Chapter XX: Section D: Shell-Shock Treatment and Results (16)

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

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

=Case 342.= (ROWS, April, 1916.)

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

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

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

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

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

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

=Case 343.= (ROWS, April, 1916.)

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

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

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

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

See remarks under Case 342.

War dreams, including hunger and thirst.

=Case 344.= (MOTT, February, 1918.)

(_Recorded Dream of a Second Lieutenant._)

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

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

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

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

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

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

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

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

Olfactory dreams: Hysterical vomiting.

=Case 345.= (WILTSHIRE, June, 1916.)

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

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

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

It seems that the vomiting was secondary to hysterical hallucinations.

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

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

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

=Case 346.= (DUPRAT, October, 1917.)

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

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

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

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

=Case 347.= (GERVER, 1915.)

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

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

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

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

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

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

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

=Case 348.= (ROUSSY, BOISSEAU and CORNIL, May, 1917.)

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

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

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

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

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

=Case 349.= (JOLLY, January, 1916.)

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

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

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

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

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

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

=Case 350.= (GERVER, 1915.)

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

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

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

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

=Case 351.= (GERVER, 1915.)

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

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

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

=Case 352.= (GERVER, 1915.)

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

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

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

=Case 353.= (GAUPP, March, 1915.)

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

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

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

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

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

Amnesia, monosymptomatic. Progressive recovery.

=Case 354.= (MALLET, January, 1917.)

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

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

Aviator shot down: Organic mental symptoms.

=Case 355.= (MACCURDY, July, 1917.)

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

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

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

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

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

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

=Case 356.= (MANN, June, 1915.)

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

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

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

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

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

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

_Re_ the corpse work, see remarks under Case 342.

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

=Case 357.= (WILTSHIRE, June, 1916.)

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

At intervals over a period of about half an hour, helped by questions, he was able to get out the following with much emotion:

“Joe, don’t go--Give me my rifle, Joe--Ten killed. Poor old
Taffy--Dreamed last night--Saw Harry Edmands with all his ribs
broken--when we had the explosion--5000 bombs or two and a half
tons of explosives blew up.--Joe--Clay said he would never
live three weeks,--Glasses blown in.--Taffy killed by shell
in stomach--S-- L-- All privates blown off him--Just after
leaving workshop.”

Between the above statements, the patient might go off into short trance states, staring and pointing out of the tent.

Next day he was found in a condition of cheerful emotion, saying that he was ever so much better; an orderly had “saved him!” This orderly had taken him to the Y. M. C. A. recreation tent, played the piano to him, and made him play himself. His whole emotional state suddenly changed over. He now had a good memory for everything previous to his reaching France, and remembered simply that there had been an explosion. He remembered two names that he had mentioned, but he could remember nothing about their fate in France. He did not know where they were but he was not anxious about them.

Shell-shock: Hallucinations; alternations of personality.

=Case 358.= (GAUPP, March, 1915.)

A soldier, 29, a helper in a wholesale house, came to a hospital by hospital train, uninjured, directly from the field, having become completely deranged under shell fire. He arrived at the clinic January 11, 1915, in deep emotion, anxiously excited, and looking tensely and suspiciously at the bystanders. He seemed to hear very badly and shouted his statements like a deaf person. Led to the sick section, he shouted out of the window, “Frenchmen!”; then he went willingly to the bath and was put to bed, unresisting. He lay in bed on his elbow, listening in the direction of the window or the wall, answering loud questions with a quick, yelling voice after a pause. He gave his name correctly. He seemed to think he was in the trenches and to see hallucinatory pictures of battle.

In the examining room he immediately sat down, back to the wall, taking the chair at the desk and leaning it against the wall. Asked why he did so, he said with a horrified expression, “The shells, they are coming over! Whew! they are shooting all the time.” He ducked, imitating the hissing and whistling of the shells. Asked if he had been struck, he said, “There are two dead and one’s head is off.” He declined to be told where he was, and when he was told that he was no longer in the enemy’s country, but in Württemberg, he said, “No, no; they don’t come so far. No, the Frenchmen don’t come so far.” He was very easily frightened and started at every touch as if wakened from a dream. Sometimes his whole body would tremble with anxiety. He would not allow his pulse to be taken, at first. He would suddenly shout, “That’s the Krupp now flying by. Now it has struck.” He cast his eyes along the ceiling as if to follow the course of the shell. Asked what he was doing, he said he was in the trench on the mountain.

He was able to tell about his family, his marriage in Berlin, and his child, and he could tell time by the clock. Then he would suddenly shout: “The shells, they are shooting everything; they are shooting like another earthquake.” Gaupp stepped up to him, in uniform, and asked if the patient knew him. He examined Gaupp suspiciously from top to toe, looked at the shoulder-straps, and then quickly cried loudly, “Physician.”

At another time he described the shell havoc with evidence of extreme anxiety. He would take food only when one broke off a piece and ate of it before him. He would not drink out of ordinary drinking-glasses but only out of his field cup, examining it carefully. He denied he was on patrol duty at Soupis. His comrade was merely asleep just now. A civilian physician in his long coat was termed by the patient “a baker” after careful examination. There seemed to be no pause in the man’s behavior, which looked absolutely genuine and dominated by strong emotion. He had the look of a man in immediate danger of death, exerting himself to escape shell fire.

This dream-like disorder of consciousness with war delirium persisted for a number of days. There was no marked motor excitement. He would remain for the most part quietly in bed, absorbed in his thoughts, watching and listening, sometimes looking about in astonishment but not getting his bearings. Gradually his emotions declined and he developed a certain confidence in the nurse. She was able to convince him that he might be in a hospital, although he objected that there were no wounded there. (He was in a mental section where there were no bandaged men.) All the while he was very hard of hearing and shouted loudly in speech. For twelve days he could not be convinced that he was in Germany. The fact that the Sister was speaking German was met promptly by the fact that in France the physicians and Sisters spoke German too.

An extraordinary change came over him January 27 (sixteen days after admission). He went into the garden, apparently deaf and shouting his answers, accompanied by Sister Margarethe, whom he always called “Sister Anna” and whom he thought came from Lichterfelde. While walking with the Sister, his condition suddenly disappeared. He began to hear; he spoke in a normal tone, in fact, rather low, and began to address the Sister by her right name, Margarethe. He was astonished at the snow in the garden, and asked the Sister whether she noticed that the artillery had just stopped firing. Gradually getting his bearings, he wondered whether he had been in the hospital since the day before. He certainly was not ill, he thought.

This normal state lasted for a half hour. The patient then relapsed into anxious semi-consciousness, becoming deaf again and shouting his words. During the next few days and weeks he had frequent changes of state like the above described. The changes to a normal state would take place spontaneously in the absence of apparent occasion, but the relapses into semi-consciousness took place when there was some outer irritation, especially some noise. Every fright would cause a relapse. Once a small cannon fired at a great distance off caused such a relapse; again, a sudden shouting at the patient.

During the clear state there was a complete amnesia for the period of illness. He did not want to believe that he had been in the hospital for weeks, declaring that he must have been in the trenches two days before.

Gradually the semi-conscious states decreased in length; the deafness and loud speech returned with the semi-consciousness. With the return of orientation, the man looked entirely normal, speaking in a low voice somewhat shyly. He was rather suspicious and could find his way about with difficulty. His memory broke off with the last days of December, 1914, at which time he was in the trenches under intense shell fire. His wife had received no word from him since December 26. Even at the beginning of February he grew anxiously tense when the word _shell_ was mentioned.

February 4, Gaupp presented him in clinic as entirely clear. He mentioned that his relapses to semi-consciousness occurred on the occasion of a loud noise or word spoken. His face was contorted at Gaupp’s remark but there was no other change in him. The next day, however, he told the Sister that Gaupp had shouted out once to “get him away.” He said he had then heard artillery fire for a moment, but pulled himself together though he had almost gone off, and had a violent headache afterward.

These states of alternating normality and semi-consciousness continued until about February 10. During a clear spell, the patient was quiet, reserved, taciturn, a little ill-tempered and seclusive, occasionally writing his wife a rather empty letter. In the semi-conscious state he was emotional and restless, seeking cover from the enemy. These states stopped altogether about the middle of February. He then became somewhat more open, though he had no idea of the gravity of his condition. He was angered by the window-bars, and offended by the opening of a letter to his wife, declaring that he would never write a word again, as it was just like a prison. These outbursts passed quickly by. He wanted to go home and believed he would soon be able to go to his comrades in the field.

At the time of the report, Gaupp felt that he could not be discharged for a number of weeks. He was pallid, gave the impression of being exhausted mentally, complained of restlessness and internal irritation. His memory gap covered at the end of March a period of about five weeks: from the end of December, 1914, to the beginning of February, 1915.

Frostbite; thrown into water by horse; horse shot under its rider who becomes: A HORSE IN THE UNCONSCIOUS.

=Case 359.= (EDER, March, 1916.)

A private in the Royal Engineers, 25, went through Gallipoli without injury and without fears. He was sent to the hospital in Malta, December 18. When observed by Eder, February 7, the frostbitten finger of the right hand was well although there was some loss of grip. He was suffering from insomnia, terrifying dreams, shaky hands. It seems that December 6, a horse started and he was thrown into the water from a bridge. The next day his horse was shot under him. A few days later, a finger was frostbitten. Then his hands began to tremble and the insomnia set in, with severe headaches.

This patient was a jovial, thickset, farmer’s son, with a diffuse enlargement of the thyroid gland, a high blood pressure, lymphocytosis, a fine tremor of the hands, irregular and rapid pulse, and anginal attacks. Extremities were cold and blue; the palms perspired markedly; there was hypersensitiveness to sound; there were occasional attacks of dizziness, with a feeling of suffocation; there was frequent desire to micturate.

The patient’s dream was always the same: He saw a Frenchman digging a knife into his horse, getting off a cart to do this somewhere in Serbia. Occasionally he had this dream in the form of a vision in the daytime. It seems that he had actually seen a French soldier plunge a knife into a mule to make it go. He had been busy with horses since childhood: as stableboy and groom. He thought that the sufferings of the mules in Gallipoli were worse than those of human beings. According to Eder, this farmer’s son was the horse of his dreams; instinctive fear had to emerge; he was pitying himself. According to Eder, “That the person should become a horse in the unconscious would not startle one who has dipped into the totems and taboos of the lower races.”

Shell-shock; gassing; fatigue: Anesthesias.

=Case 360.= (MYERS, March, 1916.)

A stretcher-bearer, 44, eleven years in the service and two months on French service, was seen by Lt. Col. Myers eight days after reporting sick and admission to a base hospital.

While he was under cover in a cellar, three days before reporting sick, a shell had jammed the door and the fumes came in. Later in the day, in another cellar, he had been blown off his seat by a shell and six other men had been laid out. The shelling continued that day and two following days. He had worked on the wounded without any rest.

On lying down he found his left arm numb and cold. The numbness then spread to the legs, especially to the left leg. There was continual tingling in terminal joints of fingers of left hand; hypalgesia over both forearms and hands, especially on left side; total analgesia over left dorsum.

Two days later, the patient could feel articles and reported that the numbness occurred only in the early morning and was followed by a tingling as the numbness passed off. On the same day, the hands and forearms showed a total loss of sensibility to pain, except for a small area on the flexor surface below the elbow joint.

_Re_ spread of anesthesia and alternation of sensory symptoms in this case. Babinski, of course, believes, that the majority of these conditions are the product of medical suggestion, but Babinski meets any critique by pointing out that any other sort of suggestion may produce such results. The heterosuggestion need not be medical. Thus, the sight of a comrade with paralysis or anesthesia, organic or hysterical, may suggest such to the soldier. Léri remarks that these may also be produced by autosuggestion alone. “From a tired feeling in a limb to a loss of power in it, there is but a small step. Another step leads to paralysis and anesthesia. The neuropathic temperament takes these small steps in perfectly good faith.” Léri has found no case in which he could exclude the influence of auto- or heterosuggestion.

Shell-shock; burial; somnambulistic state: Amnesia. Recovery of memory in hypnosis.

=Case 361.= (MYERS, February, 1915.)

A healthy-looking man, with flushed face and large dark eyes with wide pupils, complained of pains in abdomen, back, and limbs, chiefly in knees and ankles, and of visual impairment. This corporal said that his sight had been very indistinct since he was buried, and that if he looked at an electric light, he could see nothing for five minutes afterwards. He was admitted to the Duchess of Westminster’s War Hospital at Touquet, December 11, 1914, having been buried for 48 hours, December 8, when a shell blew in the trench where he lay. He said he could remember nothing until he found himself in a dressing station, lying on straw, in a barn. He was at that time unable to see and fell over something when he tried to walk.

He had gone out August 13, and had been in the last two days at Mons and then at La Bassée. He had slept badly and had taken a good deal of whiskey. He had led a fast life and had had domestic worries recently.

It appeared that his vision had improved since the day of the explosion; though he could read for a short time only when things became blurred, and only with the type close to the eyes. Bowels had not opened for five days. Vision in right eye was 5/60; left eye, 2/60.

Tested for smell, he failed to smell peppermint, ether, iodin tincture, and carbolic acid 1-40. Sugar was tasted only after tongue movements were permitted, as was also a strong solution of salt. Acid tasted salty like alum. The patient complained that he did not sleep, though in point of fact he slept well.

The patient was treated by suggestion, both in hypnosis and without, when he was transferred on the 31st of December, to the London Temperance Hospital, whence he was discharged. The treatment by suggestion occurred daily. At the second trial and thereafter, light hypnosis was easily induced, but the deeper stages, with hallucinations, anesthesia, and post-hypnotic anesthesia, could not be reached. The lighter stages brought about sleep, a gradual restoration of memory, and later an improvement in visual and olfactory acuity; in near vision, in visual fields, and in color sensibility.

The stages in the restoration of memory are as follows: December 22, he was able to describe how he was buried, how Sergeant L. dug him out, how men of another regiment than his own took him to a dressing station, whence he was packed off by the M. O. to the dressing station of his own regiment. Capt. S. had spoken to him and given him a drink. Post-hypnotic suggestion caused him to remember this latter fact after he had come out from hypnosis.

December 23, even before hypnosis, he could remember a big hospital with a stove in the center of a big square room, and gave a fragmentary account of struggling in the trench after being buried, and of going to sleep and enjoying himself at home, when somebody started messing him about. In hypnosis, he gave further details of his dreams after falling asleep in the buried state.

December 26, further details were remembered before hypnosis, such as a ride in the motor ambulance, offers of tea, cocoa, sweets, and cigarettes, a bad headache, and the like.

December 27, in hypnosis, he was able to describe with apparent accuracy the position of the trenches and their appearance. He said:

“The explosion lifted us up and dropped us again. It seemed as
if the ground underneath had been taken away. I was lying on
my right side, resting on my right hand, when the shell came.
I got my right hand loose but my wrist was fixed behind a
piece of fallen timber. At last I dropped off to sleep and had
funny dreams of things at home. One thing in particular I have
thought of many times since, I have not been able to make out
why I should dream of the young lady playing the piano. I don’t
know her name and I don’t think I have seen her above twice.”

According to Myers, it is questionable how far the patient’s memory can be trusted; and there is considerable doubt whether the man had remained in the trench for more than an hour after the shell had burst. A comrade said that the doctors at the barn thought the man off his head. Another soldier, familiar with the positions of the regiments in question, gave information suggesting that the patient had wandered in a somnambulistic state from the trench, past his own dressing station to that of another regiment.

_Re_ Shell-shock and burial cases, compare remarks of Grasset and of Foucault concerning the feeling as if dead on the part of certain buried persons. Somnambulism is a natural sequel to such feelings. For somnambulism, compare cases of Milian (364, 365, and 366).

Shell-shock; minor injuries: Somnambulistic “carrying on”; fatigueability, physical and mental.

=Case 362.= (DONATH, July, 1915.)

A lieutenant of infantry, 31, threw himself down on the earth September 9, 1914, as a shell was passing over him. The shell exploded and seriously injured a soldier one meter away. The lieutenant got up and ran for cover about twenty meters distant. Only six and a half hours later did he perceive that there was a small skin lesion between his thumb and index finger, caused by a shell fragment, as well as a superficial burn on his right temple. Neither wound bled or had to be dressed. He carried on, aware that they were marching toward the River D.; but only two or three days later did he find they had already marched to the other side of K., had rested there and spent the night in various places in between. During this whole period the lieutenant led his battalion and held a piece of woods without anyone’s noticing anything striking about him. These dazed states were twice repeated, for periods of ten and twenty-four hours respectively, and finally he was brought behind the firing lines unconscious.