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THE
CASE HISTORY SERIES

CASE HISTORIES IN MEDICINE
BY
Richard C. Cabot, M.D.

Third edition, revised and enlarged

DISEASES OF CHILDREN
BY
John Lovett Morse, M.D.

Third edition, revised and enlarged

Presented in two hundred Case Histories

ONE HUNDRED SURGICAL PROBLEMS
BY
James G. Mumford, M.D.

Second Printing

CASE HISTORIES IN NEUROLOGY
BY
E. W. Taylor, M.D.

Second Printing

CASE HISTORIES IN OBSTETRICS
BY
Robert L. DeNormandie, M.D.

Second Edition

DISEASES OF WOMEN
BY
Charles M. Green, M.D.

Second Edition

Presented in one hundred and seventy-three Case Histories

NEUROSYPHILIS
MODERN SYSTEMATIC DIAGNOSIS AND TREATMENT
Presented in one hundred and thirty-seven Case Histories
BY
E. E. Southard, M.D., Sc.D.
AND
H. C. Solomon, M.D.

Being Monograph Number Two of the Psychopathic Department of the Boston State Hospital, Massachusetts. (Monograph Number One was A Point Scale for Measuring Mental Ability by Robert M. Yerkes, James W. Bridges and Rose S. Hardwick. Published by Warwick and York. Baltimore 1915.)

SHELL SHOCK and other NEUROPSYCHIATRIC PROBLEMS
Printed in five hundred and eighty-nine Case Histories
BY
E. E. Southard, M.D., Sc.D.

Being Monograph Number Three of the Psychopathic Department of the Boston State Hospital, Massachusetts

HORSLEY, 1857-1916

DEJERINE, 1849-1917

VAN GEHUCHTEN, 1861-1914

IN MEMORIAM

SHELL-SHOCK
AND OTHER
NEUROPSYCHIATRY PROBLEMS

PRESENTED IN FIVE HUNDRED AND EIGHTY-NINE
CASE HISTORIES

FROM THE
WAR LITERATURE, 1914-1918

BY
E. E. SOUTHARD, M.D., Sc.D.

Director (1917-1918), U. S. Army Neuropsychiatric Training School (Boston Unit); Late
Major, Chemical Warfare Service, U. S. Army; Bullard Professor of Neuropathology,
Harvard Medical School; Director, Massachusetts State Psychiatric
Institute (of the Massachusetts Commission on Mental Diseases);
Late President, American Medico-Psychological Association

WITH A BIBLIOGRAPHY BY
NORMAN FENTON, S.B., A.M.

Sergeant Medical Corps, U. S. Army (Assistant in Psychology to the Medical Director,
Base Hospital 117 A. E. F.); late interne in Psychology, Psychopathic Department,
Boston State Hospital; Assistant in Reconstruction, National Committee for
Mental Hygiene

AND AN INTRODUCTION BY
CHARLES K. MILLS, M.D., L.L.D.

Emeritus Professor of Neurology, University of Pennsylvania

BY VOTE OF THE TRUSTEES OF THE BOSTON STATE HOSPITAL
MONOGRAPH NUMBER THREE
OF THE
PSYCHOPATHIC DEPARTMENT

BOSTON
W. M. LEONARD, Publisher
1919

COPYRIGHT, 1919, BY
W. M. LEONARD

To
THE NATIONAL COMMITTEE FOR
MENTAL HYGIENE
AND
ITS WORK IN
WAR AND PEACE

PREFACE

This compilation was begun in the preparedness atmosphere of the U. S. Army Neuropsychiatric Training School at Boston, 1917-18. This particular school had to adapt itself to the clinical material of the Psychopathic Hospital. Although war cases early began to drift into the wards (even including some overseas material), it was thought well to supplement the ordinary “acute, curable, and incipient” mental cases of the hospital wards and out-patient service with representative cases from the literature.

As time wore on, this “preparedness” ideal gave place to the ideal of a collection of cases to serve as a source-book for reconstructionists dealing with neuroses and psychoses. Shortage of medical staff and delays incidental to the influenza epidemic held the book back still further, and, as meantime Brown and Williams had served the immediate need with their Neuropsychiatry and the War, it was determined to make the compilation the beginning of a case-history book on the neuropsychiatry of the war, following in part the traditions of various case-books in law and medicine.

With the conclusion of the armistice, there is by no means an end of these problems. Peace-practice in neuropsychiatry is bound to undergo great changes and improvements, if only from the influx into the peace-community of many more trained neuropsychiatrists than were ever before available. This is particularly true in the American community by reason of the many good men specially trained in camp and hospital neuropsychiatry, both at home and in the A. E. F., through the enlightened policy of our army in establishing special divisions of the Surgeon-General’s Office dealing separately with those problems.

Though a book primarily for physicians, some of its material has interest for line-officers, who may see how much “criming” is matter for medical experts, by running through the boxed headings (especially of Sections [A] and [B]) and reading the simulation cases. As Chavigny remarks, “shooting madmen neither restrains crime nor sets a good example.”

But parts of the book look ahead to Reconstruction. Surely occupation-workers, vocationalists, war risk insurance experts, and in fact all reconstructionists, medical and lay, must find much to their advantage in the data of [Section D (Treatment and Results)]. Had time permitted, the whole old story of “Railway Spine”—Shell-shock’s congener—might have been covered in a series of cases from last century’s literature, together with others illustrating the effects of suggestion and psychotherapy; but this must be a post-bellum task.

The compiler, who has personally dictated (and as a rule redictated and twice condensed) all the cases from the originals (or in a few instances, e.g., Russian, from translations), hopes he has not added anything new to the accounts. The cases are drawn from the literature of the belligerents, 1914-1917, English, French, Italian, Russian, and—so far as available here—German and Austrian.

I would call the collection not so much a posey of other men’s flowers as a handful of their seeds. For I have constantly not so much transcribed men’s general conclusions as borrowed their specific fine-print and footnotes. The lure of the 100 per cent has been very strong in many authors; but the test of fine-print, viz., of the actual case-protocols, saves us from premature conclusions, and the plan of the book allows us to confront actualities with actualities. One gets the impression of a dignified debate from the way in which case-histories automatically confront each other, say in [Section C (Diagnosis)].

Obligations to the books of Babinski and Froment, Eder, Hurst, Mott (Lettsomian Lectures), Roussy and Lhermitte, Elliot Smith and Pear, and others are obvious. Yealland’s book came too late for sampling its miracles, though cases of his in the periodical literature had already been incorporated in my selection.

Some of the cases in [Section A, I], had already been abstracted in Neurosyphilis: Modern Systematic Diagnosis and Treatment (Southard and Solomon, 1917).

What we actually have made is a case-history book in the newly combined fields now collectively termed neuropsychiatry. The more general the good general practitioner of medicine, the more of a neuropsychiatrist! And this is no pious wish or counsel of perfection. Neuropsychiatry, mental hygiene, psychotherapy and somatotherapy—all these will flourish intra-bellum and post-bellum, in days of destruction and in days of reconstruction. And who amongst us, medical or lay, will not have to deal in reconstruction days with cases like some here compiled? A minor blessing of the war will be the incorporation of mental hygiene in general medical practice and in auxiliary fields of applied sociology, e.g., medico-social work.

Subsidies aiding publication are due to the National Committee for Mental Hygiene; the Permanent Charity Foundation (Boston Safe Deposit and Trust Company); Mrs. Zoe D. Underhill of New York; Mr. H. T. White of New York; and Dr. W. N. Bullard of Boston—to all of these the various military recipients of the book will be under obligations, as well as others who would otherwise have had to pay the great majoration de prix due to war times.

Of those great dead contributors to neurology laid (in the [Epicrisis]) at the feet of the neo-Attila, perhaps only Sir Victor was in a narrow sense the Kaiser’s victim: still, but for the war, they might all remain to us.

By the way, just as I found John Milton had said things that fitted neurosyphilis, so also Dante is observed in the chosen mottoes to have had inklings even of Shell-shock. To the Inferno it was natural to turn for fitting mottoes (Carlyle’s renderings mainly used). The pages might have been strewn with them. A glint of too great optimism might seem to shine—in the pre-Epicrisis motto—from the lance of Achilles with its “sad yet healing gift;” but out of Shell-shock Man may get to know his own mind a little better, how under stress and strain the mind lags, blocks, twists, shrinks, and even splits, but on the whole is afterwards made good again.

E. E. Southard.

Washington,
November, 1918.

INTRODUCTION

The duties of an introducer, whether of a platform speaker to an audience, or of a writer to his anticipated readers, are not always clearly defined. It has been sometimes said that the critic or reviewer may meet with better success if he has not acquainted himself too thoroughly with the contents of the book about which he writes, as in that case he will have a larger opportunity to indulge his imagination, but a critique thus produced may have the disadvantage of possible shortcoming or unfairness. In the case of this volume, however, I have felt it worth while to acquaint myself with its contents, no light task when one is confronted with a thousand pages.

The great war just closing has done much to enlighten us as to the causes, nature, outcome, and treatment of injuries and diseases to which its victims have been subjected. The object of this book is to present both the data and the principles involved in certain neuropsychiatry problems of the war. These are presented in a wealth of detail through an extraordinary series of case records (589 in all) drawn from current medical literature, during the first three years of the conflict. Case reporting is here seen at its best, and the experiences recorded are largely allowed to speak for themselves, although comments are not wanting and are often illuminating.

Many criticisms have been heard on the use of the term Shell-shock as applied to some of the most important psychiatric and neurological problems of the recent war; but that the designation has meaning will be evident if Dr. Southard’s book is not simply skimmed over by the reader, but is studied in its entirety. The symptoms of a very large number, if not the majority, of the cases recorded, had for their initiating influence the psychic and physical horrors of life among exploding shells. As the author and those from whom he has received his clinical supply not infrequently point out, in many cases it would appear that purely psychic influences have played the chief rôle, but in others physical injuries have not been lacking. Much more than this is true: in many instances the soil was prepared by previous defect, disease, or injury, or to use one of Dr. Southard’s favorite expressions, “weak spots” were present before martial causes became operative.

While the contributions to the medical and surgical history of the war have been somewhat numerous in current medical journals and in monographs, few comprehensive volumes have appeared. The reasons for this are not far to seek. The conflict has been of such magnitude, and the demands on the bodily and mental activity of the medical profession have been so intense and continuous, that time and opportunity for the careful and complete recording of experiences have not been often available; but works are beginning to appear in the languages of all the belligerent countries and these will increase in number and value during the next lustrum and decade, although it may be that some of the most important contributions will come after a decade or more is past. The great work before me is one that will leave its lasting impress, not only upon military but on civil medicine, for the lessons to be drawn from its pages are in large part as applicable to the one as to the other.

Looking backward to our Civil War, one is strongly impressed with the fact that the present volume, one of the earliest works of its kind to appear in book form, deals largely with psychiatry and functional nervous diseases, whereas during and after the American conflict the most important contributions to neurology related to organic disease, especially as illustrated by the work of Weir Mitchell and his collaborators on injuries of nerves. This is the more interesting when it is remembered that Mitchell not very long after the close of the Civil War became the most prominent exponent of functional neurology, from the diagnostic and therapeutic sides. To him the profession the world over has been indebted for the development of new views as to the nature of neurasthenia and hysteria and new methods for combating these disorders. In this fact is to be found matter for thought. Those who handled best the neuropsychiatric problems of the present war were in large part qualified not merely by a knowledge of psychology and psychiatry, but far more by a thorough training in organic neurology. The problems of psychiatry can be grasped fully only by those who have a fundamental knowledge of the anatomy, physiology, and diseases of the nervous system.

Dr. Southard, preëminently a neuropathologist, is well grounded in organic neurology, and shows at every turn his capabilities for considering the neuroses, psychoses, and insanities from the standpoint of the neurologist. Moreover, he clearly shows training and insight into the problems of non-neurological internal medicine.

The ideal method of training a student for neuropsychiatric work—if one had the opportunity of directing his course from the time of his entry into medicine—would be to see to it, after a good grounding in the fundamental sciences like anatomy, physiology, and chemistry, that medicine and surgery in their broadest phases first received school and hospital attention; that the fields of neurology, pure and applied, were then fully explored; and that psychology and psychiatry received late but thorough consideration. When after America’s entrance into the world war the writer assisted in preparing medical reserve officers for neuropsychiatric service, those men did best both during their postgraduate work and in base hospitals and in the field, who had built from the bottom after the manner indicated.

At the outset of Dr. Southard’s book, for more than two hundred and fifty pages, the author considers under ten subdivisions the acquired diseases and constitutional defects which may predispose the soldier to functional and reflex nervous disease. Neurosyphilis, on which Dr. Southard and Dr. Solomon have already given us a valuable treatise, the pharmacopsychoses, especially alcoholism, and the somatopsychoses covering fevers like typhoid and paratyphoid, are considered in numerous carefully chosen case reports. The reader needs only to look closely into the case records of the first quarter of the volume to get a knowledge of the affections chiefly predisposing the soldier or civilian to functional and reflex nervous diseases. To those familiar with the medical history of the war it is well known that one of the reasons for the efficiency of the American Expeditionary Force resided in the fact that the preliminary examinations of the recruits received the fullest attention not only from the points of view of acquired and inherited disease, but also from those of special psychiatric and even psychological deficiencies. Our country, however, had for its guidance the experience of nations which were fighting for three years before we entered the arena and in addition had a large surplus of material from which to cull out the weaklings.

Among the predispositional affections considered—besides syphilis, alcohol, and other drug habits, and the somatopsychoses—are the feeble-mindednesses or hypophrenoses, the epilepsies, the psychoses due to focal brain lesions, the presenile and senile disorders, the schizophrenoses including dementia præcox and allied affections, the cyclothymoses like manic depressive insanity, the psychoneuroses, and the psychopathoses. The last two subjects indicated, considered in [special] [chapters], seem to some extent to be receptacles for affections which cannot well be otherwise placed,—hallucinoses, hysteria, neurasthenia, and psychasthenia,—and under the psychopathoses, pathological lying, Bolshevism, delinquencies of various sorts, homosexuality, suicide and self-mutilation, nosophobia, and even claustrophobia with its exemplar who preferred exposure to shell-fire to remaining in a tunnel.

Under the encephalopsychoses are found interesting illustrations of focal lesions and the general effects of infection and toxemia. Cases of brain abscess, of spinal focal lesions, and meningeal hemorrhage are in evidence, aphasias, monoplegias, Jacksonian spasm, and thalamic disease receiving consideration.

All neurologists know the difficulties in diagnosticating epilepsy in the absence of opportunities to see attacks and to receive the carefully analyzed statement of the observers of the patient. All this and much more is well brought out in [the chapter on the epileptoses]. Many epileptics found their way into the armies either through the carelessness of examiners or by suppression of the facts on the part of those who desired to serve.

The fact that an imbecile can shoot straight and face fire comes out in one or two places, but this does not seem to prove that a good rifleman is necessarily an all-round good soldier.

A book like Dr. Southard’s could be made of much use in teaching students, especially postgraduates, by having them, when a particular subject like epilepsy or schizophrenia, for instance, is under discussion, use as collateral reading the case reports of this work.

Dr. Southard’s book will prove useful to many workers—to the medical officer whose duty it is to examine recruits for the service or to pass upon and treat them while in service; almost equally to the medical officer in time of peace; to authors of textbooks and treatises and to contributors to neurological and psychiatric journals; to lecturers and clinical demonstrators; to the examiner for the juvenile courts; and to members of the psychopathic, psychiatric, and neurological staffs of our hospitals.

One is not called upon in an introduction to review at length the contents of the volume, but it may prove of value to the reader to dip here and there into the pages of the work to which his attention is being invited.

It will be remembered that fifty years ago and much later, down to the time of Babinski’s active propaganda in favor of the theories of suggestion, counter-suggestion, and persuasion in hysteria, various affections of a vasomotor and thermic type were included in the list of hysterical phenomena. These and some other phenomena sometimes classed as hysterical, Babinski and those who accord with him now find it necessary to sweep entirely from the domain of hysteria, which being produced by suggestion and cured by counter-suggestion or persuasion cannot include symptoms which are beyond the control of the will and intellect of the patient.

According to the new or rather revived pronouncement, these must be due either to definite organic lesion, or to a disorder of reflex origin, connoting the occurrence of changes in the nervous centers as long ago taught by Vulpian and Charcot. In the records of cases and in the discussions thereon this differentiation receives much consideration.

It is held that the paralysis in the reflex cases is more limited, more persistent, and assumes special forms not observable in hysteria. The attitudes in hysterical palsies conform more to the natural positions of the limbs than do those observed in reflex paralysis. Probably the presence of marked amyotrophies in the reflex nervous disorders is the most convincing factor in separating these from pithiatic affections. These atrophies correspond to the arthritic muscular atrophies of Vulpian, Charcot, Gowers, and others, and cannot for a moment be regarded as caused by suggestion or as removable by counter-suggestion or persuasion. They are influenced, discounting the effect of time and natural recuperation, only by methods of treatment designed to improve the peripheral and central nutrition of the patient. Pithiatic atrophies are slight and probably always to be accounted for by disuse or the association of some peripheral neural disorder with the hysteria. Affections of the sudatory and pilatory systems are more definitely pronounced in reflex cases than in those of a strictly hysterical character.

Some of the facts brought forward by Babinski and Froment to demonstrate the differentiation of reflex paralyses from pithiatic disorders of motion are challenged in the records of this volume by others, as for instance, by Dejerine, Roussy, Marie, and Guillain. Babinski tells us that in pithiatism, properly so designated, the tendon reflexes are not affected. He believes that even in pronounced anesthesia of the lower extremities the plantar reflexes can always be elicited and are not abnormal in exhibition. Dejerine, however, produces cases to illustrate the fact that in marked hysterical anesthesia of the feet plantar responses cannot be produced. I have personally studied cases which lend some strength to either contention. In some of these I was not able to conclude that either the use of the will or the presence of contractions in extension was sufficient to exclude the normal responses.

Differences in muscle tonicity, in mechanical irritability of the muscles, and the presence or absence of fibrotendinous contractions are indications of a separation between the reflex and purely functional cases, as apparently demonstrated in some of the case records. True trophic disorders of the skin, hair, and bones observed in the reflex cases are also said to have no place in the illustrations of pithiatism.

The delver into the case histories of this volume will find numerous instructive combinations of hystero-reflex and organo-hysterical associations which are not to be enumerated in an introduction. The great importance of what all recognize as pathognomonic signs of organic disease—Babinski extensor toe response, persistent foot clonus, reactions of degeneration, marked atrophy, lost tendon jerks, etc.—is, of course, continuously in evidence. Extraordinary associations of hysterical, organic, and reflex disorders with other affections due to direct involvement of bone, muscle, and vessels and with the secondary effects of cicatrization and immobilization are brought out on many pages. In quitting this branch of our subject it might be remarked that considerable changes must be made in our textbook descriptions of nervous diseases in the light of the contributions to the neurology of the present war.

One is reminded in the details of some of the cases of the discussions some decades since on the subject of spinal traumatisms; of the work of Erichsen which resulted in giving his name and that of “railway spine” to many of the cases now commonly spoken of as traumatic hysteria and traumatic neurasthenia; of the rejoinders of Page and his views regarding spinal traumatisms; and of Oppenheim’s development of the symptom complex of what he prefers to term the traumatic neurosis. One who has taken part in much court work cannot but read these case records with interest, for the neurology of the war as presented in this volume and in numerous monographs which are now appearing, throws much light upon many often mooted medicolegal problems. I recall how many able and honest neurological observers have changed their points of view since the early days of Erichsen’s “railway spine,” a pathological suggestion which is said to have cost the corporations of England an almost fabulous sum during a score of years. I recall also that a certain Court of Appeals in one of our states even felt itself called upon to promulgate an opinion intended to exorcise entirely the plea for damages for alleged injuries if it could be shown that these were due to fright. The data of this book do not put weapons entirely into the hands of the attorney and the expert for either the plaintiff or the defendant.

Some of the French writers on the neurology of the war, as illustrated in the records collected by Dr. Southard, have brought to our attention distinctions which they draw between états commotionnels and états émotionnels—happy terms, and yet not sufficient in their invention or in the explanations which accompany them, fully to satisfy the requirements of the facts presented. These writers seem to think of the commotional states as denoting some real disease or condition of the brain, and yet one which is really curable and reversible. They explicitly tell us, however, that these commotions fall short of being lésionnel. After all, is this not somewhat obscure? Is it not something of a return to the period of “railway spine” when one of the comparisons sometimes made was that the injury suffered by the nervous tissues produced in them a state comparable to that of a magnet which had been subjected to a severe blow? At any rate, in commotion thus discussed the nervous structures are supposed to sustain some real injury of a physiochemical character, whereas in the emotional states the neurones are, as Southard puts it, affected somewhat after the manner of normal emotional functioning, except perhaps that they are called upon to deliver an excessive stream of impulses. The latter would be classed among the psychopathic, the former among the physiopathic affections, and yet the distinction between the two is not always quite clear.

In not a few instances of Shell-shock—although these are not numerous, so far as records have been obtained—actual structural lesions have been recorded even in cases in which no direct external injury of a material kind was experienced as a result of the explosion of shells. In others the evidences of external injury were relatively unimportant. Various lesions, in some cases recognizable even by the naked eye, were present. Mott, for example, found not only minute hemorrhages, but in one instance a bulbar extravasation of moderate massiveness, the patient not showing external signs of injury. Cases are also recorded of hematomyelia; others with edematous or necrotic areas in the cord; and still others with lesions of the ependyma or even with splitting of the spinal canal, reminding one of the classical experiments of Duret on cerebral and cerebrospinal traumatisms.

It has been argued that too much stress should not be laid on a few cases of this sort—but are they as few as they seem to be? The fact is that necropsical opportunities are not often afforded. May not such scattered lesions often be present without resulting in death or even in long continued disturbance? There is no essential reason why minute hemorrhages into the brain and spinal cord, and especially into their membranes, may not undergo rapid absorption or even remain unchanged for some time without dire results.

One of the reported cases in which lung splitting occurred from severe concussion without external injury is not without interest in this connection, reminding one, as the commentator says, of those cases of severe concussion in which the interior of a building is injured while the exterior escapes. In the same connection also the cited experiments of Mairet and Durante on rabbits are not without instructiveness. As a result of explosives set off close to these animals, pulmonary apoplexy, spinal cord and root hemorrhages, and extravasations, perivascular and ependymal, and into the cortical and bulbar gray were found. Russca obtained direct and contrecoup brain lesions, etc., in a similar way.

Here and there throughout the book will be found references to symptoms and syndromes which will have a particular interest for the reader—soldier’s heart, trench foot, congealed hand, tics, tremors, convulsions, sensory areas variously mapped, and forms of local tetanus, the last being distinctly to be differentiated from pithiatic contractures and those due to organic lesions of the nervous system. Cases of an affection described by Souques as camptocormia, from Greek words meaning to bend the trunk, were shown to the Neurological Society of Paris in 1914 and later, the main features of this affection being pronounced incurvation forward of the trunk from the dorsolumbar region, with extreme abduction and outward rotation of the lower limbs, pain in the back, and difficult and tremulous walking. In some of these cases, organic lesions of the trunkal tissues were present, but in addition psychic elements played a not unimportant part, and the cases were restored to health by a combination of physical measures with psychotherapy, enforced by electrical applications.

The part of this book given over to [the discussion of treatment] will doubtless to some prove the most interesting section. The presentation of the subject of therapeutics is in some degree a discussion also of diagnosis and prognosis; and so it happens in various parts of the volume that the particular subject under consideration is more or less a reaffirmation or anticipation of remarks under other headings.

Similar results are brought about by various therapeutic procedures. Nonne, Myers, and a few others bring hypnosis into the foreground, although non-hypnotic suggestion plays a larger rôle by far.

Miracle cures are wrought through many pages. Mutism, deafness and blindness, palsies, contractures, and tics disappear at times as if by magic under various forms of suggestion. Ether or chloroform narcosis drives out the malady at the moment when it reveals its true nature. Verbal suggestion has many adjuvants and collaborators—electricity, sometimes severely administered, lumbar puncture, injections of stovaine into the cerebrospinal fluid, injections of saline solution, colored lights, vibrations, active mechanotherapy, hydrotherapy, hot air baths and blasts, massage, etc. Painful and punitive measures have their place—one is inclined to think a less valuable place than is given them by some of the recorders. In some instances the element of suggestion, while doubtless present, is overshadowed by the material methods employed. Persuasion and actual physical improvement are in these cases highly important. Reëducation is not infrequently in evidence. The patient in one way or another is taught how to do things which he had lost the way of doing.

It is interesting to American neurologists to note how frequently in the reports, especially of French observers, the “Weir Mitchell treatment” was the method employed, including isolation, the faradic current, massage, and Swedish movements, hydrotherapy, dietetic measures, reëducative processes, and powerful suggestion variously exhibited, especially through the mastery of the physician over the patient. It is rather striking that few records of Freudian psychoanalytic therapy are presented.

When all is said, however, counter-suggestion and persuasion, in whatever guise made use of, were not always sufficient and this not only in the clearly organic cases, but in those which are ranked under the head of reflex nervous disorders. In these the long-continued use of physical agencies was found necessary to supplement the purely psychic procedures, these facts sometimes giving rise in the Paris Society of Neurology and elsewhere to animated discussion as to the real nature of the cases. The pithiatic features of the case at times disappear, but leave behind much to be explained and more to be accomplished. The cures wrought are not always permanent and in some cases post-bellum experiences may be required to prove the real value of the measures advocated. The reader must study well the detailed records in order to arrive at just conclusions; nevertheless, the tremendous efficacy of suggestion and persuasion stands out in many of the recitals.

Perhaps the author may permit the introducer a little liberty of comment. His non-English interpellations, especially Latin and French, may be regarded by some as overdone or perhaps pedantic, but are rather piquant, giving zest to the text. Diagnosis per exclusionem in ordine is sonorous and has a scholarly flavor, but does not prevent the reader who lives beyond the faubourgs of Boston from understanding that the author is speaking of an ancient and well-tried method of differential diagnosis. Passim may be more impressive or thought-fixing than its English translation, but this to the reader will simply prove a matter of individual opinion. Psychopathia martialis is not only mouth-filling like Senegambia or Mesopotamia, but really has a claim to appreciation through its evident applicability. It is agreeable to note that the book seems nowhere to indicate that psychopathia sexualis and psychopathia martialis are convertible terms.

The [bibliography] of the volume challenges admiration because of its magnitude and thoroughness and is largely to be credited, as the author indicates, to the energy and efficiency of Sergeant Norman Fenton, who did the work in connection with the Neuropsychiatric Training School at Boston, resorting first-hand to the Boston Medical Library and the Library of the New York Academy of Medicine. After Sergeant Fenton joined the American Expeditionary Force, Dr. Southard greatly increased the value of the bibliography by his personal efforts.

This bibliography covers not only the 589 case histories of the book, but it goes beyond this, especially in the presentation of references for 1917, 1918, and even 1919. Owing to the time when our country entered the war, American references are, in the main, of later date than the case histories. They will be found none the less of value to the student of neuropsychiatric problems.

The references in the bibliography number in all more than two thousand, distributed so far as nationalities are concerned about as given below, although some mistakes may have crept into this enumeration for various reasons, like the publication of the same articles in the journals of different countries. The list of references includes French, 895; British (English and Colonial), 396; Italian, 77; Russian, 100; American, 253; Spanish, 5; Dutch, 5; Scandinavian, 5; and Austrian and German, 476. It will be seen, therefore, that the bibliography covers in number nearly four times the collected case studies, most of these records being from reports made during the first three years of the war. The author has wisely made an effort to bring the bibliographic work up to and partially including 1919.

The manner in which the French neurologists and alienists continued their work during the strenuous days of the terrible conflict is worthy of all praise. The labors of the Society of Neurology of Paris never flagged, its contributions in current medical journals having become familiar to neurologists who have followed closely the trend of medical events during the war. Cases and subjects were also frequently presented and discussed at the neurological centers connected with the French and allied armies in France.

It may be almost invidious to specify names, the work done by many was of so much interest and value. Dejerine in the early days of the war, before his untimely sickness and death, contributed his part. Marie from the beginning to the end of the conflict continued to make the neurological world his debtor. The name of Babinski stands out in striking relief. Other names frequently appearing among the French contributors are those of Froment, Clovis Vincent, Roussy and Lhermitte, Léri, Guillain, Souques, Laignel-Lavastine, Courbon, Grasset, Claude, Barre, Benisty, Foix, Chavigny, Charpentier, Meige, Thomas, and Sollier.

For a work of this character not only as complete a bibliography as possible, but a thorough [index] is absolutely necessary, and this has been supplied. The author has not made the index too full, but with enough cross-references to enable those in all lines of medical work interested to cull out the cases and comments which most concern them.

My prologue finished, I step aside for the play and the player, with the recommendation to the reader that he give close heed to the performance—to the recital of the cases, the comments thereon, and the general discussion of subjects—knowing that such attention will be fully rewarded, for in this wonderful collection of Dr. Southard is to be seen an epitome of war neurology not elsewhere to be found.

Charles K. Mills.

Philadelphia, May, 1919.

TABLE OF CONTENTS

A. PSYCHOSES INCIDENTAL IN THE WAR

La divina giustizia di qua punge

quell’ Attila che fu flagello in terra.

Divine justice here torments that Attila, who

was a scourge on earth.

Inferno, Canto xii, 133-134.

The data from all the belligerent countries, collected in this book, go far to prove that, whatever at last you elect to term Shell-shock, you must pause to consider whether your putative case is not actually:

A matter of spirochetes?

The response of a subnormal soldier?

An equivalent of epilepsy?

An alcoholic situation?

A result of neurones actually hors de combat?

A state of bodily weakness (perhaps of faiblesse irritable)?

A bit of dementia praecox?

One of the ups and downs of the emotional (affective, cyclothymic) psychoses?

An odd psychopathic reaction in which the response is abnormal not so much by reason of excessive stimulus as by reason of defective power of response?

On a simpler basis, is not our Shell-shocker just a banal example of hysteria, neurasthenia, psychasthenia; and is not this psychoneurotic more peculiar in his capacity to be shocked than are the conditions that purvey the shocks?

Put more concretely in the terms of available tests and criteria, open to the psychiatrist, does not every putative Shell-shock soldier deserve at some stage a blood test for syphilis? Should we not be reasonably sure we are not facing a man inadequate to start with, so far as mental tests avail? Should we not verify (even at considerable expense of time and money by so-called “social service” methods) the facts of epilepsy and epileptic taint? Of alcoholism? And so on? There can be no two answers to these questions.

Upon the following page is a practical grouping of mental diseases, devised in the first place, not for war psychoses, but for the initial sifting of psychopathic hospital cases. Now the psychopathic hospital group of cases constitutes in peace practice the closest analogue of the mental cases met in active military practice, because the “incipient, acute, and curable”[1] cases, for which psychopathic hospitals are built and which flock to or are sent to the wards and outdoor departments of such hospitals, are precisely the cases that early come forward in active military practice. They are precisely the cases in which that pathological event—whatever it is—we know as Shell-shock may be expected to develop. It is precisely the “incipient, acute, and curable” instances of mental disease which we hope to exclude from our American army by cis-Atlantic winnowing-out at the hands of neuropsychiatric experts—the best preventive we hope both of Shell-shock and of other worse mental conditions, if such there be. Military mental practice plainly deals, not so much with frank and committable insanity, as with mental diseases of a medically milder but a militarily far more insidious nature.

[1] Official phrase for the scope of the Psychopathic Hospital, Boston, Massachusetts.

A further inspection of this grouping of mental diseases shows not only that it contains many conditions not usually termed “insanity” (such as, e.g., feeblemindedness, epilepsy, alcoholism, sundry somatic diseases, psychoneuroses), but that these conditions are presented for practical purposes in a certain seemingly arbitrary order. Without attempting to justify this selection of scope (not too wide for modern psychiatry, most would readily acknowledge), I shall draw out a little further what I consider to be the virtues of the order selected. In the first place, all will concede, some order of consideration of collected data is a prime necessity to the tyro. Without an order of consideration the diagnostic tyro is but too apt to find in the best textbooks of psychiatry (even more easily the better the textbook) all he needs to prove that the case in hand is—almost anything he selects to make his case conform to! And how much more dangerous this debating-society method of diagnosis (by choice of a side and matching a textbook type) may become in the fluid and elastic conditions of psychopathic hospital practice, can readily be observed by one who contemplates the formes frustes and entity-sketches that the “incipient, acute, and curable” group of cases presents.

Chart 1
PRACTICAL GROUPING OF MENTAL DISEASES

The order adopted for these groups (which roughly correspond to botanical or zoological orders) is a pragmatic order for successive exclusion on the basis of available tests, criteria, or information: the actual diagnosis is a product of still further differentiation within the several groups.

The case-histories of this book will show that

(a) most shell-shock is in group [X, Psychoneuroses],

(b) the diagnostic delimitation problem is chiefly against [I. Syphilopsychoses], [III. Epileptoses], [VI. Somatopsychoses],

(c) the finer differentiation problem is between [X. Psychoneuroses] and [V. Encephalopsychoses]. (See [Epicrisis], propositions 9-12, 40-43, 72-73.)

No conclusions are intended to be drawn in these introductory pages. Such conclusions as are risked are placed in the [Epicrisis (see Section E)]. But so much can be said: If we are ever to surround the problem of Shell-shock (intra bellum or post bellum), we must approach it with no artificial and à priori limitations of its scope. We must not even agree beforehand that Shell-shock is nothing but psychoneurosis: that would be a deductive decision unworthy of modern science. In the collection of these cases, I have tried to place the topic upon the broadest clinical base. Samples of virtually every sort of mental disease and of several sorts of nervous disease have been laid down, some obviously not instances of Shell-shock, some mixed with clinical phenomena of Shell-shock, others hard to tell offhand from Shell-shock—the whole on the basis that we shall earliest learn what Shell-shock, the pathological event, is by studying what it is not. As the sequel may show, we are perhaps not entitled to regard Shell-shock, the pathological event, as always associated with shell-shock, the physical event. We shall, therefore, find in [Section A] (see tables on pages [6] and [7]).

(1) Cases without either physical shell-shock, or pathological Shell-shock—psychoses of various kinds incidental in the war (--+).

(2) Cases with physical shell-shock but without pathological Shell-shock—psychoses of various kinds seemingly liberated by, aggravated by, or accelerated by the physical factor of shell-shock (+-+).

(3) Cases without physical shell-shock but with both symptoms of pathological Shell-shock as well as of other psychosis (-++).

(4) Cases with physical shell-shock, with clinical phenomena of Shell-shock, as well as of other psychosis (+++).

At the end of [Section A], accordingly, we shall be left with two more formulae for discussion in Sections [B], [C], and [D], viz:

(5) Cases without physical shell-shock but with symptoms of pathological Shell-shock (-+-).

(6) Cases with physical shell-shock and pathological Shell-shock (++-).

The data of [Section A] will solidly prove that Shell-shock, however picturesque the term for laymen or in the argot of the clinic, is medically most intriguing. As we cannot get rid of the term (even by suppressing it in parentheses or by condemning it to the limbo of the so-called), we must make the best of it by calling Shell-shock just the ore in the clinical mine. To say the least, the term is harmless: it merely stimulates the lay hearer to questions. These questions he must ask of the expert. But every time that the expert suavely states that Shell-shock is nothing but psychoneurosis, that expert runs the risk of hurting some patient who may or not have a psychoneurosis but has been called psychoneurotic. All the while, of course, the suave expert is perfectly right—statistically. In fine, the man you have called a victim of Shell-shock is probably a victim of psychoneurosis, but only probably!

[Section A] shows how he may—not probably, but possibly—be a victim of say ten other things. But it is not that he has an even chance of being one of these ten other things. As the reader watches the procession of cases in [Section A], he will perceive that, amongst the ten major groups there studied, some have far greater diagnostic likelihood than others. Thus, syphilis, epilepsy, and somatic diseases will in the sequel prove more dangerous to our success as diagnosticians than, e. g., feeblemindedness or even perhaps alcoholism. But now let us look at these cases systematically, just as if we dealt with so many cases of Railway-spine or any other “incipient, acute, and curable” cases.

Chart 2
PSYCHOPATHIA MARTIALIS

[2] For formulae see [Chart 3] on opposite page.

Chart 3
PSYCHOPATHIA MARTIALIS
FORMULAE

[3] In the literal formulae, S = Shell-shock, N = Neurosis, P = Psychosis.

[4] These plus-or-minus formulae are not intended to imply that the physical factor, where present (+), must have worked a physical effect upon the nervous system: the effects of the physical factor might be wholly emotional or otherwise psychic.

I. SYPHILOPSYCHOSES (SYPHILITIC GROUP)

An officer of high rank deserts his command in a crisis: alienists’ report.

Case 1. (Briand, February, 1915.)

M. X. was an officer ranking high in the French army, having military duties of a critical nature and of great importance (social reasons forbid Briand’s giving informatory details). Suffice it to say that he was brought before court-martial for abandoning his post at the very moment when his presence was most urgently required. He turned tail, without taking the most elementary military precautions.

M. X. was passed up to alienists. He was not a case of Shell-shock unless of the anticipatory sort. He was somatically run-down and of lowered morale and now 65 years of age. The campaign had been fatiguing.

The alienists decided that the officer had not been responsible for his non-military acts. He had been, they found, in a state of mental confusion at the time of desertion, such that amnesia for his duties and heedlessness of consequences had allowed him to leave the front without looking behind him or securing substitution. This state of mental confusion had been preceded by overwork and several nights of insomnia.

Moreover he was palpably arteriosclerotic. Blood pressure was high. The history was one of slight shocks and a mild hemiplegia. The confusion at the front was only the most recent of a series of transitory attacks of confusion. At the time of examination this high officer was actually in a state of mild dementia.

M. X. was an old colonial man, malarial, and had been a victim of syphilis.

A naval officer sees hundreds of submarines: General paresis.

Case 2. (Carlill, Fildes, and Baker, July, 1917.)

A naval officer, 36, during August, 1916, asserted that he could see hundreds of submarines. At one time he imagined that he was receiving trunk calls in the middle of the ocean. He was admitted to Haslar, and the Wassermann reaction of the serum was found strongly positive. The spinal fluid was not at this time examined. The officer recovered to some extent, was given no special treatment, and was sent on leave.

He came under observation again in October, 1916, having become very strange in his manner, on one occasion passing water into the coal box, and talked about impending electrocution. His ankle-jerks were found sluggish and there was a patch of blunting to pin pricks. The diagnosis of general paresis was made. The spinal fluid was afterward examined and found to be negative to the Wassermann reaction but contained 15 lymphocytes per cubic mm.

Three full doses of Kharsivan freed him from delusions and left him apparently absolutely sane. It was recommended that he should be kept at Haslar to continue treatment. However, he had been certified insane and was therefore sent to Yarmouth, from which he was discharged in February, 1917, having been in good mental health throughout his stay there.

Re syphilis and general paresis of military officers, as in Cases [1] and [2], Russo-Japanese experience was already at hand. Autokratow saw paretic Russian officers sent to the front in early but still obvious phases of disease. These paretics and various arteriosclerotics, Autokratow saw back in Russia in the course of a few months.

Re naval cases, see also [Case 5] (Beaton). Beaton thinks that monotonous ship duty, alternating with critical stress of service, bears on morale and liberates mental disorder.

Neurosyphilis may be aggravated or accelerated under war conditions.

Case 3. (Weygandt, May, 1915.)

A German, long alcoholic and thought to be weakminded, volunteered, but shortly had to be released from service. He began to be forgetful and obstinate, cried, and even appeared to be subject to hallucinations. The pupils were unequal and sluggish. The uvula hung to the right. The left knee-jerk was lively, right weak. Fine tremors of hands. Hypalgesia of backs of hands. Stumbling speech. Attention poor.

It appeared that he had been infected with syphilis in 1881 and in 1903 had had an ulcer of the left leg.

The military commission denied that his service had brought about the disease.

Case 4. (Hurst, April, 1917.)

An English colonel thought himself perfectly fit when he went out with the original Expeditionary Force. He had had leg pains, regarded as due to rheumatism or neuritis. He was invalided home after exhaustion on the great retreat. He was now found to be suffering from a severe tabes. He improved greatly under rest and antisyphilitic treatment. He has now returned to duty.

Case 5. (Beaton, May, 1915.)

An apparently healthy man, serving on an English battle-ship, severed a tendon in a finger. The injury was regarded as minor. The tendon was sutured and the wound healed. During the man’s convalescence he was accidentally discovered to have an Argyll-Robertson pupil and some excess reflexes. Neurosyphilis had probably antedated the accident. But from the moment of this trivial injury, the disease advanced rapidly.

Overwork in service; several months exacting work well performed: General paresis.

Case 6. (Boucherot, 1915.)

A lieutenant of Territorials, aged 41 (heredity good, anal fistula at 30, with ulceration of penis of an unknown nature at the same period). In 1907 when off service and married, his wife gave birth to a child; no miscarriages. Had been a good soldier in service before the war. The lieutenant was called to the colors August 2, 1914, and was detached for special duty, for the performance of which he was much praised by the commanding officers. The work, however, was too much for him and on April 1 he had to be evacuated to the hospital with a ticket saying “Nervous depression following overwork in service.” On April 14 he seemed well enough for a convalescent camp, but, apparently through red tape, was sent to a hospital at Orléans. On June 23 he had to be evacuated to the Fleury annex. His eyes were dull and features flaccid; his whole manner suggested fatigue. His pupils were myotic, tongue tremulous, speech slow and stumbling. Knee-jerks were exaggerated and gait difficult, the right leg dragging. Headaches. He could not perform the slightest intellectual work and was the victim of retrograde and anterograde amnesia. He was aware of the decline of his mental power and was fain to struggle against it, becoming restless and sad. The gaps in his memory grew deeper, he became more and more impulsive, even violent, and had spells of excitement. Dizziness and palpitation developed. Sometimes there were auditory and visual hallucinations of such intense character that he tried feebly to commit suicide with a penknife. He fell into semicoma, and then had a number of apoplectiform attacks. W. R. +

Apparently the moral and physical situation of the lieutenant was absolutely normal when the campaign began and, as he fulfilled detail duties with absolute correctness for a number of months, Boucherot argues that here is an instance of general paresis declanché by overwork.

Syphilis contracted before enlistment. Neurosyphilis aggravated by service.

Case 7. (Todd, personal communication, 1917.)

A laboring man, 42, who always strenuously denied syphilitic infection, proceeded to France eight months after enlistment. He had not been in France three weeks when he dropped unconscious. He regained consciousness, but remained stupid, dull in expression, and with memory impaired. His speech was also impaired. There was dizziness and a right-sided hemiplegia.

He was confined to bed four months and was then “boarded” for discharge.

Physically, his heart was slightly enlarged both right and left; sounds irregular; extra systoles; aortic systolic murmur transmitted to neck; blood pressure 140:40. Precordial pain, dyspnoea.

Neurologically, there was a partial spastic paralysis of the right thigh which could be abducted, could be flexed to 120°, and showed some power in the quadriceps. There was also a spastic paralysis of the right arm, but the shoulder girdle movements were not impaired. There was a slight weakness on the right side of the face. There was no anesthesia anywhere.

The deep reflexes were increased on the right side, Babinski on right, flexor contractures of right hand, extensor contractures of right leg, abdominal and epigastric reflexes absent, pupils active, tongue protruded in straight line.

Fluid: slight increase in protein. W. R. + + +

The Board of Pension Commissioners ruled that the condition had been aggravated by service (not “on service”).

Re general paresis, Fearnsides suggested at the Section of Neurology in the Royal Society of Medicine early in 1916, that in all cases of suspected Shell-shock the Wassermann reaction of the serum should be determined, and went on to say that cases of so-called Shell-shock with positive W. R. often improve rapidly with antisyphilitic remedies.

Duration of neurosyphilitic process important re compensation.

Case 8. (Farrar, personal communication, 1917.)

A Canadian of 36 enlisted in 1915, served in England, and was returned to Canada in February, 1917, clearly suffering from some form of neurosyphilis (W. R. positive in serum and fluid, globulin, pleocytosis 108).

There is no record of any disability or symptom of nervous or mental disease at enlistment. The first symptoms were noted by the patient in May, 1916, six months or more after enlistment. The case was reviewed at a Canadian Special Hospital, October 11, 1916, by a board which reported:

“The condition could only come from syphilitic infection of three years’ standing” (a decision bearing on compensation); but the general diagnosis remained:

“Cerebrospinal lues, aggravated by service.”

The picture which the medical board regarded as of at least three years’ standing was as follows:

History of incontinence, shooting pains, attacks of syncope, general weakness, facial tremor, exaggerated knee-jerks, pupils react with small excursion. Speech and writing disorder, perception dull, lapses of attention, memory defect, defective insight into nature of disorder, emotional apathy.

1. Was the conclusion “aggravated by service” sound? On humanitarian grounds the victim is naturally conceded the benefit of the doubt. But it is questionable how scientifically sound the conclusion really was.

2. Could the condition come only from syphilitic infection of at least three years’ standing? Hardly any single symptom in this case need be of so long a standing; yet the combination of symptoms seems by very weight of numbers to justify the conclusion of the medical board.

Farrar’s case and thirteen others of “Neurosyphilis and the War” were included in a general work on Neurosyphilis (Case History Series, 1917, Southard and Solomon). For military syphilis in general, see Thibierge’s Syphilis dans l’Armée (also in translation).

General paresis lighted up by the stress of military service without injury or disease?

Case 9. (Marie, Chatelin, Patrikios, January, 1917.)

In apparently good health a French soldier repaired to the colors, in August, 1914, being then 23 years old.

Two years later, August, 1916, symptoms appeared: speech disorder with stammering, change of character (had become easily excitable), stumbling gait. He became more and more preoccupied with his own affairs, grew worse, and was sent to hospital in October, 1916.

He was then foolish and overhappy, especially when interviewed. There was marked rapid tremor of face and tongue. Speech hesitant, monotonous, and stammering to the point of unintelligibility. His memory, at first preserved, became impaired so that half of a test phrase was forgotten. Simple addition was impossible and fantastic sums would be given instead of right answers. Handwriting tremulous, letters often missed, others irregular, unequal, and misshapen.

Excitable from onset, the patient now became at times suddenly violent, striking his wife without provocation. After visit at home, he would forget to return to hospital. Often he would leave hospital without permission (of course the more surprising in a disciplined soldier). No delusions.

Serum and fluid W. R. positive; albumin; lymphocytosis.

Neurological examination: Unequal pupils, slight right-side mydriasis, pupils stiff to light, weakly responsive in accommodation, reflexes lively, fingers tremulous on extension of arms.

The patient had, December 5, 1916, an epileptiform attack with head rotation, limb-contractions and clonic movements. Should this soldier recover for disability obtained in service? Marie was inclined to think military service in part responsible for the development of the paresis. Laignel-Lavastine thought so also, but that the amount assigned should be 5%-10% of the maximum assignable.

SYPHILITIC ROOT-SCIATICA (lumbosacral radiculitis) in a fireworks man with a French artillery regiment.

Case 10. (Long (Dejerine’s clinic), February, 1916.)

No direct relation of this example of root-sciatica to the war is claimed nor was there a question of financial reparation.

There was no prior injury. At the end of March, 1915, the workman was taken with acute pains in lumbar region and thighs, and with urgent but retarded micturition.

Unfit for work, he remained, however, five months with the regiment, and was then retired for two months to a hospital behind the lines. He reached the Salpêtrière October 12, 1915, with “double sciatica, intractable.”

There was no demonstrable paralysis but the legs seemed to have “melted away,” fondu, as the patient said. Pains were spontaneously felt in the lumbar plexus and sciatic nerve regions, not passing, however, beyond the thighs. These pains were more intense with movements of legs; but coughing did not intensify the pains. Neuralgic points could be demonstrated by the finger in lumbar and gluteal regions and above and below the iliac crests (corresponding with rami of first lumbar nerves). The inguinal region was involved and the painful zone reached the sciatic notch and the upper part of the posterior surface of the thigh.

The sensory disorder had another distribution, objectively tested. The sacral and perineal regions were free. Anesthesia of inner surfaces of thighs, hypesthesia of the anterior surfaces of thighs and lower legs. The anesthesia grew more and more marked lower down and was maximal in the feet, which were practically insensible to all tests, including those for bone sensation. There was a longitudinal strip of skin of lower leg which retained sensation.

Position sense of toes, except great toes, was poor. There was a slight ataxia attributable to the sensory disorder—reflexes of upper extremities, abdominal, and cremasteric preserved, knee-jerks, Achilles and plantar reactions absent.

The vesical sphincter shortly regained its function, though its disorder had been an initial symptom. Pupils normal.

The “sciatica” here affects the lumbosacral plexus.

As to the syphilitic nature of this affection, there had been at eighteen (22 years before) a colorless small induration of the penis, lasting about three weeks. There was now evident a small oval pigmented scar. The patient had married at 20 and had had three healthy children.

The lumbar puncture fluid yielded pleocytosis (120 per cmm.). Mercurial treatment was instituted.

The treatment has not reduced the pains. Long thinks it was undertaken too long (six months) after onset. The warning for early diagnosis is manifest. There was somehow a delay under the medical conditions of the army.

Re syphilis in munition-workers Thibierge has much to say of French conditions. Throughout his work on syphilis in the army, he stresses the large number of venereal cases in men mobilized for munition-work. Medical inspections ought, according to Thibierge, imperatively to be made in the munition-works and upon all mobilized workmen, whether French or belonging to the Colonial contingents. These men are under military control in France, but they have more opportunities than the soldiers for contracting and disseminating syphilis. They are, in point of fact, very often infected and in a higher proportion than are the soldiers at the front. The munition-workers should also be obliged to report their infections to the physician, whether or no they are under treatment by military or by private physicians.

Thibierge devotes a chapter to syphilis as a national danger. Not only do available statistics prove that there is more syphilis in the population since the outbreak of war, but the number of married women going to special hospitals for syphilis is abnormally high and entirely out of proportion to the number of married women resorting to these clinics in peace times. A certain number are contaminated by their husbands on leave. Thibierge calls attention to the fact of the extraordinary frequency of syphilis in young men (two or three, sixteen to eighteen years of age, at Saint-Louis Hospital at each consultation).

A disciplinary case: Syphilitic?

Case 11. (Kastan, January, 1916.)

Reports varied about a certain German soldier who came up for discipline. Inferiors thought he was harsh and tricky. A lieutenant declared that the man always wanted to have proper respect paid to him, and that he was unduly excited by trifles. The man had become latterly very nervous on account of battle strain and protracted shelling.

July 28, 1915, the man, who had been drinking with comrades the night before, was excitedly talking to an officer concerning relief of a guard. The soldier stated, “As a sergeant on duty with a service record of 15 years, I think it is my affair.” The lieutenant replied, “So far as I am concerned, the matter is settled.” The sergeant yelled, “As far as I am concerned, it is settled also. By the way, my name is Mr. Vice Sergeant …,” and with that the sergeant wrote down the lieutenant’s words and refused to obey the lieutenant’s order to “Stop writing.” The lieutenant drew his sword and said, “Take your hands down.” The sergeant replied, “Surely I am permitted to write.” Lieutenant: “Subordination; don’t forget yourself, Vice Sergeant.…” The sergeant jeered, “You forgot yourself anyhow;” whereupon the lieutenant: “Well, such a thing never happened to me before.” The sergeant, jeeringly, “Nor to me either. If I were not in undress I should know what to do.” The lieutenant: “Vice Sergeant …, remain here. This matter will be settled at once.” The sergeant: “It is Mr. Vice Sergeant …,” whereupon he gave his notebook to a hornblower and said, “Write.” The lieutenant: “Stay.” The sergeant: “What, stay here. No, I’ll not stay,” and made off. The lieutenant called after him, “Put on your service dress and see the captain.” He made ready but said, “This half-idiot gives an order like that to a sergeant with 15 years’ record.”

The examination showed that the man had a hypalgesia. He complained of violent headaches. He said that he had had syphilis 10 years before; there were no bodily stigmata.

Regulations broken: General paresis.

Case 12. (Kastan, January, 1916.)

A German 1st-lieutenant, on active service before the war, had left the service because there was not enough for him to do in peace times. During his war service, he became drunk and had two soldiers bound to a doorpost, with coats unbuttoned and without their caps—a process quite verboten. While in Königsberg, he reported himself ill, and failed to go to a designated hospital. He was accordingly treated as a deserter. He ran up bills with landlady and servant girls, saying that he was going to receive money from his wife. Under hospital examination, he said he was only a Baden man with a lively temperament. He got angry at the phrase test feeding, refused food, got excited when asked to help in the care of other patients, and wrote a letter saying, “If it is the idea to make me nervous by removing the air from me, by prescribing rest in bed—a punishment only suitable for a boy who cannot keep himself neat—and such chicaneries, these philanthropic attempts are bound to fail on my robust peasant nerves. Of course I know that money considerations make the stay of every paying patient desirable, but I am really too good for that. [The expenses were being borne by the state.] I have openly stated what is being here done with me is foolery, and I stick to that phrase. The food, already poor enough, is no better, when the meat of a half-rotten cow comes twice to the table.” This patient was, according to Kastan, a victim of general paresis.

Re general paresis and delinquency, Gilles de la Tourette long ago maintained that there was a medicolegal period in paresis. Lépine in his work on Troubles Mentales de la Guerre speaks of the unexpected frequency of general paresis in the army, and calls attention at the outset to the medicolegal period. The danger of overt delinquency is, in fact, greater under military than under civilian conditions on account of the closer surveillance of the soldier. Desertion and thievery are the main forms.

Unfit for service: General paresis.

Case 13. (Kastan, January, 1916.)

Kastan describes a non-commissioned officer, who came voluntarily into the clinic. It seems that he had absented himself (?) from the army in the suburbs of Königsberg, September 3, 1914. He was arrested October 7th. Once before he had been brought to Kastan’s clinic on the suspicion of general paresis, but had been dismissed as non-paretic. Brought in again in a condition of marked fear, he declared that he had to fall behind his company while he was on the march on account of a feeling of weakness. He had been taken to a hospital and then carried to the suburbs of Königsberg, examined, and found unfit for service.

He had in his 20th year become infected with syphilis, and had recently become forgetful, subject to fears, and easily excitable. He had been very unhappily married with a woman who was hysterical and threatened to shoot and poison him. He lived in a condition of continual quarrels with her. The symptoms that he felt on the march were numbness of the legs and a rush of blood to the head. In the clinic, he was subject to much dreaming and raving about the war. There was excessive perspiration.

1. As to the proper interpretation of this case, details are lacking as to the physical and laboratory side. In fact, it would appear that the suspicion of paresis at his first reception in a clinic was dismissed without resort to laboratory findings.

There are no neurological symptoms in the case clearly suggestive of neurosyphilis, except perhaps the numbness of the legs. The remainder of the picture appears to be entirely psychic. Sensory and intellectual symptoms are missing unless we count the war dreams and mania as intellectual. It appears wiser to count these as emotional in the sense that they were roused by emotion-laden memories. The fear, perspiration, and feelings of head flush are perhaps to be best interpreted as satellites about an emotional nucleus.

Hysterical chorea versus neurosyphilis.

Case 14. (De Massary and Du Sonich, April, 1917.)

There were various complications in the case of a lieutenant (nervous tic in childhood; travel 23 to 30), who was at Antwerp during the period of mobilization. He was taken there by the Germans; was a prisoner in their hands for 55 days; and succeeded under great strain in escaping.

He then entered his regiment, and, passing the examinations, was made an adjutant, and went to the front, March, 1915. He stayed ten months in the Verdun region, under heavy bombardment, and in June was bowled over and buried by a 210. He seemed to be fearless, getting no sensation from shell-bursts except a griping sensation in the bowels.

However, his character had altered in the direction of irritability; and by the end of January, 1916, he had to be evacuated for the first time from the front, for general weakness, with the diagnoses: neurasthenia, neuralgia, dyspeptic troubles, great general fatigue, marked depression. In fact, at Narbonne he was asked no questions for several days on account of his obvious depression. He was given ice-bags for violent headaches, complete rest in bed, cacodylate and sodium nucleinate. In two weeks he was up and about.

At this time appeared choreiform movements, which reached their maximum in two or three days, whereupon he was sent, March 4, 1916, to the neurological centre at Montpellier. Here W. R. positive! Neosalvarsan on the second injection (0.45 and 0.60) yielded a strong reaction, with fever, delirium, vomiting, and then jaundice.

About a month later, he was given twenty more intravenous injections, whereupon the choreic movements now decreased, and July 15 he was given convalescence for three months. October 15 he went back to his dépôt cured; and October 20, on request, went to the front. He was potted and under machine-gun fire at times during the next three months, but the choreic movements did not reappear. January 1 he left the trenches as the division went into billets. January 8, suddenly, without any emotional cause, he began to “dance” again. Accordingly, he was evacuated for the second time, January 10, 1917, with the diagnosis: choreic movements, especially on left; evacuate to special centre.

At Royallieu, a lumbar puncture showed a slight lymphocytosis. The headache improved. He was evacuated January 24, 1917, to Val-de-Grâce, with a diagnosis: Recurrent chorea; first attack followed commotio cerebri, nervous depression, inequality of pupils, various pains, contracted in the army. Another W. R. was positive. Twelve intramuscular injections of oxygen cyanide were given, besides baths. He was then sent to Issy-les-Moulineaux with a diagnosis of tic. He showed choreiform movements affecting the legs alone. When sitting, legs extended and flexed, the knees would abduct, then adduct; the thighs flexed. When standing, flexor movements were produced alternately on the left and the right, the knee being raised high, sometimes striking the patient’s hand. In walking, the thigh and lower leg flexion was always out of proportion to the required step. There was thus a sort of saltatory chorea limited to the legs. The reflexes so far as they could be tested were normal save that the left pupil was fixed to light and accommodation; the right pupil was sluggish to light but accommodated normally. Leucoplakia of the cheeks; nocturnal headaches; and pains resembling lightning pains in arms and legs. Lumbar puncture, March 26, showed blood-stained fluid, and the puncture was followed by headache, vomiting, and slow pulse. The fluid showed a slight lymphocytosis; W. R. negative.

It is clear that a diagnosis limiting itself to the leg trouble would probably content itself with “hysterical chorea.” The lieutenant said that when he saw people “dance” he did have a tendency to imitate them; and when he was cured of that, he did not want to go to Lamalou because he would see the ataxic patients there and might fall back into his “dancing.” However, in view of the pupillary inequality, the lymphocytosis, the leucoplakia, the W. R., and the initial neurasthenia and depression found in the very first hospital in which he was examined, we probably should be entitled to consider that general paresis played a part in the chorea.

Shrapnel fragment driven through skull: General paresis.

Case 15. (Hurst, April, 1917.)

A private, 31, was wounded December 7, 1916, by a shrapnel fragment which entered the skull above the left ear and lodged in the brain, an inch above and 2½ inches below the middle of the right orbital margin. At Netley, December 30, he proved to show a complete internal and external left sided ophthalmoplegia, with the exception of the external rectus. On the right side, there was a complete paralysis of the superior rectus and a partial paralysis of the inferior rectus and levator palpebrae superioris. There was a paresis of the left side of the face. The right plantar reflex was said to have been extensor at the clearing station, but at Netley it and the other reflexes proved to be normal, as were the optic. The patient was stuporous and had incontinence of urine and feces for two days. Shortly after admission, slurring of speech with a long latent period occurred. It was clear that the shrapnel fragment must have passed far above the crus, and it was not plain how isolated lesions of the third and seventh nerve nuclei could have been brought about without injury of the long tracts of the crus.

The Wassermann reaction of the serum was negative, but that of the spinal fluid was positive. Iodide and mercury secured considerable improvement in the mental condition and some diminution in the paralysis. The patient is now extremely pleased with himself and has a speech suggestive of paresis.

Head trauma: Shell-shock effects, over in a few months. Manic-depressive (?) attack more than two years later. X-ray evidence suggesting brain lesion. Serum Wassermann reaction positive.

Case 16. (Babonneix and David, June, 1917.)

A bullet glancing from his gun barrel November 28, 1914, wounded a man in the head, whereupon he lost consciousness and was carried to a hospital and trephined. On coming to, he found that he could not hear and felt pains; but the latter disappeared in a few months. He was given sedentary employment and did his work properly until February, 1917, when he suddenly became sad, wept, slept poorly, stopped eating, had an absent air, and began to complain of his head. He passed whole days without moving, in a sort of stupor, which was then followed by a hypomaniacal agitation in which he walked furiously up and down in the room and threw objects about.

He was found subject to a generalized tremor and he was distinctly weaker on the right side. The tendon reflexes were excessive. The bony sensibility, as well as the pain and temperature sense, and the position and stereognostic senses were completely abolished on the right side. The scar lay on the left side. It was deep and very sensitive to pressure, so that if it was touched ever so slightly the patient began to weep. X-ray indicated loss of substance in the posterior part of the left parietal region. Remains of the projectile were found subcutaneously in the right supraorbital region. The W. R. of the serum was positive. There was no lymphocytosis in the spinal fluid.

Interpretation of this case is manifestly difficult. Four possibilities exist: Syphilis, manic depressive psychosis, traumatic brain disease, and functional shock effects. More than two years had passed between the trauma and the change of character.

Skull trauma in a syphilitic.

Case 17. (Babonneix and David, June, 1917.)

A soldier, 31, sustained fracture of the occiput from shell-burst, and thereafter showed confusion and total loss of memory. Operation November 11 withdrew bony fragments and clots, whereupon the man returned practically to normal. He developed, however, a few seizures, in which he struggled, fell, and lost consciousness, afterward suffering from headache. The tendon reflexes were increased. The occipital cicatrix was a little depressed and slightly painful on pressure.