Chapter V: Section D: Shell-Shock Treatment and Results (1)

473. Deafmutism: Spontaneous cure _Mott_, 1916 672

474. Two returns to the front _Gilles_, 1916 675

475. Vicissitudes in 15 months _Purser_, 1917 676

476. Deafmutism: Spontaneous cure _Jones_, 1915 678

477. Course of an oniric delirium _Buscaino_, _Coppola_, 1916 679

478. Same _Buscaino_, _Coppola_, 1916 681

479. Paraplegia: Cure by Iron Cross _Nonne_, 1915 682

480. Mutism cured by getting drunk _Proctor_, 1915 682

481. Mutism cured by working in vineyard _Anon_, 1916 683

482. Deafmutism: Spontaneous recovery of speech.
Recovery of hearing by isolation _Zanger_, 1915 684

483. Excess of sympathy on furlough _Binswanger_, 1915 685

484. Hysterical seizures treated by hydrotherapy _Hirschfeld_, 1915 688

485. Low blood pressure treated by pituitrin _Green_, 1917 690

486. Manual contracture: Various treatments _Duvernay_, 1915 691

487. Massage and mechanotherapy _Sollier_, 1916 692

488. Mine explosion; headache: Lumbar puncture _Ravaut_, 1915 693

489. Hysterical clenched fist: Treatment by fatigue of flexors
_Reeve_, 1917 694

490. Hysterical adduction of arm: Treatment by induced fatigue
_Reeve_, 1917 695

491. Hysterical cross-legs: Treatment by induced fatigue
_Reeve_, 1917 696

492. Hysterical torticollis: Treatment by induced fatigue
_Reeve_, 1917 697

493. Claw foot (2 years): Cure by induced fatigue _Reeve_, 1917 698

494. Traumatic and post-traumatic effects: Surgical treatment
_Binswanger_, 1917 699

495. Vomiting: Cure by restoration of self-confidence
_McDowell_, 1917 701

496. Self-accusatory delusions: Treatment by “autognosis”
_Brown_, 1916 702

497.} Deafmutism in three men shell-shocked at one time
498.} _Roussy_, 1915 703
499.}

500. Vomiting; incontinence, abasia: Cure by persuasion
_McDowell_, 1916 705-706

501. Hysterical convulsions cured by an explanation _Hurst_, 1917 706

502. Course of a case with crises of trembling _Roussy_, 1915 706

503.} Two cases of lameness cured by persuasion _Russel_, 1917 707
504.}

505. Head trauma: Treatments by bandage, isolation,
open air and to-and-fro transfers _Binswanger_, 1915 708

506. Rationalization of war memories _Rivers_, 1918 712

507. Same _Rivers_, 1918 713

508. Same _Rivers_, 1918 714

509. Same _Rivers_, 1918 715

510. Same, without redeeming feature as nucleus of
rationalization _Rivers_, 1918 716

511. Paraplegia cured by removal of crutches _Veale_, 1917 717

512. Same _Veale_, 1917 718

513. Paraplegia: Chocolates _versus_ isolation _Buzzard_, 1916 719

514. Blindness, mutism, deafness. Immediate spontaneous
recovery from the first; gradual recovery from
second; deafness cured by “small operation” _Hurst_, 1917 720

515. Deafness: Treatment by stimulating vestibular apparatus
_O’Malley_, 1916 721

516. Mutism: Treatment by operative manipulation _Morestin_, 1915 722

517. Visual impairment: Treatment by suggestion,
faradism injections _Mills_, 1915 724

518. Aphonia: Treatment by manipulation in larynx _O’Malley_, 1916 725

519. Same _Vlasto_, 1917 727

520. Mutism, amnesia: Treatment by faradism;
climatic cure in dream _Smyly_, 1917 728

521. Blindness: Cure by injections in temple _Bruce_, 1916 729

522. Deafness cured by suggestion in writing _Buscaino_, 1916 730

523. Reproduction of Shell-shock story in hypnosis: Recovery
_Myers_, 1916 732

524. Same _Myers_, 1916 733

525. Automatism, amnesia, deafmutism: Recovery by hypnosis
_Myers_, 1916 734

526. Mutism: Recovery by hypnosis _Hurst_, 1917 736

527. Stammering: Cure by hypnosis _Hurst_, 1917 737

528. Mutism and amnesia: Cure by hypnosis _Myers_, 1916 739

529. Victoria Cross winner: Bayonet clutch contracture
revealed by hypnosis _Eder_, 1916 741

530. Contracture: Hypnotic cure “indecently quick” _Nonne_, 1915 742

531. “Doll’s head” anesthesia: Mutism: Cure by hypnosis
_Nonne_, 1915 744

532. Mine explosion: Tremors (also _ante bellum_ tremors):
Cure by hypnosis _Grünbaum_, 1916 745

533. Astasia-abasia: Cure by hypnosis _Nonne_, 1915 747

534. Crural monoplegia: Cure by hypnosis _Hurst_, 1917 748

535. Tremors and sensory disorders: Cure by hypnosis _Nonne_, 1915 749

536. Paraplegia of gradual development: Cure by repeated hypnosis
_Nonne_, 1915 751

537. Visual impairment and dysbasia: Cure by hypnosis
_Ormond_, 1915 752

538. Blindness cured by hypnosis _Hurst_, 1916 753

539. Postoperative retention of urine: Relief by hypnosis
_Podiapolsky_, 1917 754

540. Postoperative pains: Relief by hypnosis _Podiapolsky_, 1917 755

541. Stereotyped war dream and _ante bellum_ headache:
Cure by hypnosis _Riggall_, 1917 756

542. Amnesia and _ante bellum_ headache: Cure by hypnosis
_Burmiston_, 1917 757

543. Convulsions cured by hypnosis _Hurst_, 1917 759

544. Two attacks of mutism: Spontaneous recovery from
one in 18 months, from the other by hypnosis _Eder_, 1916 759

545. Neurasthenic symptoms cured by repeated hypnosis
_Tombleson_, 1917 760

546. Neurasthenic symptoms: Improvement under repeated hypnosis
_Tombleson_, 1917 761

547. Convulsions “Jacksonian” and dysbasia: Cure by hypnosis
_Tombleson_, 1917 762

548. Agoraphobia: Cure by hypnosis _Hurst_, 1917 763

549. Manual tremors: Treatment by forcing and isolation
_Binswanger_, 1915 764

550. Mutism: Psychoelectric cure _Scholz_, 1915 766

551. Hemiplegia and deafmutism; (also convulsions by
heterosuggestion): Improvement by faradism;
full recovery by suggestion _Arinstein_, 1915 767

552. Deafmutism, cures, relapses and eventual cure by anesthesia
_Dawson_, 1916 768

553. Deafness: Cure by suggestion on emerging from ether
_Bruce_, 1916 770

554. Aphasia, hemiplegia, hemianesthesia, and (by medical suggestion)
trismus: Cure by anesthesia and suggestion _Arinstein_, 1915 771

555. Triplegia, mutism, jumping-jack reactions: Cure by
anesthesia, verbal suggestion, faradism _Arinstein_, 1915 773

556. Mutism and musical alexia: Cure by anesthesia _Proctor_, 1915 775

557. Deafmutism: Deafness cured by anesthesia _Gradenigo_, 1917 776

558.} Interaction of two cases (deafmute and mute)
559.} under treatment _Smyly_, 1917 777

560. Dysbasia: Cure by stovaine anesthesia _Claude_, 1917 778

561. Same _Claude_, 1917 779

562. Deafmutism _Bellin_, _Vernet_, 1917 780

563. Monoplegia: Cure by electricity administered with a
bored and authoritative look _Adrian_, _Yealland_, 1917 782

564. Monoplegia after sling: Technique of electrical suggestion
and “rapid” reëducation _Adrian_, _Yealland_, 1917 783

565. Hysterical “sciatica”: Treatment by faradism and
verbal suggestion _Harris_, 1915 785

566. Prognosis of intensive reëducation in reflex
(physiopathic) disorder _Vincent_, 1916 786

567. Hysterical contracture (with physiopathic features)
brutally conquered _Ferrand_, 1917 788

568. Paraparesis: Cure by exercises electrically provoked
_Turrell_, 1915 790

569. Astasia-abasia: (“Lourdes-like” cure) _Voss_, 1916 791

570. Abasia: Rapid cure _Schultze_, 1916 792

571. Heterosuggestive brachial paresis: Electric suggestion
and recovery in five days _Hewat_, 1917 794

572. Contracture of right index finger and thumb:
Psychoelectric cure _Roussy_, _L’Hermitte_, 1917 795

573. Brachial monoplegic able to descend ladder with arms only
_Claude_, 1916 795

574. Brachial monoparesis: Vicissitudes of treatment
_Vincent_, 1917 796

575. Paresis and sensory disorder: Reëducation _Binswanger_, 1915 798

576. Seizures (of _ante bellum_ origin), astasia-abasia,
anesthesias: Reëducation _Binswanger_, 1915 800

577. Progress in case of paresis of foot and spasticity of hip
_Binswanger_, 1915 805

578. Mutism (Reëducation) _Briand_, _Philippe_, 1916 808

579. Stammering: Isolation and reëducation _Binswanger_, 1915 810

580. Deafmutism: Phonetic reëducation _Liébault_, 1916 814

581. Aphonia: Pressure on sternum and respiratory gymnastics
_Garel_, 1916 816

582. Stammering: Reëducation _MacMahon_, 1917 817

583. Speech disorder: Reëducation _MacMahon_, 1917 818

584. Camptocormia: Psycho-electric cure: lameness cured by
reëducation _Roussy_, _L’Hermitte_, 1917 819

585. Deafmutism: Speech recovery by suggestion and reëducation:
Hearing by reëducation _Liébault_, 1916 822

586. Mutism; stammering; Reëducation; hypnosis _MacCurdy_, 1917 823

587. Anesthesias: Spontaneous gradual recovery: “Paralysis”
cured by reëducation _Binswanger_, 1915 824

588. Deafmutism; head movements, anesthesia: Cure by
faradism, massage and reëducation _Arinstein_, 1916 827

589. Amnesia and paralysis: Reëducation _Batten_, 1916 828

SECTION E. EPICRISIS

PARAGRAPH
TERMINOLOGY 1-8

DIAGNOSTIC DELIMITATION PROBLEM 9-39

THE NATURE OF WAR NEUROSES 40-74

DIAGNOSTIC DIFFERENTIATION PROBLEM 75-99

GENERAL NATURE OF SHELL-SHOCK 89-102

TREATMENT: GENERAL OBSERVATIONS 103-114

A. PSYCHOSES INCIDENTAL IN THE WAR

La divina giustizia di qua punge
quell’ Attila che fu flagello in terra.

Divine justice here torments that Attila, who
was a scourge on earth.

Inferno, Canto xii, 133-134.

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

A matter of spirochetes?

The response of a subnormal soldier?

An equivalent of epilepsy?

An alcoholic situation?

A result of neurones actually _hors de combat_?

A state of bodily weakness (perhaps of _faiblesse irritable_)?

A bit of dementia praecox?

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

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

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

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

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

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

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

CHART 1

PRACTICAL GROUPING OF MENTAL DISEASES

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

The case-histories of this book will show that

(_a_) most shell-shock is in group X, Psychoneuroses,

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

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

I. Syphilitic Psychoses SYPHILOPSYCHOSES

II. Feeblemindedness HYPOPHRENOSES

III. Epilepsy EPILEPTOSES

IV. Alcoholic, Drug, and Poison
Psychoses PHARMACOPSYCHOSES

V. Focal Brain Lesion Psychoses ENCEPHALOPSYCHOSES

VI. Symptomatic (Somatic) Psychoses SOMATOPSYCHOSES

VII. Presenile-Senile Psychoses GERIOPSYCHOSES

VIII. Dementia Praecox and Allied
Psychoses SCHIZOPHRENOSES

IX. Manic-Depressive and Allied
Psychoses CYCLOTHYMOSES

X. Psychoneuroses PSYCHONEUROSES

XI. Other Forms of Psychopathia PSYCHOPATHOSES

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

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

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

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

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

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

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

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

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

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

CHART 2

PSYCHOPATHIA MARTIALIS

⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫
⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫
SHELL-SHOCK SHELL-SHOCK PSYCHOSIS
(THE PHYSICAL FACTOR) (NEUROTIC SYMPTOMS) (SYMPTOMS NON-NEUROTIC)

ABSENT ABSENT INCIDENTAL

PRESENT ABSENT LIBERATED,
AGGRAVATED,
ACCELERATED
PSYCHOSES

ABSENT COMBINED NEUROSES
AND PSYCHOSES
[2](FORMULA -++)

PRESENT COMBINED NEUROSES
AND PSYCHOSES
(FORMULA +++)

ABSENT NEUROSES ABSENT
(QUASI SHELL-SHOCK)

PRESENT NEUROSES ABSENT
(TRUE SHELL-SHOCK)

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

CHART 3

PSYCHOPATHIA MARTIALIS

FORMULAE

⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫
⎧‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾⎫
S, N, P[3] = SHELL-SHOCK SHELL-SHOCK PSYCHOSIS
(THE PHYSICAL[4] (NEUROTIC SYMPTOMS) (NON-NEUROTIC
FACTOR) PRESENT PRESENT SYMPTOMS) PRESENT

P = - - +

SP = + - +

NP = - + +

SNP = + + +

N = - + -

SN = + + -

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

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

I. SYPHILOPSYCHOSES (SYPHILITIC GROUP)

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

=Case 1.= (BRIAND, February, 1915.)

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

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

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

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

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

A naval officer sees hundreds of submarines: General paresis.

=Case 2.= (CARLILL, FILDES, and BAKER, July, 1917.)

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

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

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

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

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

Neurosyphilis may be aggravated or accelerated under war conditions.

=Case 3.= (WEYGANDT, May, 1915.)

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

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

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

=Case 4.= (HURST, April, 1917.)

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

=Case 5.= (BEATON, May, 1915.)

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

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

=Case 6.= (BOUCHEROT, 1915.)

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

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

Syphilis contracted before enlistment. Neurosyphilis aggravated by service.

=Case 7.= (TODD, personal communication, 1917.)

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

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

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

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

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

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

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

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

Duration of neurosyphilitic process important _re_ compensation.

=Case 8.= (FARRAR, personal communication, 1917.)

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

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

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

“Cerebrospinal lues, =aggravated by service=.”

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

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

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

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

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

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

=Case 9.= (MARIE, CHATELIN, PATRIKIOS, January, 1917.)

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

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

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

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

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

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

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

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

=Case 10.= (LONG (DEJERINE’S clinic), February, 1916.)

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

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

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

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

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

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

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

The “sciatica” here affects the lumbosacral plexus.

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

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

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

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

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

A disciplinary case: Syphilitic?

=Case 11.= (KASTAN, January, 1916.)

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

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

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

Regulations broken: General paresis.

=Case 12.= (KASTAN, January, 1916.)

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

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

Unfit for service: General paresis.

=Case 13.= (KASTAN, January, 1916.)

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

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

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

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

Hysterical chorea versus neurosyphilis.

=Case 14.= (DE MASSARY and DU SONICH, April, 1917.)

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

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

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

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

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

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

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

Shrapnel fragment driven through skull: General paresis.

=Case 15.= (HURST, April, 1917.)

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

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

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

=Case 16.= (BABONNEIX and DAVID, June, 1917.)

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

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

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

Skull trauma in a syphilitic.

=Case 17.= (BABONNEIX and DAVID, June, 1917.)

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

Lumbar puncture showed a very slight lymphocytosis (5 to 6 cells), practically negative globulin reaction, and a low albumin titer. There were no signs of syphilis in the eyes. The W. R. in the serum was strongly positive. Very possibly the traumatic phenomena in this case can be safely disengaged from the syphilitic phenomena.

_Re_ the mechanism by which trauma evokes or accelerates the course of neurosyphilis, it is probable that most neuropathologists believe that the _commotio cerebri_ causes sundry chemical or physical effects in the nerve tissues such that spirochetes are moved into new and more dangerous places, or such that more appropriate food is supplied to the organisms, which then begin to multiply. Whether the organisms live in a kind of symbiosis in the tissues under ordinary circumstances in the pre-paretic period of the development of neurosyphilis, is unknown. Possibly fat embolism should be added to the list of possible causes of the hastening of the neurosyphilitic process. Fat embolism in the brain has been shown by various authors to be accompanied by minute hemorrhages, in the midst of which by proper stains the fat embolism can be made out.

Shell-wound in battle: General paresis.

=Case 18.= (BOUCHEROT, 1915.)

A soldier in the Territorial Infantry, 42, a gardener who went to taverns, as he said, “like everybody else,” a widower with two children, a good worker though irascible, had had syphilis as a youth. He was called to the colors at the outbreak of the war and got on well despite tremendous strain. March 9, 1915, he was in a bayonet charge with his regiment and was bowled over by a shell of which a fragment wounded him above the knee and several fragments in the thorax. All these fragments were extracted at a temporary hospital, March 11. The man now became strange, refused to obey orders and did a number of peculiar things so that he was sent to Orléans temporary hospital whence he was evacuated to Fleury Asylum, March 19. He refused to give up his things because he was the master. He did not want to go to bed and wanted to keep on walking constantly. He was without sense of shame, satisfied with himself, grandiose as to his millions in bank and the thirty-six decorations he believed had been awarded him. He mistook the identity of the landscape and of the people about him.

Tongue tremulous; pupils unequal; knee-jerks exaggerated; dysarthria; gaps in memory. In May occurred a number of violent reactions.

In June, however, there was a remission; the ideas of grandeur disappeared first, then the tremors and reflex disorder and finally the speech disorder. There was a slight seizure at this point and the man said he had had another such just before he came to the army. July 20 he was invalided out much improved.

In this case of general paresis there is, besides the syphilis, also alcoholism to consider, so that it is not entirely plain that the exertions of campaign liberated the paresis.

_Re_ wounds and paresis, see also Case 5 (Beaton), in which neurosyphilis advanced rapidly from the time of a trivial injury.

Shell-explosion: Syphilitic ocular palsy.

=Case 19.= (SCHUSTER, November, 1915.)

Schuster notes briefly a curious result of the explosion of a shell, which caused the patient in question to lose consciousness. Shortly after the explosion, the patient came to his senses again, but a surprising paresis of the eye muscles had developed. This paresis looked precisely like a syphilitic paresis clinically.

Examination of the blood serum yielded a strongly positive Wassermann reaction.

According to Schuster, the explosion of the shell had brought about hemorrhage in vessels supplying the region of the eye muscle nerves or nuclei. The reason for the selection of these vessels for rupture due to shell explosion is, according to Schuster, that the vessels were probably already syphilitically diseased.

_Re_ hemorrhages in the neighborhood of the oculomotor nuclei, the phenomena of polioencephalitis may be recalled. In that disease, the predisposition to hemorrhage is presumed to be alcoholic, as the cases of ophthalmoplegia of this group almost always appear in alcoholics. However, the first case of hemorrhagic superior polioencephalitis was a non-alcoholic one of Gayet (1875), in which the symptoms followed three days after a boiler explosion.

A tabetic lieutenant “shell-shocked” into paresis?

=Case 20.= (DONATH, July, 1915.)

An apparently competent German professor in an intermediate school, a lieutenant of infantry reserves, 33 years old, on the 17th August, 1914, was stunned for a while by the shock of a cannon-firing 25 feet away. Urination became difficult. Headaches and limb pains ensued, with paralysis of fingers, gastric troubles, forgetfulness, especially for names, insomnia, and general scattering of mental faculties.

Neurologically, the pupils were irregular, left larger than right; Argyll-Robertson reaction. Right knee-jerk livelier than left. Achilles reactions absent. Slow and dissociated pain reactions in feet, lower thighs and lower quarter of upper thighs, with hypalgesia or analgesia. Station good; gait steady. Mentally depressed, slow of thought. Speech poor and of indistinct construction (mild dementia). Calculation ability poor. No pleasure in work.

Wassermann reaction of serum weakly positive.

It seems that for a year the patient had been subject to spells of anger. He was irritated by his wife who had been nervous since an earthquake.

_On the occasion of the earthquake_, 1911, the patient himself had had a spell of _difficulty with urination_. The spell had lasted two or three months. The patient had had a chancre in 1902, “cured” in four or five weeks with xeroform. In 1908, when about to marry, he had had six mercurial inunctions.

_Re_ tabes, Lépine shows that tabetics are numerous. They are numerous among officers and also in the auxiliary service, in which latter tabetics are maintained on desk duty. Perhaps they had been admitted to such work as unable to march or fight, on the basis of having had so-called “rheumatism.”

Shell-explosion may precipitate neurosyphilis in the form of tabes dorsalis.

=Case 21.= (LOGRE, March, 1917.)

An artilleryman, 38, had a large calibre shell explode very near him and afterward could not hear the whistle of a shell without falling down in a generalized tremor, sweating profusely, urinating involuntarily, in a mental state approaching stupidity. Here was a case that might be regarded as one of morbid cowardice in a psychopath, following violent emotion.

The artilleryman proved to be a victim of tabes and of general paresis. The incontinence of urine under the influence of emotion was nothing but an effect of tabetic sphincter disorder. The crisis of cowardice proved nothing but an initial symptom of general paresis.

Shell-explosion; burial: Tabes dorsalis incipiens.

=Case 22.= (DUCO and BLUM, 1917.)

A French soldier was buried by effects of shell explosion September 8, 1914. He sustained no wound or fracture.

Incontinence of urine developed. Anesthesia of penis and scrotum. Reflexes absent; pupils sluggish. Wassermann reactions suspicious.

The diagnosis =tabes dorsalis incipiens= was made (hematomyelia of conus terminalis eliminated).