache in the left parietal region and of sleep interrupted by

frightful dreams. At first the condition remained unchanged. There was

much insomnia, and the slightest noise caused fright. Headaches in

the daytime also were produced by any noise, and these headaches were

localized in the left parietal region. The tremors of the right hand

persisted except as he caused them to stop as above mentioned. He could

write well with his left hand. He would drum with his left hand on the

table until the tremor of his right hand disappeared. He could play on

the piano, playing first with the left hand until the right had become

quiet. He was a very irritable man, passing into anger and extreme

profanity at the slightest occasion, and it was very difficult to bring

him to any kind of orderly activity or persistence in therapeutic

measures. These consisted of baths, massage, and gymnastics, but they

proved quite unavailing.

As the fellow got more and more intolerable, and as upon May 27 at

about 9 o’clock in the evening, he disturbed the quiet of the entire

hospital by a severe paroxysm of scolding, he was placed in a single

room in the psychiatric department. He was placed in bed, cut off from

all communication with others, and forced to carry out his exercises.

For two days he was surly, crabbed and obstinate, but then changed

his demeanor completely; he became friendly and obedient. The tremor

completely disappeared.

Five days later he was able to carry out all active gymnastic exercises

with great energy and without the slightest disturbance in the right

arm. At date of report he was busy in the garden.

Five weeks’ field service: Loss of speech. Cure by verbal and electric

suggestion in three weeks.

=Case 550.= (SCHOLZ, December, 1916.)

A grenadier, 21, of healthy stock, physique, and habits, lost his

speech, April 15, 1916, five weeks after going into the field. May 5,

examination showed him a well-nourished healthy man (lively reflexes

and slight dermatographia), able to communicate only by signs and

writing. The laryngoscope showed almost complete immobility of the two

vocal cords, which lay in the cadaveric position, as in paralysis of

the recurrent nerves. In endeavoring to pronounce the vowels ā and ee

the cords trembled but failed to move toward each other. The patient’s

effort to speak was such that his head soon got deep red and sweat

streamed from the forehead.

Speech exercises were started by passing the electric current through

the larynx during the processes of laryngoscopy. The patient was

meantime assured that his larynx was healthy and that he would soon

learn to speak again. At the first sitting, the patient felt himself

able to cough aloud.

After a few days, the patient was able to speak the separate vowels

tolerably well, and was then made to go on with such words as Anna,

Otto, Hurrah. The vocal cords began to move better. Fatigue was a

feature of the first treatments, of such a degree that words that could

be pronounced during the first part of the sitting were lost toward the

close.

The grenadier assiduously set himself to say over and over again the

words that he had learned, and would come to the sister radiant with

joy at his success. In ten days he was able to speak again perfectly,

though giving the impression of a slight stuttering. After three weeks

hospital stay he was discharged cured and fit for service.

Struck by a rifle butt on right side of head; old wound of right thigh:

Hysterical right hemiplegia and deafmutism. Treatment by faradization:

Return of speech and improvement of hearing. Full recovery by

suggestion. Hysterical CONVULSIONS developed BY HETEROSUGGESTION from

convulsive neighbor.

=Case 551.= (ARINSTEIN, 1915.)

A Russian corporal, 21, was knocked unconscious, September 13, 1915,

by a butt of a rifle which struck the right side of his head. He came

to in a short time. He was examined in hospital, early in October, and

besides a small skin wound of the head, there was evidence of a wound

on the anterior aspect of the thigh. There was paralysis of both right

arm and right leg, and anesthesia of the entire right side of the body,

face and even of the tongue. There were also pains over the whole

right side of the body. The abdominal reflexes were present on both

sides; the tendon reflexes were in excess on the hemiplegic side; there

were no pathological reflexes of any sort. The patient’s hearing was

diminished, and he could not speak at all although he could understand

the speech of others perfectly.

Speech returned after a single séance of suggestion with faradism to

the throat. Hearing began to improve. The patient’s suggestibility

was a favorable factor in his cure, but there were some unfavorable

features. One day, he saw a neighbor go into convulsions and proceeded

to develop convulsions himself. These hysterical convulsions continued.

According to Arinstein, such undesirable complications appear under

conditions of extreme crowding of hospital patients suffering

from shell-shock. Progressive séances of psychotherapy caused the

disappearance of all the signs of paralysis, and at the time of the

report, there was no disability, except that the full use of the hand

had not yet been regained.

Shell-shock and burial; labyrinthine disease on one side: DEAFMUTISM.

Cures, relapses and eventual cure by general anesthesia, more than four

months after shock.

=Case 552.= (DAWSON, February, 1916.)

A private, 30, had been 12 years in the service. July 8, 1915, he was

partially buried by a shell which killed two companions.

On admission to hospital he spoke a few sentences but was deaf, and

next morning could neither speak nor read, nor did he take food for 36

hours thereafter.

Admitted to the King George Hospital, July 18, he was found stuporous,

but started violently if touched, made signs indicating his wants, took

no interest in surroundings, and resisted efforts to arouse him. He was

without signs of organic disease. It seems that he had been a nervous

child, with nightmares and fits.

July 24, he was given gas for dental extraction, partly in the hope

that he would recover speech; but though he struggled violently, he

made no sound. He had by this time become rather intelligent in a

childlike manner, being pleased to see his small boy, but taking no

notice of his wife. It transpired afterward that he did not recognize

her.

Phonation in whisper now began. There was then a relapse, and for a

week or more no food was taken. Such relapses with irritation and

hypobulia and an obstinate constipation recurred; but improvement

came on slowly. He became able to read short printed words, and later

handwriting.

For another month there was no improvement and he lost heart and the

will to get well, brightening up only when offered a motor drive or

something else pleasant. He was transferred to an auxiliary hospital,

against his will, September 18.

November 1, he was brought back to the King George Hospital, excited,

shouting, struggling and evidently drunk. On a day’s leave from the

convalescent hospital he had come up to London, and in alcoholic

elation began to laugh and talk. Morphia did not reduce his violence.

He insisted on seeing the physician, to tell him the good news. Hearing

was still diminished, though if attention were diverted, direct answers

were given to some questions. Sleep followed.

The next day he spoke perfectly but could hear nothing. There was no

further progress for three weeks, though he occasionally caught sounds.

He now became bright and pleasant and had lost all irritability and

sulkiness. Galvanic and faradic current had no effect on the ears.

November 27, after elaborate preparation to heighten the suggestive

effect, the patient was kept in bed and given gas and ether up to the

abolition of the corneal reflex. As he was coming round, the doctor

shouted that he could now hear well. He was overcome with joy and had

hysterical convulsions. He could hear, but with the right ear only. In

point of fact, the left ear on examination showed signs of labyrinthine

deafness. He was placed on home service.

_Re_ etherization for functional deafness and mutism, Ninian Bruce

maintains that ether is more satisfactory than chloroform. The loss

of consciousness in cases of deafness and mutism ought to be a

relatively slight one, and the patient should be suddenly roused to the

realization that he is speaking. Recovery from chloroform anesthesia

is, according to Ninian Bruce, too slow to allow the patient to catch

the point that he is now speaking and hearing when he was formerly dumb

or deaf. A failure with the method is a bad thing for the patient, as

he loses confidence in the method, whereupon some other method must be

resorted to.

_Re_ etherization for deafmutism, see technic of Ninian Bruce under

Case 553. Penhallow has a case in which during primary etherization the

patient reviewed in a loud voice the whole story of his speech loss.

He was found to have recovered speech and hearing after coming out of

ether.

_Re_ anesthesia by gas, Abrahams has used nitrous oxide for cure of

hysterical paraplegia. Proctor also reports the use of light ether

anesthesia for bringing out the voice of functional mutes.

Shell-shock functional deafness (five months). Yes-No test. Cure by

suggestion on emerging from ether anesthesia.

=Case 553.= (BRUCE, May, 1916.)

A soldier was admitted to the Royal Victoria Hospital, Edinburgh,

completely deaf in the left ear. He had been under shell fire a number

of times in France and was eventually thrown down and made unconscious

by a shell explosion on his left. He did not remember the noise of the

explosion or anything until he found himself in hospital. After the

explosion he had begun to stutter, and the stuttering had grown worse.

Examination of the ear indicated that the deafness was functional. He

was given ether and when just under was asked if he could hear anything

spoken in his right ear. He said, “Yes.” With the right ear closed he

was asked if he could hear when his left ear was spoken into. He said,

“No.” This test was repeated several times. After covering his right

ear, he gave his name, regiment, etc., in reply to questions whispered

into his left (previously deaf) ear. The incongruity was pointed out.

He was now suddenly wakened. He laughed hysterically with joy over his

recovery.

But the next morning he was again stone deaf in the left ear.

Blistering and electricity failed to produce benefit. He was, however,

puzzled about himself.

After a fortnight he was again given ether and a little chloroform was

added. The yes-no test was again positive. He was allowed to recover

gradually from the chloroform, but he had now lost recollection of what

had happened. The left ear remained deaf. Ether was again given. He was

asked to close his right ear with his finger. While answering questions

addressed to his left ear, he was suddenly awakened and immediately

said that his hearing had come back. This return proved permanent. He

returned to his dépôt. In the conversations under ether there was no

stuttering. He had been totally deaf in the left ear for five months.

Blow in neck by rifle butt: aphasia, right hemiplegia and

hemianesthesia, and especially (here MEDICAL suggestion) trismus:

Recovery by anesthetic and suggestion.

=Case 554.= (ARINSTEIN, September, 1915.)

A Russian soldier was struck in the head and neck by a rifle butt, and

developed paralysis of right arm and leg with loss of speech. After the

excitement experienced by the patient when exhibited to the students

by the late Prof. M. N. Szukowsky in the neurological clinic of the

Military Medical Academy, trismus developed.

The patient spent a year in various hospitals, the most diverse methods

of treatment by drug therapy, electricity, and suggestion yielding no

results. The patient had to be fed chiefly by nose and rectum, though

small quantities of fluids were fed through the mouth through an

opening formed by the falling out of one tooth in the upper jaw. The

patient became greatly emaciated and weak and was, October 29, 1915,

brought into the nervous wards of the hospital.

He showed flaccid paralysis of left arm and leg, together with

anesthesia, analgesia and thermanesthesia over the whole left side of

the head, extreme general atrophy of muscles, somewhat more marked on

the palsied side. The temperature of the paralyzed half of the body

was not lowered. No knee or Achilles reflex obtained upon either the

affected or the healthy side (general exhaustion?). Abdominal and

testicular reflexes lively. The pupils responded well to light. Corneal

reflexes lively. The neck was held awry to the left, and the head

was inclined somewhat downwards and leftwards; hearing on left side

impaired. The jaws could not be opened even with the greatest effort.

Wassermann reaction negative.

Patient thought himself incurable. Purves Stewart’s case, in which

chloroform and oxide of nitrogen were used, was the basis of

Arinstein’s treatment. It was suggested to the patient that he submit

to narcosis with the proviso that he would not be operated upon. His

consent was secured; with the coöperation of others, the chloroform

was administered November 6. The stage of excitability was not well

marked. 8 gr. of chloroform was used altogether, by the drop system.

Nevertheless, even with the weak initial excitability, the patient

became capable of some movements with paralyzed hand and foot. On

opening mouth, the patient yawned yet uttered no sound. Between the

jaws was put a rubber insertion and upon awakening the patient was

let see with his own eyes that his jaws were open and that therefore

food might be introduced through the mouth. Upon repetition of the

narcosis, 5 gr. of chloroform was used altogether, and the stage of

excitability was this time better marked. To strengthen movements in

the paralyzed extremities, the device of pricking the patient with a

pin on the unaffected half of the body, with the unaffected hand and

leg held horizontal by assistants, was adopted. The patient then made

reflex defensive movements in the paralyzed extremities, especially the

hand. At this point the narcosis was suspended, and the irritation with

the pin was continued until consciousness returned. At this moment, the

patient’s attention was called to the disappearance of the paralysis

and his restored ability to move the paralyzed extremities.

From that time on, the patient’s condition underwent a sharp

transition. Artificial feeding became unnecessary. The patient ate by

mouth; the mouth was opened by the leverage of a small stick held by

the patient between his teeth. Speech returned gradually. In reading

aloud the patient aided the movements of his lips with his hands. At

the time of report the patient spoke well, ate normally, had gained in

weight, and with some effort could sit down and even stand and walk.

All this was attained in a relatively short time after a whole year of

paralysis.

The author felt that the success attained in this case gave him the

right to use the same method where the cause was not a contusion.

Ten months’ field service; severe FEBRILE DISEASE: Afterward hysterical

TRIPLEGIA, MUTISM, “JUMPING-JACK” reactions to stimulation of feet.

Cure by anesthesia, verbal suggestion, faradism to palate.

=Case 555.= (ARINSTEIN, September, 1915.)

A Russian private, 30, brought to a field reserve hospital, June 20,

1915, was in a grave condition diagnosed typhoid. By the end of June

the general condition had improved and the temperature had fallen.

July 9, worse; happening to be in the company of a sanitary in a

privy, he was observed suddenly to fall unconscious, with both feet

and left arm paralyzed. Soon afterward he lost the power of speech.

From September 30 to October 19, he lay in field hospital; but was

then transferred to the nerve hospital with diagnosis: convulsive

paralysis and aphasia. At entrance, complete paralysis of both legs

and left hand; loss of speech and aphonia (speech understood). Upon

touching a foot, strong convulsions developed with legs rapidly drawn

apart and drawn together much in the manner of dancing toys. The mouth

was twisted to the left. Though he silently opened his mouth and made

rapid movements with the lower jaw, he could not utter a single sound,

either vowel or consonant. Left hypalgesia. Hypesthesia of skin of hand

and mucosa of tongue. Knee-jerks absent because of the strain of the

muscles of the legs. Wassermann negative.

The history showed that the speech of the patient had been incorrect

and indistinct from childhood. Moreover, in 1908, in chopping wood in

the forest he had fallen under a sleigh and hurt his left hand, which

had not since fully recovered. He had volunteered for the war.

The psychogenic character of the disease seemed clear. Suggestion was

followed by ether narcosis, during which, on pricks of the healthy side

with a pin, the patient made defensive movements with the paralyzed

hands, and also moved both legs. Speech was not regained either during

or immediately after the narcosis, although the patient gave forth

indefinite sounds. Speech was restored on the same day, September

7, with verbal suggestion and faradic brush applied to palate. The

patient at once began to speak clearly and distinctly, read his prayer

book, and described distinctly and in detail how he went to war. From

that moment the convulsive movements in the feet disappeared, the

region of anesthesia on the left side narrowed, speech was permanently

reëstablished, and the patient began to move with his feet and finally

began to walk after six months of paralysis. Before that time no

medical treatment had had the slightest effect. The effort to stop

mechanically the jerks even temporarily by means of plaster casts had

been unsuccessful. In sleep the twitches ceased, but upon reawakening,

even before full consciousness returned, the jerkings would resume. It

is curious to note that upon falling asleep under the anesthetic the

patient would issue always one and same kind of yells--“_Help, there

goes the German! They are shooting! Russians, do not yield!_”

_Re_ chloroform anesthesia, Milligan remarks that the treatment should

be carried out in a quiet, single room, with the chloroform slowly

administered and the suggestions made by the anesthetist during the

optimal phase for suggestion,--just before the stage of involuntary

struggling.

Shell-shock; unconsciousness: Mutism and musical alexia. Cure by

anesthesia.

=Case 556.= (PROCTOR, October, 1915.)

A private, 23, was admitted to the Duchess of Connaught’s Hospital at

Taplow from Gallipoli, September 10, 1915. A shell had exploded behind

this man. He had been picked up, unconscious, and remained so about a

day. He recovered without the power of speech. Cerebration was slow at

first but improved steadily.

The man had been a professional musician. Curiously enough, though his

ability to read ordinary print was as good as ever, his reading of

music was lost with the speech.

September 20, he was etherized, but being of a phlegmatic type, he

was not readily excited and took the anesthesia very quietly. After

perseverance, however, he was induced to talk. The ability to read

music returned with the voice. He was discharged, October 4, 1915.

_Re_ the use of anesthetics for curing deafmutism, Colin Russel rather

disapproves of this method on the ground that no attempt is made to get

at the genuine pathogenesis of the case and that accordingly there may

be a tendency to recurrence.

_Re_ the peculiar musical alexia, see discussion under Cases 353 and

450 of confusion and amnesia. The most highly selective amnesias

have been found in confusional cases. However, Case 556 had been a

professional musician and the effect may have been a highly specialized

suggestion. See also Case 369 of Feiling for differentiated musical

disorder. Mott has used the retained knowledge of tones as an avenue of

approach in certain mute cases.

Shell-shock; burial (24 hours?); unconsciousness, 13 days: Deafmutism.

Chloroform narcosis cured the deafness (!), not the mutism.

=Case 557.= (GRADENIGO, March, 1917.)

An Italian infantryman was buried under Mt. Zebio after shell

explosion. After 24 hours he was found and dug out. He remained

unconscious for 13 days and came out absolutely deaf and mute.

At hospital he was markedly depressed and cried very readily on being

spoken to. The tympanic membrane had lost its sensitiveness to pain.

As for the speech mechanism, the larynx proved negative. All the

movements of the soft palate, tongue and vocal cords could be normally

performed. The tongue was anesthetic to touch, but the taste function

was perfectly preserved. The cheeks and various parts of the face were

also anesthetic to touch, and the lobules of the ears could even be

pierced with large pins without reaction by the patient.

He tried to pronounce labials, opening and closing the lips rapidly;

but the expiratory movement was too weak, and not a single sound was

made.

At the patient’s request, he was chloroformed. During a very violent

excited phase, he did emit groaning sounds. The narcosis, however, did

not put an entire stop to the mutism, since only a few inarticulate

sounds could be emitted, and those only after great efforts. Curiously

enough, however, the chloroform narcosis had caused the _deafness_

to disappear entirely. Another narcosis upon the patient’s insistent

request was given but remained without results, and at the time of

report, the patient though cheerful and intelligent-looking, was still

mute.

Treatment of two cases.

=Cases 558 and 559.= (SMYLY, April, 1917.)

A soldier was out with a bombing party when a shell burst. He came to

in a casualty clearing station, and was sent on to Salonica, deaf, dumb

and jumpy. Two months later, an attempt at hypnosis failed; faradism of

vocal cords failed.

The patient dreamed one night that if he vomited he could speak. Ipecac

produced vomiting without speech. The patient, however, wanted a second

dose, and while waiting for it, uttered an exclamation, which he did

not himself hear, however. In the meantime, Dr. Smyly had been trying

to hypnotize a second soldier, dumb but not deaf. This man’s dug-out

had been blown in on him seven months before, whereupon the patient

became very shaky, but did not become sick for a week. He was then

sent to hospital, and his voice gradually disappeared. He suffered

from violent headache and spasmodic movements of the arms and legs.

Suggestion seemed powerless, and ether was unexpectedly given to the

patient. While going under the ether, he said, “Oh dear, oh dear”

several times indistinctly. It seems that another physician had already

tried to cure the patient of dumbness by removing teeth without an

anesthetic.

While this therapy was proceeding with the dumb man, the deaf-and-dumb

man disappeared. It seems that the smell of the gas had caused him to

take refuge on an outhouse-roof. The next day he had recovered voice

and hearing completely, partly from shock and partly through suggestion.

The etherized patient did not recover voice but lost the spasmodic

movements and his insomnia. A week later ether was again administered,

and the patient was strapped down; as he was coming to, faradism was

applied to the head and face. The patient then quickly recovered his

voice and still retains it.

Shell wound: Hysterical dysbasia from contracture. Many methods of

treatment fail. Success with “a new measure,” _e.g._ stovaine.

=Case 560.= (CLAUDE, March, 1917.)

A sergeant was struck in the suprapubic region, December 15, 1915, by a

shell fragment and got a large hematoma in the perineal region (shell

fragment visible on X-ray). The man was treated a year in a center for

physiotherapy and was then treated in a neurological center, where a

faulty position of the right thigh maintained in extensor rotation and

abduction was found. The patient walked on crutches, legs wide apart,

balancing with body.

Upon transfer to Bourges, an intraspinal injection of stovaine (after

withdrawal of 2-3 cc. fluid, 1 cc. stovaine, 0.07 to the cc., mixed

with cerebrospinal fluid) was made. This reduced the contracture and

permitted the patient to place his legs parallel. They were then

bandaged in the parallel position. The bandages were removed two days

later and the limbs did not reassume their faulty position. The man was

shortly able to walk with a cane; progress was rapid. This man was very

desirous of cure and refused to be invalided, believing he was to be

cured, and had received medal and war cross. Simple motor reëducation

in competent hands had been without effect. A new kind of measure, such

as stovaine, proved successful.

_Re_ “new measures” for hysteria, see items under Case 516. See also

remarks upon cures by lumbar puncture under Case 488.

Burial: Hysterical dysbasia. Treatment by stovaine anesthesia.

=Case 561.= (CLAUDE, March, 1917.)

A chasseur, buried June 24, 1916, had a number of general symptoms,

apparently got well and was given seven days’ leave at home. On the way

he felt abdominal pain which he thought due to the jolting of the car.

Suddenly he felt his legs trembling on extension. He left the train

and went into a hospital where a diagnosis of radicular and spinal

lesions was made. Two months later he was sent to Claude who found that

he could walk only with knees flexed. If he was requested to stand up

and extend his legs on the thigh, a trembling set in suggestive of an

epileptoid trepidation. Even in the horizontal position the same clonic

trepidation occurred which only stopped if the patient flexed his legs

on the thighs.

However, no sign of organic lesion could be found. There was an

analgesia limited to the ankles. Psycho-physiotherapeutic treatment was

unavailing. January 28, 1917, the stovaine injection method was tried.

After anesthesia had set in, it was found possible still to produce the

spastic state by extending the legs; but a half hour after injection

the spastic state could no longer be produced. The patient was shown

that the trepidation was abolished. During the period of return of

sensibility, the legs were constantly moved and the patient constantly

told to make movements himself. He was convinced of his power. There

was no longer any clonus. The patient remained all day in bed without

epileptiform movements. Next day he complained merely of weakness in

the legs and was got to walk without having convulsive tremors. During

the next few days he began to walk with a cane, later without support,

and there were no more contractions except transiently in the left leg

if the patient walked a little too long. He left the hospital cured.

Shell-shock deafmutism: Psychic treatment.

=Case 562.= (BELLIN and VERNET, January, 1917.)

A soldier in a colonial regiment was sent, August 14, 1916, to an

evacuation post with a diagnosis “deafness following shell-shock, unfit

for service.” The patient asked that he be spoken to very loud because

he could not hear, and he himself spoke in whispers. He kept watching

his interlocutors’ lips and moved his own as if to pronounce the words.

A shell had burst nearby fourteen months before in June, 1915. After

being in several hospitals, he was sent to an oto-rhino-laryngological

service where he had his hearing reëducated and was taught lip reading.

It was soon perceived that he could hear without lip reading and he

was assured that he could be cured at once, but naturally he was not

convinced. He produced a carefully filed paper stating “atrophic

ozenous rhinitis, deafness from labyrinthine shock following shell

explosion, hearing diminished 60 per cent right, 30 per cent left.”

However, energetic psychotherapy was started and in the absence

of electricity, subcutaneous injections of ether were given. Such

patients had always been cured, and a drug injected under the skin,

not dangerous but extremely painful would cure him! This treatment was

carried out in a dugout near enough to the lines to be daily “potted.”

The patient was left for a space to reflect, and he finally accepted

the chance of cure. He was exhorted to stand courageously the pain and

to breathe deeply and to repeat a word more and more loudly. Finally

he was made to speak normally and eventually to cry out loudly. He now

felt much astonished, and in his astonishment forgot his deafness. He

said that he had never spoken or heard since the accident, that he had

been a deafmute from the first month of his illness, and that for the

last three months he had been able to speak only in a whispered voice.

He should have been watched a few days to confirm the cure. This was

impossible in the crowded dugout and no risk could be run of his

escaping. Kept over night he was found next day unable to hear and

talking in the same voice as before.

He was now found to be either an exaggerator or a simulator. He was

given a half hour to exercise his voice in and told that he must

succeed unless he was a simulator. At the end of half an hour it was

found that he had skipped. He was sent back by the division surgeon

with orders to send him to the otological service for inquiry. The

otological service found an atrophic ozenous rhinitis, a normal larynx,

perfect audition. He was given a psychic X-raying and a few electric

sparks were also drawn from his neck. He then began to talk in a loud

voice and to hear normally. August 30, he was sent out completely cured

and rejoined his regiment.

_Re_ treatment of deafmutism by other means than pseudo operations

and anesthesia, see remarks under Case 556 concerning Colin Russel’s

opinion that anesthesia does not get at the true genesis of cases. _Re_

the teaching of lip reading to Shell-shock deafmutes, see discussion

under Case 580.

Brachial monoplegia. Cure by electrical suggestion (physician

bored-looking, brief, and authoritative).

=Case 563.= (ADRIAN and YEALLAND, June, 1917.)

Adrian and Yealland had occasion to treat an officer with a persistent

functional paralysis of the arm, which had successfully withstood

hypnotism, psychoanalysis, rest, massage, anesthesia with ether, and

painful electrical treatment.

This patient knew something of the functions of the brain and was

prepared to discuss his condition exhaustively. He was told, however,

that he had come to be cured and that the nature of his cure would be

explained to him afterwards. Without further discussion, the motor

areas of the cortex were mapped out rapidly. The measurements were

repeated aloud to impress and mystify the patient. He was assured that

as soon as the shoulder area of the cortex was stimulated faradically,

he would be able to raise his shoulder, and that then the rest of his

arm would recover. An exceedingly mild faradic current was then applied

to the scalp for a few moments and he was then ordered to move his

shoulder. He did so at once. In a few minutes, all of the paralysis had

vanished and the patient could raise 30 pounds. Adrian and Yealland

believe that the success here was largely due to the fact that the

patient was not allowed to discuss the case or criticize the treatment

beforehand.

It is essential that the patient should be convinced that the

physicians understand the case and can cure him. No physical sign

should be examined as if it were interesting or obscure. An attitude of

“mild boredom bred of perfect familiarity with the patient’s disorder”

is cultivated. If the case is exhibited it should be exhibited “as a

perfect example” of the type of case that is cured in five minutes by

appropriate treatment. “Rapidity and an authoritative manner are the

chief factors in the reëducative process.”

_Re_ psychoelectric treatment, see Yealland’s book, published while

this compilation was going to press, _Hysterical Disorders of Warfare_,

1918.

Brachial monoplegia following use of sling after bruise or wound.

Technique of electrical suggestion and rapid reëducation.

=Case 564.= (ADRIAN AND YEALLAND, June, 1917.)

Adrian and Yealland give the following typical case of paralysis of the

arm as a very frequent and very curable form of war neurosis, occurring

as a rule after a slight wound or bruise necessitating the use of a

sling. The patient, having received a slight wound of the forearm,

for months had a useless arm, which he could move but slightly at the

shoulder on exerting a superhuman effort. Occasionally he could flex

the fingers through a small angle. There was complete anesthesia of the

hand and arm of long-glove type. This anesthesia was not complained

of, and might not be noticed until suggested to the patient by the

physician. It is well to elicit the anesthesia, however, in view of the

treatment to be applied. There was no wasting of muscles; the sensory

loss was typical of hysterical anesthesia; nor could the whole arm

have been involved by an injury that did not affect the upper arm and

shoulder.

The patient was told that he was very lucky to have come off with such

a slight injury; his arm was to be set right in five minutes by the

application of a special form of electricity. He was then made to sit

on a large pad electrode connected with an induction coil; the other

terminal is connected with a wire brush. The first effect, he was told,

would be the return of feeling in the forearm; power would return with

the feeling. The wire brush with a fairly strong current was drawn

downwards over the forearm from elbow to wrist. He was told that he

could now feel as far as the wrist, and a pin was used to convince him

that he could thus feel. If he had not felt the pinprick, the current

would have been increased in strength until he could feel. The hand was

now treated in the same way.

He was now told that, as feeling had returned to the arm, the power

of movement would be restored shortly. Adrian and Yealland remark

that laymen seem to consider that loss of power and loss of feeling

are inseparably connected. The electrode was now used to produce

contraction in the muscles. Under these circumstances, the arm will be

used hesitatingly, with an appearance of great effort; but the patient

is nevertheless convinced that power is returning.

“Rapid reëducation follows at once. He is given no time to think, but

urged to move the arm more and more strongly, to grip the physician’s

hand, to flex and extend the elbow, etc., and the pressure is not

relaxed until the whole arm has returned to its normal vigor. If

recovery is stationary, faradization is repeated with stronger and

stronger currents. If it seems as though he might relapse on leaving

the hospital, he is told that this is very unlikely, but that if it

should occur, he should report sick at once and come back for treatment

with a current far stronger than that already used.”

Adrian and Yealland claim that they have applied their combination

of suggestion and reëducation in more than 250 cases (including 82

cases of mutism, 34 of deafness, 18 of aphonia, 37 brachial or crural

monoplegia, 46 paraplegia, 16 hemiplegia, and 18 of non-organic gait

disturbance), and that although a majority of the cases have been

of several months’ standing, treatment has been almost immediately

successful in at least 95 per cent of the cases.

Exposure in the retreat from Mons: Persistent hysterical sciatica.

Treatment by faradism and verbal suggestion.

=Case 565.= (HARRIS, 1915.)

A soldier developed pains about the hips and down the right thigh after

getting wet through in the retreat from Mons, August, 1914. He was

treated for a period of nine months in various convalescent homes and

military hospitals, incidentally receiving forty baths at Droitwich. He

hobbled on a stick, leaning upon the left leg and dragging the right

stiffly. The thigh was tender and hyperesthetic.

The proper treatment of cases of hysteria, according to Harris, is

strong faradism, applied by a small electrode or wire brush to the

moistened skin. The stimulus is made powerful enough to force the

patient to admit that he feels. The theory is that the powerful

stimulation “breaks down the psychical auto-inhibition which produces

the hysterical anesthesia.”

Faradism is only the first phase of the treatment. Verbal suggestion

follows. Building on the basis of the feeling produced by the faradism

or on the basis of the ocular evidence of motion in the hitherto

paralyzed muscles, the patient is informed that the electricity will

now be more and more strongly felt and that he will be cured in a few

minutes.

The two elements in the therapy, then, are: encouraging verbal

suggestion and the suggestion afforded by the paraphernalia of a

complex looking, noisy machine. The knowledge on the part of the

patient that a powerful and mysterious stimulus, namely, electricity,

is being employed is a third element of suggestion.

Persistent hysterical sciatica, such as that of the present case, may

require prolonged treatment. In this instance, the man was completely

cured in five minutes, so that he was made able to run across the room.

He said he would now be able to go back to the front, and wondered why

he could not have been cured before.

Prognosis of intensive reëducation in reflex (physiopathic)

disorder--complete recovery (except for the hysterical fraction of the

disease) not expected.

=Case 566.= (VINCENT, 1916.)

A young soldier was superficially wounded in the left knee, in August,

1914. A year later, he showed amyotrophy of the left calf, which

measured 2.5 cm. less than the right, a weak slow Achilles reflex on

the left side, cyanosis and hypothermia of the left foot, weakness and

limitation of movements in the left foot, with slight contracture in

flexion of leg upon thigh.

Thenceforward and for eight months, this soldier was submitted at

the Tours Centre to intensive reëducation. For two hours every day

upon prescription he walked, ran, and hopped upon the left leg. In

September, 1916, after twelve month’s training, there was a certain

improvement in his disorder. The leg was now completely extended upon

the thigh, and the amplitude in the movement of the foot was almost

normal; but the amyotrophy, vasomotor disorder and certain electrical

disturbances remained quite unchanged. The man himself recognized that

his status was greatly improved, but he could not walk more than four

or five kilometers without great fatigue.

In view of the inferior results of reëducation in some of these cases,

should any attempt at all be made to reëducate? Vincent thinks that

that should be; but that it should be borne in mind that sometimes no

results may be obtained. If the reflex disorder (in the Babinski sense)

is minimal and the chief difficulty is hysterical, then sometimes

the man may go back to service after reëducation; but in intense

examples of reflex (physiopathic) disorder, invaliding has often proved

necessary.

_Re_ values of intensive reëducation, Vincent’s technique and results

have logical resemblances to those of Yealland and of Kaufmann. Vincent

established in the 9th district neurological center a method of

intensive reëducation which is particularly suited to _old_ hysterical

cases. He divides the treatment into three stages: First, the stage

called by the _poilu_ by the picturesque name of _torpillage_;

secondly, the stage of fixation; thirdly, the stage of training.

According to Roussy and Lhermitte, there are few cases at the front

suitable for the treatment of Clovis Vincent, which is especially

devised for the old cases. See under Case 574 for further details of

Vincent’s treatment.

_Re_ prognosis of the physiopathic disorder, there has been some

controversy in France. See discussion under Case 530. _Re_ suitable

treatment for physiopathic disorders, Babinski and Froment suggested

the application of heat. The warm bath test is also of value in

diagnosis. Babinski and Froment claim progressive improvements with hot

baths, hot air douches, and light baths--but counsel great prudence.

The improvement is never rapid.

Wound of calf; operations: hysterical contracture with “physiopathic”

features. “Brutally conquered” by reëducation.

=Case 567.= (FERRAND, March, 1917.)

A French infantryman, class of 1912, was wounded, May 12, 1915, in

the upper third of the right calf. His posterior tibial artery had to

be ligated. In a few weeks the wound was healed, but he began to walk

badly, presenting a contracture of the calf with retraction of the

tendo Achillis.

Toward the last of 1915 a surgeon under the impression that the disease

was organic cut the tendo Achillis but the soldier could not walk any

better. As he could not take the position of equinism, he semiflexed

his knee and walked upon a crutch.

Another surgeon was now found to perform a tenotomy on the flexors of

the leg and put the patient in a plaster cast to correct the flexion

and immobilize in extension. This second operation was in July, 1916.

The patient now walked without a crutch.

He was then sent to a neurological center, Dec. 8, 1916, walking

on two canes, right leg in forced extension on thigh, in permanent

and absolute contracture. All movements except leg flexion could

be executed, though slowly and weakly; but positive movements were

impossible, except flexion of the knees. There was no sensory disorder.

Reflexes were normal save that the leg reflexes were a little stronger

on the affected side, and the patellar reflex on that side was

nullified by the contracture. Electrical reactions proved normal. There

were marked trophic disturbances of the right foot and of the lower

third of the lower leg. There was a certain amount of edema, cyanosis,

coldness and thickening of skin; marked muscular over-excitability of

the distal extremity of the leg. In short, Ferrand was here dealing

with a case of Babinski’s group of the so-called physiopathic cases.

The man was somewhat feeble-minded, and anxious and a trembling

suppliant for cure.

He was put, December 15, in a reëducation room and by means of fatigue,

induced by violent physical exercises, was (Ferrand states) “brutally

conquered.” The contracture after a half hour of physical movement of

flexion and extension of the leg ceased. The patient was shown how

he could himself both flex and extend the limb himself; he was then

caused to do this spontaneously. These active movements were aided and

at times provoked by somewhat painful galvanic discharges. The patient

then walked slowly, and flexed both knees to the maximum. He was cured

after a treatment of 2½ hours. There were, of course, some (surgical)

intra-articular adhesions in the knee and it was necessary for the

patient to break these adhesions. An X-ray had shown the bone to be

intact. A slight hydrarthrosis developed the next day, but a few days

later he was able to walk as well as anyone. For five weeks he followed

a training platoon in the reëducation work and was evacuated, January

23, 1917, to his station, though he had entered the neurological center

with the idea that he was to be invalided with a pension.

He had a few relics of physiomotor disorder when he left, including

the abnormal delicacy of skin and muscular over-excitability above

mentioned. On the basis of this and similar cases Ferrand believes

that, although the physiopathic group of Babinski exists, it does not

signify a separate clinical syndrome and the occurrence of physiopathic

symptoms does not contraindicate psychotherapy.

_Re_ this controversy, see remarks under Case 530.

Shell-shock: Paraparesis. Cure by electricity.

=Case 568.= (TURRELL, January, 1915.)

Turrell, in a paper on electrotherapy at a base hospital, narrates

a case of spinal concussion which rapidly yielded to the persuasive

influence of Bergonié’s machine for electrically provoked exercises.

Turrell grants that such a rapid cure would probably be attributed to

suggestion, but thinks that the term _demonstration_ might be preferred

on account of the vigor and amplitude of the muscular contractions

excited.

This soldier was driving an ammunition wagon at the front, when a shell

exploded under the wagon, killing one horse and severely wounding

the other. The patient himself was blown into the air, fell, dragged

himself to a trench where he lay all night, and found himself in the

morning unable to walk or stand. He recalls that pins were stuck into

his legs by the examining medical officer and that they produced no

sensation. When he was finally brought to the Third Southern Medical

Hospital, he was unable to draw up or move his legs, or to stand up

(yet neurologically normal).

After a few days’ rest in bed, he found himself able to walk a few

steps with assistance, and was then transferred to the Radcliffe

Infirmary for electrical treatment. This treatment consisted in

electrically provoked exercises to the back (positive) and seat and

thighs (negative). He was able to walk back to his ward, leaning on

a wheelchair. Next day he walked to the electrical department with

sticks, and after the exercises were repeated, he was found able to

walk without assistance. On the third day, the Morton wave current was

applied to the back, to clear up any persistent stiffness. The patient

was then discharged on sick furlough.

_Re_ the Morton wave and similar applications of electricity,

Zeehandelaar speaks of a high frequency hall fitted up at Berlin.

Touching the walls of the hall with the finger elicited a powerful

spark. The scheme appeared to be on a commercial basis, and it was

proposed to start similar institutions for poor metabolism and neuroses

in other cities.

A year’s field service, gunshot; typhoid fever: Astasia-abasia:

Lourdes-like cure: Residual amnesia.

=Case 569.= (VOSS, November, 1916.)

A soldier in service from the outbreak of war, shot in September,

1915, afterward suffering from fainting spells, was treated in several

hospitals. He developed a typhoid fever at Lindau, which was at first

taken for hysterical fever. Eventually he came to the observation of

Voss, unable to stand and falling hysteria-wise if compelled to walk.

Thorough examination was made. It was emphatically explained to him

that there could be no reason why he should not stand or walk.

A miracle occurred. From the second day of his hospital stay he

not only walked about but began to polish doors and windows with

inexhaustible strength.

But when he was about to be told that he must now be looked upon as

well, the miracle was not so manifest. It now transpired that he had

serious gaps of memory and disorders in recognition, a sphincter

disorder and ever since his typhoid incontinence with fluid feces.

In short, waking suggestion had caused a very prominent symptom to

disappear, but the total personality remained sick. According to Voss,

the procedures of Kaufmann are dubious just because they cannot stand

the test of time. Yet so far as the cure of this man’s astasia-abasia

was concerned, it was not at all unlike the cures wrought at Lourdes.

_Re_ miracles of this sort, see cases of Colin Russel (503 and 504)

as well as those of Veale (511 and 512). Voss’ arguments run parallel

with the contentions of various persons that the miracle cures (such

as those by anesthesia, electric suggestion, and hypnosis), do not get

sufficiently to the bottom of the affections in question. Buzzard,

in the preface to Yealland’s book on the _Hysterical Disorders of

Warfare_, remarks that the question of the ultimate prognosis in cases

thus suddenly cured must be left unanswered.

Dysbasia after a fall: “Kaufmann” cure in six weeks.

=Case 570.= (SCHULTZE, August, 1916.)

Severe dysbasia, due to monoplegia of the right leg of sudden origin (a

fall), was variously treated 64 weeks without effect.

July 15, 1916, the patient walked in on a stick, and fell down on

trying to walk without. August 1, 1916, at 9 o’clock, he was rapidly

examined: Anesthesia to pain and temperature; inability to lift right

foot; the right knee could be lifted about a hand-breadth above the

body if the foot was supported.

At 9:10, a small electrode was applied: sensibility became normal at

once. Second application: leg raised much better. The man was told

that he was better and that his hand could be put under the heel.

Third application: Leg raised 8 cm. The patient showed pleasure at the

advance. Fourth application (slightly increased strength): Patient

able to stand and to lift knee with flexion at 135° while standing.

Walking exercises under direction. At 9:30, five minutes recess was

given for fatigue, whereupon the exercises were taken up again and

transition made from stationary running to walking without aid as well

as a variety of other associated acts (grasping handkerchief instead of

physician’s hand, and the like). The patient became exhausted after 8

or 9 minutes running about, and another pause was given.

The large brush electrode with stronger current was now given to the

back and to the back of the right leg. Practice in slow walking,

lifting knee, and holding hip joint firm. The patient became tired, but

remained very willing. Exercises in pulling on stockings, in climbing

stairs--the whole concluded at 10 o’clock, whereupon it was found that

the patient could walk alone for a distance of 50 meters. The patient

was a very suggestible one. It was striking that the patient in the

time between 9:35 and 9:40 minutes could walk better on the right

(that is, the previously affected leg) than upon the left. Rest in bed

and phenacetine were ordered, with the suggestion that in the morning

he would walk much better. He became irritated after the treatment but

grew quieter in the afternoon.

On August 3, he was found able to walk well, better when not observed

than when observed. August 5, he complained that his leg was worse

and used a cane, without permission. He was roundly scolded by the

physician and threatened with being sent to bed if he did not practice

earnestly. August 7, he was better, and confessed that he could not

walk as well on command as he could alone; the exercises were nothing

but a fraud and he could go out and beat everything up (_alles

zerschlagen_) if he did not have to carry out such exercises.

August 15, he was much better, quiet, and satisfied. The lameness was

practically gone. August 30, there was no sign of lameness, even when

he was observed. According to Schultze, the Kaufmann method is not

merely an Erb tradition, and rather special measures need to be taken

in executing it.

_Re_ Kaufmann’s cure, Imboden sums up this “highly logical and brutal

method” as a method in which powerful electric shocks and loud military

orders to perform certain exercises secure results. Imboden suggests

that relapses may follow, sometimes on the slightest provocation.

Mann states that Kaufmann’s method of suggestion and electric shock

forms very good treatment; yet Mann states there have been two deaths

under this treatment: in both instances there was an enlarged thymus

at autopsy. A better technique, especially the use of the faradic

current alone, might have avoided these deaths. Mann himself prefers

to Kaufmann’s _Ueberrumpelung_ milder methods, such as rest. Kaufmann

keeps up the sitting until the man is cured, even if it takes two hours

of electricity and staccato commands. For similar persistance, see the

treatment by induced fatigue of Reeve (Cases 489-493).

Wound of shoulder: Heterosuggestion of BRACHIAL paresis. Electrical

suggestion of muscular power. Recovery in five days.

=Case 571.= (HEWAT, March, 1917.)

A reënlisted soldier arrived at the Royal Victoria Hospital, as a case

of ulnar paralysis. He had been wounded in France six months before by

a bullet which passed through the fleshy part of the shoulder, above

the middle third of the clavicle. Power in the right arm gradually

diminished; yet two months after the wound he seemed fit enough to be

sent to Egypt. The paresis developed, and in a month’s time he was

invalided home. He had been unable to use a rifle for months.

The healed bullet wounds were found about the region of the brachial

plexus. The patient was sure the bullet had damaged the nerves in

that region. The right arm and hand were limp and over-inclined to

blueness, and the muscles were flabby. Active movements of all sorts

could be carried out with the arm but not against resistance. There was

a definite anesthesia and analgesia throughout, and responses to touch

and pain stimuli were irregular.

By way of treatment, the patient had the muscles of the paretic arm

stimulated electrically, and at the same time he was told that no nerve

of the neck had been injured. He was greatly surprised to see his

palsied arm move vigorously.

A milk isolation treatment in bed behind screens was adopted, whereat

the patient was angry, looking upon the Weir-Mitchell treatment as

punishment.

On the next day, another electrical application secured complete power

in the arm and abolished sensory disturbance. Three days later the man

went back to full duty. According to Fergus Hewat, someone doubtless

had suggested to this patient that he had received a nerve injury.

He had become obsessed thereby and developed a typical functional

paralysis. This was a “cortical misinterpretation,” which disappeared

upon forcible demonstration of the error.

Exposure; intestinal disorder in weakminded neuropath: Camptocormia and

hysterical paraplegia: Cure by psycho-electric treatment.

=Case 572.= (ROUSSY AND LHERMITTE, 1917.)

A French territorial, 45, was observed at the Centre Neurologique,

August 28, 1916. He was a victim of hysterical paraplegia with tripod

gait. There was a stiffness of the lumbar vertebral column which had

lasted six months. This paraplegia had begun spontaneously after cold

and an attack of diarrhoea followed by constipation. The camptocormia

and disorder of gait had come on gradually in the ambulance. He came

on a stretcher. He was found to be able to walk with great difficulty

by leaning both hands on a cane. The two legs were tremulous in a

pseudospastic gait. The next day, after a single psycho-electric

treatment, cure was complete. This patient was mentally somewhat weak

and a constitutional neuropath. He was discharged, cured, October 20,

1916.

Brachial monoplegia, hysterical (or feigned?). Found able to descend

ladder with arms only.

=Case 573.= (CLAUDE, July, 1916.)

Claude had a case of a soldier with right-sided brachial monoplegia,

which had lasted for 18 months and defied efforts to cure. There was a

question of simulation, and Claude handed the case over to Vincent.

The case came on service, June 20, and was seen June 21. He was then

treated and found able to descend a ladder applied to a wall with the

help of his arms only. On June 24, he was found able to lift a weight

of 10 kilos, and could now write with the right hand, although he had

been writing only with his left. This man had looked like a simulator

to many physicians. He may have been a simulator or an hysteric. In any

case, he was cured.

Vicissitudes of treatment of hysterical brachial monoparesis (shell

burial).

=Case 574.= (VINCENT, July, 1917.)

A French private was buried in a trench upon the explosion of a large

shell, November, 1914. He said he had had a “fracture of the occiput”

and had fainted away without regaining consciousness for several hours.

He was evacuated to Dunkirk, then Saint Nasire, and then to

Sables-d’Olonne. He showed no paralysis or paresis of limbs. During the

first month, he had violent pains in the head, spells and vomiting.

There was a slight aphasic disorder. He was treated by cupping upon the

head and by applications of ice.

After the visit of the inspector general, he was sent to Nantes to be

trephined. Dr. Mathieu regarded an operation as useless. He was treated

with bromides and the faradic current by Miraillé, applied to the right

arm, which had become paretic.

June, 1915, he started on a three-months convalescent leave in Paris.

From October to December, he had electric treatment at the Grand-Palais.

December, 1915, he went to the Salpêtrière under P. Marie, where he was

given electric treatment.

January 1916, he went to Maison-Blanche under Laignel-Lavastine, where

he was given electricity 4½ months.

April 4 he went back to his dépôt.

Presented to the invaliding board, May 11, at Decize, he was sent to

the neurological center at Bourges. He was there given massage and

movements. Upon entrance he had a functional inactivity of the right

arm. He should have been cured a long time before by the therapeutics

employed. He was then sent to Vincent at the neurological center at

Tours for special motor reëducation. Vincent found almost complete

functional incapacity of the right arm, without atrophy, with normal

reactions, no R. D., and normal arterial pressure. June 26, 1916, the

patient was able to write, although slowly. He could sign a letter, and

could lift a weight of 10 kilos.

The details of Vincent’s method mentioned under Case 566 are pursued,

to use his own words, with _methodical ruthlessness_. This form of

reëducation consists in manoeuvres that make the patients yield

despite themselves. The galvanic current is used to force a man to

react voluntarily or automatically. See, for example, Claude’s case of

a hysterical brachial monoplegic (Case 574) found able to descend a

ladder with the use of his arms only. After the physician’s victory is

secured, then a sort of consolidation must be obtained by means of the

execution of certain movements on the part of the patient for an hour

or two. As another factor in the situation set up by Clovis Vincent,

is the enthusiasm generated in the moral atmosphere in which the cure

takes place. Mott has also insisted upon this atmosphere of cure, which

Mott believes is in part responsible for the good results of Adrian and

Yealland. Roussy and Boisseau, at Salins, started out with a process

similar to that of Vincent, with a preliminary period of isolation.

Roussy also uses the faradic current instead of the galvanic (see

remarks of Mann concerning deaths with the Kaufmann method in Germany,

under Case 570). Vincent’s three stages are given in Chart 19, page

897.

Struck by shell fragment; run over by shell; paresis and regionary

sense disorder. Treatment by reëducation.

=Case 575.= (BINSWANGER, July, 1915.)

A German subaltern officer, 27, was wounded September 25, 1914, in a

battle in France. He gave the following account:

“We had been firing without interruption four days, and then were sent

back. While going back from cover we were under shell fire. Three or

four horses fell. I got a glancing blow from a shell fragment in the

back of the head, and fell down. I was not quite unconscious. I tried

several times to get up, but I could not, for I had very bad pains

in the head and a confused feeling in it, too. I remember also that

a wheel ran over my foot, and that I got a sharp blow in the chest.

Then I was unconscious for about an hour. When I awoke, there were two

comrades busy over me and they pulled me back of the firing-line. Then

I got to a field hospital.”

The man arrived at the nerve hospital (Jena), October 8, 1914, with

insomnia, respiratory disturbance, sudden perspiration, feelings of

cold in the right foot, and poor appetite. He had had nausea for a few

days. Lungs and heart proved normal. X-ray of the right foot showed

normal relations. The man was a small, powerfully-built man, well

nourished, with lively reflexes, especially the knee reflexes, of which

the right was greater than the left; slight patellar clonus, right;

left plantar reflex greater than right; segmental disorder of touch

and pain sense in the right foot and lower leg, a zone of analgesia

lying above the zone of total anesthesia. Gait was lame on account of

inability to move the right ankle joint. In walking, the right foot was

trailed.

Treatment was suggestive and supported by active gymnastic exercises,

breathing exercises, exercises in moving the right leg, massage,

faradism and local hydrotherapy. The gait gradually improved, the cold

feeling disappeared from the right leg, disturbances of pain and touch

sense disappeared. The patient was released on the 2d of February,

1915, capable of garrison duty.

With respect to this man, who was married, he was from a healthy family

and had healthy children. He is said, however, to have suffered from

convulsions for a long time in early life, but thereafter had never

been sick in any way. He was a good student and had been a post-office

official since 1908. After two years’ military service, he became, in

1910, _Unteroffizier-Aspirant_. Later he was advanced to his subaltern

position in the reserve.

This case seems to be a characteristic example of segmental disorder of

sensations of both touch and pain, combined with a paresis in the same

region. Mechanical and mental factors seem to have been present, and

the case belongs in what Binswanger calls the “hysterosomatic” group.

_Re_ Binswanger’s so-called hysterosomatic group, he defines the cases

as having emotional, mechanical, and toxic (gas) factors. On the whole,

they are best classified as a kind of psychoneurosis. Binswanger finds

all physical and drug treatment without result except as supportives.

He has used hydrotherapy and electrotherapy with the perfectly clear

conception that the procedures were of suggestive value only. In fact,

Binswanger had before defined such procedures as _Realsuggestionen_ or

material suggestions. Common verbal suggestion, says Binswanger, will

work sometimes only when aided by these material suggestions. See also

under Case 576.

Post-traumatic (ANTEBELLUM) seizures with unconsciousness: Further

seizures, astasia-abasia, anesthesias, following no special period of

stress in field service. Recovery by reëducation.

=Case 576.= (BINSWANGER, July, 1915.)

O. F., 26, healthy, of a healthy family, in military service,

1908-1910, a miner in October, 1912, had fallen into a shaft from a

considerable height, and is said to have been unconscious for three

days and two nights and to have had some sort of attack a short time

after waking. Later he had another attack, beginning with violent

headaches, running from the back to the fore part of the head, then

dizziness, then a fall with unconsciousness. The whole attack lasted

about four minutes and was followed by feelings of extreme fatigue.

It seems that in the spring of 1913 these attacks had begun to repeat

themselves two or three times a week. In the spring of 1914 there had

again been two attacks at an interval of two weeks. They had occurred

on the way to work and had been introduced by the same symptoms as

before. They lasted about half an hour.

He was in the war in France from August 6, 1914. While he was cooking,

one day, in the middle of September, he had an attack and this without

special occasion. The next attack occurred a little while afterwards,

at the time of an assault. He said that he fell down and lost his

senses. When he came to his senses again, he found he could not move

his legs.

He was taken to a reserve hospital in Germany, and while there had

several attacks with unconsciousness and spasmodic convulsions--the

last on December 7, 1914. He was transferred to the Jena Hospital on

the 11th.

The Jena examination had the benefit of an inquiry concerning the case.

It seems that he had left the field hospital in the enemy’s country, in

a half-conscious condition, and rode away therefrom aimlessly. It was

only in Germany that he, on his own story, found his bearings again.

However, upon admission the disturbance in walking was very noticeable,

since the patient came hobbling through the garden of the clinic with

the upper part of his body bent forward, and with the support of two

canes. The legs were moved with difficulty; he seemed to take short,

tripping steps, with the toes dragging on the ground. His inability to

walk he explained through the violent pains which he would feel in the

joints of the legs and an extraordinary weakness in his legs.

Physically, the man was a tall, strongly built and well-nourished

subject. Neurologically, the knee-jerks were somewhat decreased and

weaker on the right side than on the left; the Achilles reflexes

were lively. The plantar reflex was not obtainable on the left side;

decreased on the right. The abdominal reflexes were absent on both

sides.

Most remarkable was the general diminution in sensitiveness of the skin

to touch and pain, involving the whole body, up to the neck, where the

sensory impairment abruptly ceased in a sharp line. The anesthesia

was not everywhere complete. In a few places pencil strokes were

successfully localized and recognized. Deep pin-pricks were everywhere

recognized as itching. When the trunk was everywhere examined on both

sides symmetrically, a strong pressure with a pin-head was felt as a

strong pressure on the right side, but was felt not at all on the left

side. Anesthesia and analgesia were total in the legs. Deep folds of

skin could be punctured by needles without reaction.

The legs could be moved freely upon urgent request with the patient in

dorsal decubitus. Still these movements were slow and difficult, as

explained by the patient, on account of violent pains in the joints.

If put on his feet, he would begin to sway greatly and permit himself

to slide down to the ground, stating that he was quite incapable of

standing or walking without aid. With two canes, however, he could move

freely about in the ward and in the garden, and even with considerable

speed, in a peculiar, dragging, shuffling way; in the execution he gave

no sign of pain, contentedly smoking a cigar or a pipe.

While his status was being taken on admission, he became suddenly dull

and irresponsive, with a staring look. He could not state his age or

his birthplace. However, he became clear shortly, upon urging, and

explained the spell by saying that the blood had risen to his head.

A few days later, he was transferred to the psychiatric division. He

was given strict rest in bed, smoking was forbidden, prolonged baths

were used, and the legs were massaged. He felt very comfortable in the

prolonged baths and could then move his legs without pain.

A few days later he was taken out of bed several times a day, the canes

being removed immediately, and he was led about the day-room with the

light support of two nurses. Being promised a cigar as a reward, he

proved able to walk through the day-room supported by but one nurse.

A week later the pains in walking exercises had disappeared. He had

become able to walk alone, supporting himself lightly along the wall

with one hand. Walking was still uncertain and slow.

December 20, the patient could stand free without support, swaying

slightly; improvement became rapid. He could shortly stand and walk

without support though his walk was still awkward and on a wide base

with knees pressed in and body bent forward, soles were kept applied to

the ground. December 22, the patient could walk in the garden without

aid.

December 23, there was a spell of great weariness and complaint of

being sick. The patient lay down on the bed, cried aloud, and had

rhythmic twitchings and sudden movements with arms and legs. He

scratched the right half of his face with his right hand. This spell

lasted about a minute. It was repeated in the same way twice within the

half hour.

He had complete amnesia for these attacks. The pupillary reactions were

entirely normal in the attacks. He had been in bad spirits that day

because a Christmas furlough had been refused. The attacks provoked

no bad consequences and his gait improved. He was on furlough from

the 30th to January 3; on the 4th he was transferred to the nerve

department, but on the 12th of January he was reprimanded for a breach

of discipline, whereupon at 9:15 he had an hysterical attack with the

same coördinate rhythmic motions as before. This attack lasted about 20

minutes. Two hours before the attack he had complained of weariness and

a boiling-hot feeling in the body. Long walks were taken. On February

15 he began to feel very happy. He was informed that the charge against

him for leaving his troop had been dropped. He complained of sudden

weariness and headache and was markedly depressed, but he had no

hysterical attack.

After February 23 he took part regularly in gymnastics, executing the

movements with joy and without special weariness. He wanted to be

discharged. He was discharged as fit for garrison duty and he has since

gone back to field service.

_Re_ gymnastics, Binswanger holds that they have a special value

in overcoming inner psychic resistances and weak-willed persons.

The _Realsuggestionen_ (see under preceding case, 575), such as

hydrotherapy and electrotherapy, serve to concentrate the person’s

attention on certain regions. These regional suggestions then smooth

the way for the curative suggestion, namely, the constant and

monotonously repeated assurance that recovery is advancing. At the next

stage, according to Binswanger, gymnastic exercises may be brought

in to overcome hopelessness, indifference, or exaggeration of morbid

feelings. Binswanger sets methodical tasks for the attention and the

will (a so-called _Uebungstherapie_). If these gymnastics lead to

manifest improvement, then a proper educational therapy is prescribed,

which is no longer a merely exercise therapy, but consists of actions

of actual value in hospital routine. The convalescents are gradually

led to carry on housework, food service, gardening (the latter under

supervision). Hospital clerical work is a suitable occupation.

_Re_ supervision over gardening, mentioned by Binswanger, Canadian

experience indicates that the idea of supervision may be greatly

extended. Particularly is this true in vocational reëducation. Kidner

describes the functions of a vocational counsellor, who has to have

an expert knowledge of industry and methods of industrial training,

as well as an acquaintance with the varying demands for workers, a

knowledge of the seasonal variations in employment, and a knowledge

of occupational diseases. _Re_ occupational therapy, Todd estimates

that from 0.5 to 1 per cent of wounded men in France will require

vocational reëducation. Occupational therapy is the proper vestibule to

vocational training. He lists the following forms of treatment used in

institutions for vocational reëducation:

Active mechanotherapy.

Passive mechanotherapy.

Galvanic, static, and faradic electricity.

Vibration.

Hot air baths and blasts.

Water baths.

Colored light.

Massage.

Gymnastics.

Central specialized institutions such as those developed in France

are necessary, and such centres should be large rather than small,

according to Todd, and should contain not less than 200 beds. Todd

insists that work is, after all, the most important measure of

reëducation; and Turner, speaking of the home for neurasthenics at

Golders Green, says that during a period of three months (the number of

the patients is limited to 100, and three months is the limit of stay),

the vast majority, even of the most obstinate cases, get well through

the effects of sympathy and insistance upon work. Near Golders Green

is the Maida Vale Hospital for nervous cases, so that in case of need

the physicians there may treat the patients. Salmon gives a list of the

occupations which are suitable for these cases.

Blown up by shell; wounds, right side, distention and bloody urine:

Paresis of right foot and spasticity of hip; later rectal and bladder

incontinence.

=Case 577.= (BINSWANGER, July, 1915.)

A Russian from the Ukraine was received at the nerve hospital, Jena,

December 12, 1914. Through an interpreter it was established that he

was a peasant, had been under shell fire in a skirmish at the beginning

of November, and had been hurled (so he said) 1¼ meters into the air

without loss of consciousness. There was a wound of the right shoulder

and also, he thought, of the legs, from the air pressure. Becoming a

German prisoner, he had been treated in various hospitals.

He was a strong man of medium height, with a healthy complexion. There

were two healed wounds of the right shoulder, and near the twelfth

spinous process a third similar scar. There were a number of ulcers and

furuncles over the os sacrum.

Neurologically, the knee-jerks and Achilles jerks could not be

obtained, and the plantar reflex, extinct on the left, was weak on

the right. Sensitiveness to pain on both sides was lost from the

knee downwards but there was hyperalgesia in the thigh. Inaccurate

statements in response to tactile tests were made, apparently on

account of lack of understanding. In lying down, there was a slight

restriction in the movements of the legs, and active movements of

the joints of the foot on the right side were impossible. Gait was

ataxic-paretic, more markedly so right than left. He could walk only

with two canes, and during walking the musculature of the thigh fell

into a spastic tension. The tongue deviated to the left. There were

severe rheumatic pains in the thighs.

It appears that some weeks before, this Russian soldier had suffered

from severe rheumatic pains in both sides and was at that time

absolutely unable to walk or stand. At that time, however, there was no

question of a crural paraplegia of organic origin, since the man could

move his legs well enough when in dorsal decubitus. There were no

signs of paralysis of the rectum or bladder at that time.

Treatment at Jena consisted in regular walking exercises with support

at the shoulders. The lower legs and feet remained weak and paretic.

The decubital ulcers disappeared.

About the middle of December rectal incontinence began, the stool being

discharged without the patient’s noticing it while being led to the

bath. Later there was incontinence of feces in bed. Pains in the legs

were constantly complained of. Nevertheless improvement in walking was

maintained. The toes were dragged at every step and the knee-joints

were thrown outward in walking. The musculature of the lower legs was

weak. Knee-jerks could not be elicited more than before. He constantly

complained of pains in the knees and right hip. The rectal disorder did

not again occur during January.

Toward the close of January, the patient’s right lower leg and left

foot would occasionally feel asleep; both legs felt cold and itched.

In a general way, however, the pains had become less marked than they

were at first. It seemed that he had no sensations at stool, and

consequently had to resort to the closet at a definite time. Moreover,

urine was discharged irregularly and involuntarily when he coughed. It

appears that a few days after receiving his wounds in battle, there had

been pains on micturition as well as blood in the urine, and it appears

that he had been catheterized. It is probable that he had suffered

from distention, as he described his abdomen, thighs and sex organs as

swollen.

In February he began to be able to move alone with two canes through

the ward, but he moved his legs from the knee downward very little, and

dragged them after the rest of the body. Upon galvanic examination, the

peroneal and tibial nerve trunks were found normally excitable. At this

time the sensibility situation had changed somewhat, since complete

analgesia was present only in the foot, and hypalgesia had developed

upon the anterior surfaces of the lower legs. Pin-pricks were described

as touches. The posterior surface of the left lower leg was normally

sensitive. There was an oblong stripe about 3 cm. long, beginning in

the popliteal space and stretching downward on the left side. The

right lower leg was entirely insensitive. The posterior surfaces of

both thighs as far as the gluteal folds were completely insensible

to pain. The Wassermann reaction of the blood was negative. In this

condition the patient was transferred to a prison camp hospital.

_Re_ bloody urine, see Section B, Case 202. _Re_ rectal incontinence,

it might be inquired whether this was possibly functional. Roussy

and Lhermitte devote a chapter to visceral disorders. They do not

list rectal incontinence amongst the disorders noted in this war, nor

have any cases of hysterical anorexia or disorders of sensation in

the intestinal tract been seen during the war despite the occurrence

of these latter disorders in the civilian group. The main digestive

disorder that the war cases show is vomiting (see Cases 495 and 500).

Emotionality: Shell explosion; mutism. Recovery by reëducation.

=Case 578.= (BRIAND and PHILIPPE, September, 1916.)

A plumber, 27, went into the infantry. He was very emotional and was

but a short time in the trenches when the explosion of shells threw him

into a state of mutism. Deafness, rather curiously, did not manifest

itself for several days. He had to go back on horseback, and, as he was

a poor horseman, slipped off the horse, giving himself a bad fright.

When he got up, he had lost his hearing.

He was sent to several hospitals and finally to Val-de-Grâce, in July,

1915. He recovered hearing in fifteen days, but the mutism persisted

several months. According to Briand and Philippe, this is a typical

case, except for the duration of the mutism. The first treatment was

given this patient August 6. His respiration was examined and tracing

was taken. August 15, on the morning visit, he was found able to

whistle very distinctly the first bars of “Au Clair de la Lune,” and

then began to sing the first verses, articulating distinctly, but

stammering a little. He was now left to his own resources, without

special exercises, from August 15 to September 26, and completely lost

the benefit of his previous exercises. A week of special treatment

allowed him to recover speech again, enough to take up every day life.

The patient went out well.

The general lines of the examination in this case took up attitude

in abdominal respiration and the question of respiratory pauses,

especially pauses in abdominal respiration, which, in the above case,

were exaggerated. Expiration was deficient and disordered. The normal

adaptations that had been established during his childhood learning of

speech had failed, and the patient would not have been able by himself

to regain proper balance of respiration for speech.

The examination was continued to learn the difficulties of innervation

of the muscles of phonation whose proper delicacy had been lost. Such

a patient is a kind of bad gymnast, executing an exercise known to be

hard by contracting all the muscles of the region, both the antagonist

and the agonist muscles. Reëducation must, therefore, endeavor to sweep

away the contractions that block sound. Then the patient must be made

to perform the contractions necessary in phonation and articulation

unconsciously. The methods used for teaching children might here be

employed, but more elaborate and designed methods can be used with the

adult, _e.g.,_

1. Breathing exercises, especially with the idea of making

respiration complete.

2. Blowing exercises.

3. Whistling.

4. Vowel sounding.

Séguin and Rouma, on the other hand, counsel beginning exercises with

consonants in stammerers and dyslalics.

_Re_ tests for functional deafness, Ranjard states that on account of

the complexity of Shell-shock deafness, exact diagnosis needs to be

made. Examination of the hearing by speech alone, or by the watch-tick,

yielded poor results; and an accurate mathematical acoumeter (_Sirène

à voyelles_, Marage) is recommended. See especially chapter on the

functional examination of audition in Bourgeois and Sourdille’s _War

Otitis and War Deafness_, a work translated and highly recommended by

the English otologist, Dundas Grant.

Three days’ skirmish on East front: Unconsciousness, later delirium,

still later (six weeks) stammering, hysterical stigmata: Recovery by

isolation and reëducation.

=Case 579.= (BINSWANGER, July, 1915.)

A traveling salesman in civil life, 36, as a non-commissioned officer

took part in severe fighting in the East shortly after the outbreak of

the war. He was under violent shell fire at one time for five hours at

a stretch. In the middle of November, after a skirmish in the woods

which had lasted for three days, he was found unconscious. According

to his own story, he was awakened from this unconsciousness about a

week later in a hospital. He described himself as quite unable to say

anything about what had gone on during that week.

The medical report on the case stated that he arrived at the hospital,

November 18, in a dormant state of mind. He had appeared markedly

excited and kept incessantly talking about military matters, such as

the placing of machine guns, the occupation of the edge of the woods

by his company, addressing the nurse as “Captain,” and the sister as

“Mrs. Captain,” making as it were an official report to them. He showed

shyness, and always an extreme excitement. His hands and legs were in

constant motion; he complained of headaches and itching finger-tips.

Sleep could be achieved only by drugs. This mental state lasted till

November 26, when he became oriented. Sleep improved, but he complained

of pains in the back of the head.

Upon transfer to a convalescent home, December 5, he was still

occasionally excited and sometimes sleepless. On December 30, the

patient began to stammer; his speech had before this been somewhat

difficult, but the stammering began suddenly; speech was indistinct and

slow; syllables failed to follow one another at like intervals. The

headache at this time radiated from the middle of the top of the head

to the side of the neck. There was a complaint of vibrating pains on

the two sides of the vertebral column, and a feeling of weakness and

unsteadiness in walking. The patient would sway with eyes closed and

turn sidewise. The heart action was tumultuous, the pulse irregular and

uneven.

The patient was transferred back to the reserve hospital on January 2,

1915, whereupon the stammering became worse, sleep restless, and arms

and legs subject to spasmodic pains and twitching. On January 25, he

was removed to the Jena Hospital. He remarked that at the convalescent

home he became very much excited at the Christmas celebration and had

to cry, whereupon his speech became more and more difficult; he could

not find the beginnings of words and had to stammer. Upon admission

he also complained of sharp pains in the soles of the feet and in the

finger-tips.

Neurologically, there was marked dermatographia, the deep reflexes were

increased, abdominal reflexes were absent; there were points of pain

on pressure in both supra-orbital regions, and there was a general

hypalgesia with the exception of the head, the lower legs, the feet,

the scrotum, the penis and the anal region. Pin-pricks were recognized

on the right side only, when the patient was tested bilaterally. They

could be recognized on both sides when the patient was examined on one

side at a time. There was a static tremor on both sides (?). He could

move his arms, but in dorsal decubitus he could move his legs only

jerkily and uncertainly. His gait was waddling with dragging of toes.

There was a marked photophobia. The palatal and swallowing reflexes

were in excess; speech was hesitant and stammering. The first letters

of words, especially initial consonants, could be pronounced with

difficulty, explosively with cheeks blown up, after several attempts.

The consonant would be repeated several times before the vowel could

be added. The patient’s name was Singer, and he would pronounce it: _S

… S … S … Si … n … n … ger_; the last syllable (_ger_) being brought

out with a strong accentuation. The whole process took five seconds.

The word _Flanelllatten_ took 14 seconds. It seems that the patient

had already suffered (in 1907) from nasal catarrh and disturbance of

hearing from stoppage of the Eustachian tubes. Another attack in 1908

had been accompanied by an irritating cough, and there seems to have

been catarrh on the right in 1913, as well as cerumen on the left side.

Treatment: The patient was isolated; in the next few days there was

improvement in the headache. The patient complained of muscular

twitchings, which would occur suddenly in different parts of the body.

On February 1 there was a subjective feeling of happiness since all

pains had disappeared.

The patient was given regular exercises in speaking and there was

gradual improvement in speech. Body-weight increased, regular walks

were taken, and the patient occupied himself with garden work.

By June, 1915, he had still further remarkably improved, working now

all day long, partly in the garden, partly in the hospital office.

Disturbance of speech was not noticed except for hesitation before the

last syllables of long words during comparatively long conversations.

All trace of difficulty in walking had disappeared. In this patient no

hereditary taint could be proved. He appears to have been of normal

development, serving in the army from 1901 to 1903. In his life as a

traveling salesman, there was frequently catarrh of the throat, and

in 1912 there was a marked swelling of the vocal cords with extreme

hoarseness and inability to speak, which condition was cured after

local treatment.

_Re_ hysterical speech and voice disorders, Binswanger has found them

amongst the most obstinate conditions, often persisting when all other

hysterical phenomena have dropped away. He states that apparently the

cure of some of these cases must be postponed until the end of the war.

_Re_ general results of the therapeutic treatment of the war hysterias,

Binswanger states that he has been able to send some cases back to

the front that have successfully stayed there. He has had failures,

however, even amongst men who have had no _mauvaise volonté_ and have

themselves desired to be sent back to the front.

Gordon Wilson observed 250 cases of Shell-shock at the Ypres salient

and on the Somme. Fifty of these cases complained of deafness, and 17

of the 50 were found to have actual nerve deafness. Wilson treated

“fixed idea” cases by hypnotism, and sometimes by cold water run into

the ear. He, in general, divides the cases in to (_a_) cases of nerve

deafness, (_b_) fixed idea cases, and (_c_) malingerers.

Marage states that frequent exposure to the noise of shells for long

periods may produce a permanent deafness, as has long been known

in naval gun-makers and boiler-makers in peace times. He advocates

obturators, a good form being plasticine wrapped in gauze moulded to

the shape of the internal meatus. Celluloid plugs, sometimes used, have

been known to be set afire by the flash of a shell. Cerumen sometimes

protects against deafness, but Mott speaks of the driving of the wax

into the tympanum as a dangerous effect in certain shock cases.

BURIAL by shell explosion: DEAFMUTISM. Treatment: phonetic reëducation.

=Case 580.= (LIÉBAULT, 1916.)

A machine gunner, 26, was buried at Rheims, January 5, 1915, by the

explosion of a large shell bursting over the dugout. He was unconscious

three days and deafmute on coming to, without amnesia but with a

feeling of constriction in the throat.

After fifteen days in the ambulance he was sent for four months to the

Maritime Hospital at Brest, and treated by hypnotism. Seven or eight

sittings had no other result than to fatigue him. There were then three

months of convalescence. Returned to Vannes, September 20, 1915, he

was put into the auxiliaries. As he could not work much he was sent,

December, 1915, to the Hôtel-Dieu at Nantes. Here electric vibratory

massage was given, which secured a few hoarse sounds.

Phonetic reëducation was then undertaken at Prés-à-goutrière, May 10,

and his respiratory capacity increased from 170 the first week to 250

and 300 the following weeks. His blowing strength was raised from 15

to 20 to 25 at the same time. In a few weeks he was much improved and

June 27 passed on to his auditory reëducation. The respiratory capacity

in this man was insufficient. He could not speak, but his respiratory

movements were good and he learned again to speak in a voice as good as

ever.

According to Liébault, it is a general principle that, if the

respiratory capacity is increased, the voice will clear or become

better; but, if the respiratory capacity remains stationary, the voice

will not improve. It is the same with normal persons. A subject with

a very subnormal respiratory capacity cannot speak loudly, but, if

his respiratory capacity approaches normal, he can speak normally.

According to Liébault, all cases of this sort have had some respiratory

anomaly and each case must be systematically examined with the aid of

anthropometric tables, including weight, height and chest capacity.

The vocal disorder is proportionate to the degree of functioning of

the phonating apparatus taken as a whole. It is not merely that the

larynx should be examined, but the motor side of the apparatus, the

respiratory muscles, the resonating apparatus, the lips, the mouth, the

nasal fossæ and the pharynx.

_Re_ curability of different types of war deafmute, Roussy and Boisseau

maintain that the type (_a_) that comes gesticulating, pointing to the

ears, and desirous of writing, is the type that responds most rapidly

to psychotherapy. There are two other types less responsive: (_b_) is

an apathetic type, with impassive and stupid facies, lies immobile

in bed, or sits in a chair in mental confusion; type (_c_) shows a

facies of terror, looks haggard and anxious, confused, disoriented, and

possibly delirious.

_Re_ general treatment of deaf cases, Zange suggests that emotion

should not be aroused by intense auditory impressions, that he

should not be reminded of his shock, and should be kept as cheerful

as possible. Zange states that he found the static electric current

of service, and got good results in hysterical deafness of sudden

development by applying a strong faradic current.

A year’s service; leave: Hysterical aphonia developed at home.

Respiratory gymnastics.

=Case 581.= (GAREL, April, 1916.)

A soldier, 35, went on leave August, 1915. Arriving at his farm, he had

a violent feeling of moral perturbation and suddenly lost his voice.

When he returned from leave he seemed stupid, spoke very few words

and seemed to look about in a vague and undecided way. He was several

months in this state and sent January, 1916, to Saint-Luc.

The vocal cords were there found of a normal color and without

paralysis. “It was, therefore,” remarks Garel, “a nervous aphonia

susceptible of instantaneous cure.” The patient was made to make a

sound in the lowest tone possible. While he was making this attempt,

sharp pressure was exerted upon the lower part of the sternum, to

provoke expiratory reinforcement. The sound emitted was loud, to the

great astonishment of the patient, who, thus aided by suggestion,

shortly began to talk aloud.

In this particular patient a temporary return of voice was readily

obtained, but not maintained. Special exercises had to be instituted,

whereupon the patient immediately fell back into a complete aphonia. He

was then made to scan words, syllable by syllable, executing with his

arms classical movements of respiratory gymnastics, or sometimes with

the utterance of every syllable the epigastrium was manually compressed

or the shoulders suddenly lowered. The patient could now read a book

in a jerky manner, and after a few lines he could read without his

shoulders being pressed.

Another plan was to have the man read or talk while walking. As soon

as he was stopped and accosted, however, he lost his voice again. Up

to the time of report it was impossible to secure a definite return of

voice, as the patient was not willing to associate words with peculiar

movements. It might make him ridiculous. Accordingly, the nurses were

requested not to fulfil requests unless they were made aloud. Recovery

was to be hoped for from this measure.

Wounded: Recurrent stammering: Reëducation.

=Case 582.= (MACMAHON, August, 1917.)

A young English officer, previously cured of stammering while a boy,

fell to stammering again after being twice wounded. The impediment was

of the laryngeal type. When spoken to he was often quite speechless. In

Shell-shock stammering, the chief difficulty according to MacMahon is

in the production of voice consonants and vowel sounds. In mild cases

the trouble is best left alone.

This officer was anxious to pass into the regular army from the reserve

to which he was attached. The stammering prevented this. He was treated

nine months and improved rapidly. He passed through the trying ordeal

of the medical board successfully and went to his regiment.

In severe cases the patient is taught how to fill his lungs properly.

He is taught to acquire an inferior lateral costal expansion in

inspiration. During expiration the abdominal muscles are trained to

contract slowly and strongly, pressing the diaphragm upwards and

drawing the lower ribs downwards and inwards. This steady breathing

produces a sensation of repose in the stammerer. He is not to raise the

upper chest and not to tense the throat, tongue or jaws.

The main vowel sounds are now taught. The main vowel sounds are oo,

oh, au, ah, a and ee. They combine in six ways, oh and oo in the word

wound, ah and ee make the long i, au and ee in boy, oh and oo in road,

a and ee in rain and fair, ee and oo in new and you. There are also

words in which no main vowel or compound sounds appear, which may be

placed either on the open ah position or the closed ee position. Such

words as long, abbot, among, which are on the position of ah and such

words as it, sister, minister which are in the position of ee. The

voice consonants are b, d, g, j, l, m, n, r, v, w, y, z, w being oo

sound and y the ee sound. The breathed consonants are c, f, h, k, p, q,

s, t.

The treatment of stammering intensified by Shell-shock is more

difficult than that of Shell-shock stammering de novo.

Wound of face: Speech disorder. Recovery by reëducation in two months.

=Case 583.= (MACMAHON, August, 1917.)

An officer was wounded under his left eye, October 7, 1916. His speech

was affected only five days later in a casualty clearing station.

Observed by MacMahon, November 5, he was found to speak with great

difficulty and became exhausted after a few words. He was tensing all

the muscles in attempting to speak. Breathing advice was given and

counsel how to relax in the abnormal efforts.

November 12, the officer, who was at Number One London General

Hospital, began to speak with more freedom. “I am getting a bit better.

I feel I must keep quiet, and it comes after a bit. I think far quicker

than I speak.” He said that the breathing exercises had helped him most.

November 15, he still spoke in a rather staccato way; but the words

did not check as they had. In a week further there had been so much

improvement that he was discharged with a prognosis of complete

recovery.

January, 1917, he had recovered.

Shell wound and burial: Camptocormia (psychoelectric treatment

successful in one séance) and lameness (long reëducative treatment

successful).

=Case 584.= (ROUSSY and LHERMITTE, 1917.)

At a Neuropsychiatric Center, September 2, 1916, arrived a chasseur,

29, showing lameness of a pseudocoxalgic type on the left side,

combined with an anterior camptocormia. The whole situation had lasted

a year. The chasseur had been wounded by shell explosion on the left

side and was buried on July 29, 1915. He lost consciousness and had

respiratory trouble and mutism. His arched walk and lameness began

August 20, 1915.

He had a number of terms in hospital and six months at the dépôt. He

was sent back to the front, June 20, 1916, being proposed for auxiliary

work. There was some mental weakness. After one séance of electric

treatment, the improper attitude of the trunk was corrected. The

lameness, however, persisted and required long daily reëducation.

The patient was discharged cured, October 20, 1916, without lameness or

camptocormia. There were a few persistent lumbar pains.

_Re_ treatment of war psychoneuroses, Roussy and Lhermitte recommend

rational and persuasive psychotherapy after the manner of Dejerine,

Dubois, Babinski, and others. Hypnosis, they say, should definitely be

rejected. Mental contagion must be staved off, and Roussy and Lhermitte

believe that almost all cases are curable and should be sent back as

competents.

They maintain that the medical officer himself plays the leading part.

Many patients are “cured” when they find “good masters”; this mastery

of the combined confessor and educator is greatly aided by prestige.

He must speak with authority, with “iron in the velvet glove”; but

with patience and persistence. If a long sitting fails, postpone work

on the pretext of resting the patient. The patient must not be early

threatened with discipline. Even exaggerators and malingerers must be

talked to as if neuropathic.

A careful medical examination, besides correcting false diagnoses and

demonstrating hystero-organic associations, will give the patient

confidence in his physician.

A new patient is more easily cured than an old one. In general,

patients should be treated as soon as possible after the shock.

Contractures are habitually more persistent than paralysis; tremors and

tic are more pertinacious than deafmutism; ante-bellum psychoneuroses

are less easy to treat than cases developed by the war alone.

The neurological centers near the front, with their discipline,

inaccessibility to friends, and nearness to the front, present a

situation which yields easier and quicker cures than the interior; but

after the two-years’ experience which proved this fact, according to

Roussy and Lhermitte, many cases still get sent back into the interior

for many months,--cases that ought to be cured near the front. Cases

having convulsive attacks get confinement in separate rooms; chronic

neuropaths are kept in bed on a milk diet.

The general features of the treatment of psychoneuroses commended by

Roussy and Lhermitte are summed up in what they call the psychoelectric

and reëducative method, divided into four stages: A stage (_a_) of

persuasive conversation; (_b_) isolation; (_c_) faradization; and

(_d_) physical and psychical reëducation. Roussy and Lhermitte got

during six months in one of the army neurological centers, 98 to 99

per cent of recoveries. Clovis Vincent, in a special interior hospital

(see for Clovis Vincent’s treatment, a summary under Case 575). _Re_

the first stage of persuasive conversations, Roussy and Lhermitte

discuss on the day of admission the general nature of the patient’s

condition, and place him in the atmosphere of cure, in contact with

recovered patients. The conversation takes place in the physician’s

consulting room. The patient is gotten to promise on oath that he will

submit to any methods of treatment. Although one may pass from the

first stage to the third or electrical stage, forthwith, Roussy and

Lhermitte recommend several days of isolation. The patient is placed

in a separate room, and kept in bed on a milk diet. This isolation

treatment of Weir Mitchell allows reinforcement of the suggestion by

talks on the medical rounds, allows the patient, perhaps, to beg for

the electrical treatment, which he may have refused at first, and

lengthens the period of observation. According to Roussy and Lhermitte,

spontaneous recovery not infrequently takes place during this phase of

isolation. Lameness of long standing, tremors, and deafmutism disappear.

The third stage is that of faradization, executed by the physician

with only such attendants as may be necessary to support the patient.

At first, the man lies nude upon the bed, but later may be treated

while sitting, standing, walking, or running. Feeble currents are used

at first; later stronger ones. The poles are applied to the affected

parts, and sometimes to especially sensitive parts of the skin, such as

the ears, neck, lips, soles, perineum, and scrotum. Energetic treatment

by the rapid method is indicated in the vast majority of cases,

especially at the front. If a case is seen early, the rapid energetic

treatment almost always cures at once. The success of the method

depends upon the production of a crisis, which ought to be produced

at the first sitting. Sometimes this sitting has to be continued for

hours. Some patients require two or three sittings; some, still more.

Instead of faradism, a cold jet of water, or even painful subcutaneous

injections of ether, may be used.

The fourth stage is that of physical and psychical reëducation,

important in long-standing cases. The various forms of physiotherapy

are carried out by special assistants or head nurses, accompanied by

psychotherapy, and if necessary by electricity. According to Roussy

and Lhermitte, these reëducative methods used alone, without previous

faradic treatment, are not successful. Relapse follows premature

transference from the front to hospitals in the interior, and too early

sick leave.

Shell-shock deafmutism. Speech recovered by suggestion and reëducation;

hearing by reëducation.

=Case 585.= (LIÉBAULT, October, 1916.)

A corporal, 20, was exposed to the shock of an aerial torpedo, January

18, 1916, at Souchez. The torpedo fell a meter away. There was no loss

of consciousness, but the patient was agitated for several hours, not

knowing what he was doing. Evacuated to hospital, he remained several

days in a stupid state. He was completely deaf and remembered poorly

what had happened. He made every effort to speak, but could not. His

head felt on fire. He could not open his mouth well and his lower jaw

was almost in a state of contracture. He felt that his tongue could not

move easily. In this status he remained until February, always trying

to talk, but not succeeding.

He then arrived at Hôtel-Dieu. The mouth was now opening better and

he was in a better general status, though always feeling fatigued.

Vibratory massage was given to the laryngeal region. He was gradually

got to emit a few sounds in a low voice. He was sent, April 26, to

Prés-à-goutrière. He was now somewhat vocal, but at times would become

completely aphonic once more. The voice during the first few weeks of

treatment became better, and the respiratory capacity was increased

from 450 the first week to 460 and 500 in the next two weeks.

May 12, he suddenly lost his voice again and wanted to commit suicide.

However, in three more days he was able to speak normally again and has

had no relapse. He was then put under auditory reëducation and at the

time of report his hearing had slightly improved.

Liébault remarks that during the time when the patient could not speak

his jaw muscles were contracted and his tongue could not mobilize well.

He could think words but could not articulate them. It was accordingly

important to cultivate the normal functioning of these muscles.

Gassing; tracheitis; crash from airplane; unconsciousness: mutism;

stammering. Reëducation; hypnosis.

=Case 586.= (MACCURDY, July, 1917.)

A lieutenant in the Royal Flying Corps, 23, described as “unusually

normal,” a successful business man, athletic, socially popular, had

been for a year in the Infantry. He was caught suddenly in a gas

attack, and, though he recovered after a few days in bed, had a severe

tracheitis and laryngitis. The lieutenant had been very proud of his

voice and its carrying power. He went to a laryngologist in London, who

said that he would never be able to sing again--a matter of some worry.

He soon became an expert airman. In the spring of 1917 he was shot

at by antiaircraft guns in a trip over the enemy’s lines. One of the

wings was hit and so weakened that in landing the lieutenant crashed to

the ground. He was unconscious for three hours and on coming to tried

to shout to his servant in the distance, who, on arrival, found the

lieutenant quite unable to speak.

According to MacCurdy, there was here a conversion hysteria with

regression to the tracheitis that followed the gassing. The mutism

MacCurdy regards as a pathological degree of an effort of protection

for his voice. In hospital three weeks later he learned to whisper a

few words, though with great mental effort. He regained the voiced

sounds by coughing and then saying “ah.” Stammering now developed.

Not more than one or two words could be said at a breath. Training to

say two, three, four and then five letters in one expiration yielded

improvement in the stammering. Under mild hypnosis, to the degree

merely of distraction, normal speech was re-attained. There was no

relapse. Singing was then practiced and in a period of six weeks the

singing voice was virtually as good as it ever had been.

Shell-shock: Loss of consciousness, possibly hemorrhage from head:

Spontaneous gradual recovery from anesthesias in three months: Recovery

from paralysis by reëducation in a few more weeks.

=Case 587.= (BINSWANGER, July, 1915.)

A German youth of 19 volunteered at the outset of the war as a motor

cycle rider. About the end of October, he was hurled from his wheel by

a shell which struck close beside him and exploded, knocking his back

against a pile of beams. He lost consciousness. There may have been

hemorrhage.

He came to, two hours later, in the dressing station, hardly able to

move his limbs. Such movements as he could make were painful. There

was an evident contusion of the back. He had a fainting fit after his

bath in the field hospital and then could get to bed only with support.

Severe pains in the legs, especially in the knee.

In the reserve hospital, there was a second similar fainting spell,

followed by buzzing in the head, feelings of pressure in the chest and

an irregular pulse; all of which phenomena disappeared the morning

after the fit.

A careful examination about the middle of November showed the

persistence of a severe paresis of the left arm, and a less marked

motor weakness of the right arm. Both legs were paretic, and there

were no spontaneous movements of the leg. This paresis of the legs was

combined with complete anesthesia and analgesia. Sensory impairment was

found only in the right arm and trunk, and there was no evidence of

sensory impairment in the left arm. Both motor and sensory disturbances

of the arm disappeared rapidly.

However, at the beginning of December, 1914, the complete insensibility

of the lower extremities up to the groin still persisted. The

anesthesia then began to retreat, so that four days later, the upper

limit of anesthesia was somewhat below the groin. There could be found

a circumscribed area of anesthetic skin over the os sacrum up as far as

the second vertebra of the os sacrum; but the skin around this area,

as well as over each tuber ischii, gave normal sensation.

The anesthesia continued to retreat: to the middle of the thigh at the

middle of December; to a level 3 cm. above the knee-cap at the end of

December; to the upper end of the knee-cap on the right side and the

middle of the left knee-cap, January 1. January 11, the anesthesia had

retreated to a level 10 cm. below both right and left patella. February

8, sensibility in the legs had entirely returned.

While the anesthesia was pursuing this favorable course, the motor

symptoms failed to improve to any marked extent, although active motion

of the legs with the patient in dorsal decubitus had gradually returned

to a limited degree.

The diagnosis upon arrival at the Jena Nerve Hospital was “rheumatism

of the left side of the body and dislocation of the spine.”

The treatment consisted at first of rest in bed and moist dressings of

the legs, but the treatment had to depend greatly upon the diagnosis.

The patient complained of difficult micturition; yet there were no

other positive signs of organic disease, of spine or cord.

Hysteria was the diagnosis preferred to rheumatism, despite the fact

that examination at the Jena Hospital failed to show any disorder in

pain or tactile sense.

The patient was a rather tall man of slender build, with a slightly

accentuated second pulmonic sound, decidedly increased tendon reflexes,

weak plantar reflexes, and many points painful on pressure in various

parts of the head, over the spine, and in the sciatic regions. The

vertebral sensibility to pressure was most acute in the region of

the third, fourth, and fifth thoracic vertebrae. There was a marked

dermatographia. There was no other sensory disorder and no motor

disorder of the arms, though the left hand-grasp was weak. All passive

movements could be successfully carried out with the legs. Upon bending

at the hip, there were subjective feelings of tension in the posterior

parts of the thighs. In active motion there was a marked limitation in

leg movements, which appeared to be executed with great difficulty with

but small excursion and with considerable trembling. The knee-joint

could be flexed only when the sole of the foot had support. The lower

leg could not be extended. The excursion in the joints of the feet and

toes was slight. Muscular strength was in general decreased. There

were no feelings of pain in muscular action but merely feelings of

great effort. Gait was slow, shuffling, unsteady, hesitating and only

possible with support. Fatigue set in after a few steps. In walking,

the legs could hardly be bent at the knee. The soles of the feet

dragged on the ground. The patient was unable to stand upright, and

when placed upon his feet, anxiously and stiffly clung to some support.

Without support, he fell over backwards. When supported he could move

his legs at the hip and lift the feet from their base by bending the

knee-joints. The patient could not sit in a chair or in bed except with

support; otherwise he would fall to the right side. In dorsal decubitus

he complained of pain in the loins.

With this hysterical picture, treatment of a psychotherapeutic nature

was carried out. The patient was given methodical exercises in walking

and standing, during which affirmative suggestions about his new

capacity to walk and stand were given with monotonous repetition.

For the first fortnight he walked with the support of two nurses for

a half hour every day. He was very industrious and willing to execute

this treatment; and later began to exercise with a cane. Two days

later, he omitted the cane and found himself able to walk about without

support. He was shortly able to stand without swaying, although for

some time the walk was upon a rather wide base and somewhat slow and

suggestive of spastic paresis.

The general condition of this patient remained good. His appetite and

sleep were good. After the middle of March, 1915, there were no more

peculiarities in walking, and the patient was able to take somewhat

long walks in the city and vicinity. He applied for work in the airship

division, for which he already possessed some experience.

The youth appears to have been of a normal mental and bodily

development, though his mother is said to have been nervous and a

sister died of convulsions in childhood.

Shell-shock with loss of consciousness: Deafmutism, rhythmic head

movements, anesthesia, asymmetrical areflexia. Recovery by suggestion

with faradism, massage and reëducation.

=Case 588.= (ARINSTEIN, September, 1916.)

A Russian private, 30, literate, lost consciousness upon the explosion

of a large shell, November 10, 1915. He was brought to hospital,

November 14, completely deaf and dumb, and with his head rhythmically

swaying sidewise 60 to 70 times per minute. The swaying ceased during

sleep. The head was carried inclined to the right; there was complaint

of headache. The left leg, the trunk and the hairy part of the head

were anesthetic. The knee-jerks were obtained with difficulty, the

Achilles jerks were lively; the throat and conjunctival reflexes were

absent; the abdominal and cremasteric reflexes were lively. The right

plantar reflex was absent; the left normal. The vision of the right eye

was impaired, and there was a monocular diplopia of this eye. The drum

membranes were pulled in, and the disorder of hearing was explained on

the basis of labyrinthine shock.

After a séance of written suggestion with faradism to neck and small

palate and vibratory massage to throat, speech returned. November 26,

the patient read in a loud voice a written phrase. He did not speak

again independently until early in December, when he read aloud written

matter. The return of spontaneous speech was gradual. Hearing returned

December 5, when he was able to hear in the right ear by means of a

tube. In the sitting posture there was less swaying of the head. If the

patient lay down, rhythmic movements of the head became stronger and

more rapid (120).

Shell explosion; unconsciousness: Amnesia; paralyses. Reëducation.

=Case 589.= (BATTEN, January, 1916.)

A corporal in the Belgian army was mobilized when the war broke out,

and was in action continuously in the retreat from Liège, in the siege

of Antwerp, and finally on the Yser until October 27, 1914, when the

explosion of large shells rendered him unconscious. He recovered

consciousness only in hospital at Calais. Though he was able to see and

hear well, he was dazed and remembered nothing of what had happened. In

fact, he did not understand what was said to him.

In a week’s time, his memory and intelligence returned, save for

periodic attacks in which he was dazed. From the very beginning he had

been quite unable to move his legs, and at first the arms were weak. He

had a series of attacks of violent struggling in November and December,

1914, which the corporal himself called fainting attacks, claiming

that he did not move his legs in the attacks but only his arms. In

fact, he claimed that he could move neither head, body, nor legs, but

only the arms. He said, “Sometimes I try hard and set my teeth, but

I do not know how to move my head and my legs; I try but they do not

move.” Sphincter control was maintained. Although he could see, when he

attempted to read, everything went black.

He was finally admitted to the National Hospital for the Paralyzed and

Epileptic on July 8, 1915, on the service of Major Walshe. He was thin

and wasted. He was firmly convinced, according to the notes of Major

Walshe, that he was seriously paralyzed. He said he could not lift his

head; when his body was lifted, his head fell back, or rather perhaps

was definitely thrown back, lolling about alarmingly. However as he lay

in bed he frequently lifted his head unconsciously and placed his hands

under it. When asked to lift his head, the sternomastoids were strongly

contracted, but at the same time the neck extensors also, so that the

head was stiffly and strongly held in an extended position. Despite

the patient’s statement that he could not move the trunk muscles, he

could turn over readily in bed, and when trying to move the head the

trunk was fixed in a strong opisthotonos, and the abdominal walls were

rigid. When requested to move his legs, he made no movement whatever,

though during head movements the legs were strongly fixed in extension.

On passive movements, there was no active muscular resistance. There

was an indefinite blunting of all kinds of sensations. Reflexes were

normal.

Major Walshe worked hard with the patient, inducing him first to lift

his head from the pillow, and finally to move the legs. In three weeks’

time, the corporal could just sit up, and at the end of another month,

he was able to stand in the walking machine. At the end of a third

month, he was walking upon crutches, and at the end of another, he

could walk upon two sticks with his feet wide apart, moving as if glued

to the floor. To quote Batten, “The corporal will eventually get well

but not, I think, before the end of the war.”

E. EPICRISIS[8]

Così od’ is che solava la lancia

d’Achille e del suo padre esser cagione

prima di trista e poi di buona mancia.

Thus I have heard that the lance of Achilles,

and of his father, used to be occasion

first of sad and then of healing gift.

Inferno, Canto XXXI, 4-6.

[8] Material is here drawn _passim_ from the compiler’s

SHATTUCK LECTURE on =Shell-shock and After=, read before the

Massachusetts Medical Society, Boston, June 18, 1918.

TERMINOLOGY

=1.= =Shell-shock, a lay term, usually refers to the medical entity or

disease-group: functional neurosis, or more briefly, neurosis.=

The history of the term Shell-shock will repeat that of Railway

Spine in the last century; the term will fall into disuse when the

cases subsumed thereunder get their exact medical diagnoses--which,

_statistically speaking_, will prove to be as a rule psychoneuroses,

either hysteria (pithiatism), neurasthenia (nervous exhaustion,

“prostration”), or psychasthenia (obsessive neurosis).

=2.= =But the laity cannot be got to use the term Shell-shock in this

exact sense, because the laity cannot make exact diagnoses.=

In the post-bellum and reconstruction period the physician will need

to guard against regarding all cases _called_ Shell-shock as really

neuroses, merely on the ground that Shell-shock is _probably_ neurosis.

Laymen will in the reconstruction period succumb to the lure of the 100

per cent and gossip about cures and failures in the same loose manner

that is but too familiar in discussions of Lourdes, Christian Science,

the Emmanuel Movement. It will be worth while to preserve a certain

generality and comprehensiveness for the term Shell-shock, which will

stand to medicine as the term weeds stands to botany.

=3.= =In short, keep the connotation but try not for any denotation of

this lay term Shell-shock in the lay mind!=

The dangerous history of the term _dementia praecox_ may be recalled.

Neither _dementia_ nor _praecox_ is an exact term except for the

statistical majority of cases of schizophrenia. Yet does not the layman

hearing the term _dementia_ feel entitled to assume that a victim must

be _demented_ or become so?

=4.= =The term Shell-shock appears to be a perfect term for the

ordinary man, as it means much and little, connotes enormously and

denotes a minimum and casts the lay hearer back upon the expert.=

But confronted by the term _Shell-shock_, the ardent social worker or

the ordinary man fails to get any incorrect notion about the nature,

and especially about the prognosis, of the condition. If there is any

suggestion of prognosis, it is the correct suggestion of curability

possibly conveyed by the suddenness implied in the term shock; but

I defy the ordinary man to get from the ordinary term Shell-shock

very much that denotes anything in particular. All he gets is an

enormous connotation. This connotation may run back for the race into

tree stumps, savages brandishing spears, palatial decorations, the

protrusion of animal spirits, the Leyden jar (sometimes familiarly

known as the “shock bottle”), and the aspen shaking of the man in

fear or its interior equivalent. But whether the slang runs back so

far or no, and whether the shell is a shell of powder or a shell of

fear, and whether the shock is of solid particles or in a moral sense,

the problem is implicitly laid down in the slang (see historical

discussion, Shattuck Lecture).

=5.= =The terminological difficulties are clarified somewhat by the

French distinction of états commotionnels and états émotionnels in the

Shell-shock group.=

The French very neatly distinguish what they term _états commotionnels_

from _états émotionnels_. They think of the _états commotionnels_ or

commotional states much as we think of _commotio cerebri_, that is, of

a physico-chemical happening in the brain of an essentially curable

(or reversible) nature; that is, of something that falls short of

being, as they say, _lésionnel_, namely, as bringing about a structural

lesion. That is, they distinguish a brain with a visible focal lesion

from one which has sustained a physical jar or commotion, and they

distinguish the effects of both of these from the _états émotionnels_

or emotional effects of an injury. The nomenclature here brings out one

of the most fundamental difficulties in the whole field of so-called

Shell-shock, namely, the distinction between structural conditions,

microscopic or macroscopic, on the one hand, and functional conditions

of a psychopathic nature, on the other. The _commotion_ would affect

the neurones themselves in some perhaps invisible but still genuine

physico-chemical way, whereas the _emotion_ would affect these neurones

merely after the manner of the normal emotional life, except that the

neurones would perhaps deliver an excessive stream of impulses.

=6.= =Terminology, especially in the matter of explanations to laymen=

(Americans demand monosyllabic explanations as a preliminary to taking

suggestions!), =is not always assisted to clearness by physicians= on

account of the old ontological fallacy that Charcot insisted on.

Would that the medical profession understood neuroses at their

true value! Only too frequent is the impression on the part of

the profession that _imaginary_ symptoms are by the same token

_non-existent_! I have even heard a physician well-trained in somatic

lines say that Shell-shock did not exist because Shell-shock was

nothing but neurosis, and neuroses were characterized by imaginary

symptoms,--accordingly neuroses, being imaginary, do not exist! All of

which reminds us that many of the profession were entirely skeptical

when Charcot made his original observations. Some men here in America

felt that, whereas hysteria might occur in Paris, it did not occur to

any extent in America. The Shell-shock data of this war will abundantly

prove to the profession the existence of the neuroses, and I feel

that physicians will have to brush up their ontology to the extent of

conceding that _a symptom may be_ in a sense _imaginary and yet not_ in

any sense _non-existent_.

=7.= =Babinski points out a case of hysterical paralysis of a leg

which led the patient to lean so heavily upon his arm as to produce an

organic crutch paralysis.= It would be to no point to argue that the

hysterical paralysis was here non-existent. Of course we shall have to

meet the false analogies drawn from methods of cure. If a paralysis can

be cured in a few minutes by the electric brush, or by hypnosis, or on

emergence from chloroform, or by some other modern miracle.

=8.= =Is it too much to ask the profession not ever to say that this

rapid and seemingly miraculous cure was brought about because the

disease was non-existent?=

DIAGNOSTIC DELIMITATION PROBLEM

=9.= =The delimitation problem=, taken up in Section A, =is not

identical with the differentiation problem=, taken up especially in