Chapter VIII: Section D: Shell-Shock Treatment and Results (4)

In the Charité Clinic he had three attacks, two of them nocturnal, one in the daytime, followed by a long period of somnolence. He once cried out suddenly in the night as if warding off an attack. He complained of headaches, and was often irritated and out of humor. Somatically, there was a hemihypesthesia on the side of the injury.

The history indicates that this patient up to his sixteenth year had been a victim of occasional enuresis, often cried out in his sleep or even rose from bed. Occasionally he suffered from such violent sudden headaches that he would have to sit down. He was easily irritated, and had once been arrested for assault. As a soldier, however, he had never been guilty of any breach of discipline. Mild headaches would follow drinking. These phenomena in the history pointed in the direction of epilepsy. According to Bonhoeffer, we cannot entirely exclude contusion of the brain from the shell injury. However, there were no cerebral symptoms, and the interval before the occurrence of the attacks rather indicates that we are dealing with a genuine epilepsy. As for the hemihypesthesia, this is a hysterical “_superposition_,” which does not interfere, according to Bonhoeffer, with the genuineness of the epilepsy.

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

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

An infantryman, 30, a gardener, was wounded in the right forearm by a shell fragment, which fractured the ulna, September 7, 1914, at Revercourt. Despite much fragmentation of the bone and suppuration, the wound healed with two cicatrices, where the fragments had gone in and had come out. The scarring process was over in December.

However, in the middle of January, 1915, this man began to suffer from headaches and insomnia, with vertigo and buzzing in the head, “as if an airplane inside.” Sometimes arms and legs would stiffen, and the man would tremble, have to lie down, and even lose consciousness for a quarter of an hour, waking up tired, wandering, and with feelings in his head. These crises, at first occurring every week, later grew frequent. Finally there was a very complete attack, in which he fell out of bed, got up, made several turns about the room, and went back to bed; and in the morning, was dull and disoriented. Accordingly, he was sent to the central military neuropsychiatric service of the general hospital at Montpellier, November 10.

Besides the two extensive cicatrices, there were motor disorders. Pronation and supination were almost impossible, as well as extension of the hand and fingers and abduction of the thumb. There was a radial paralysis without R. D. Electrical excitability of the extensors was diminished on the right. The hand was weak. The right thumb was atrophic. There was a hypertrichosis as well as redness, heat and perspiration of the right hand. There was a hypesthesia for all forms of stimulation in the hand, especially in the radial region; less in the ulnar region. This hypesthesia rose along the posterior surface of the forearm and covered all the territory of the ulnar nerve; but there was a corresponding hyperesthesia in the musculocutaneous distribution, as well as in the internal cutaneous distribution. Above the scar there was a region of complete anesthesia. The hyperesthesia rose higher along the circumflex nerve and the posterior branches of the cervical nerves and included the great occipital distribution, even involving the superficial cervical plexus, though not the territory of the trigemini. There was some hyperesthesia of areas governed by a few dorsal intercostal nerves. There were also spontaneous pains in these hyperalgesic regions. The _musculocutaneous nerve_ could be felt to be _thick and swollen_, indicating a perineuritis. There were no neuropathic stigmata, but the knee-jerks were exaggerated a little more on the right side.

The convulsions appeared two or three times a day, the pain would get worse along the arm, rise to the head, following the hyperesthetic zone, then invade the interior of the head, whereupon objects would appear to turn and the ears would buzz. The right leg, and especially the right arm, would begin to tremble. The man would have to support himself to avoid falling. He saw shadows moving, colored trees, occasionally persons. When the vertigo got stronger, he lost consciousness. The extremities of the right side stiffened and carried on jerky movements. These sometimes extended to the left side. The seizure lasted from five to fifteen minutes, and sometimes occurred in the middle of the night. Fatigue followed but headache disappeared after an attack.

The diagnosis of Brown-Séquard’s epilepsy was made. If the musculocutaneous trunk was compressed, a crisis was produced with pain radiating to the head, obscuration of vision, numbness in the arm, and tremors. Electrical treatment was resorted to for analgesic effect. There was a certain improvement during May, so that the diurnal dizziness disappeared. May 19 he had a period of 24 hours without any vertigo. In June no further improvement occurred.

An operation was performed June 23, 1915. The two cicatrices were excised, and some fragments of cloth were removed. Three Jacksonian crises followed the operation, and there was another seizure next day. Frequent headaches followed without crises. More seizures appeared in the night during July, and their frequency increased. Pains persisted along the arm and in the back of the head; the musculocutaneous perineuritis was still intense. Prolonged baths for the arm were begun August 4, two baths of two hours each, at 40 deg. each day. Following August 10 there was an improvement, which stopped as soon as the baths were omitted, with diminution of the vertigo and the hyperesthesia. This improvement continued; the baths were made to last three hours. There were no attacks from August 21 to 26 whereupon they then returned for two days. The pains had much diminished in the arm but persisted in the occiput. A few night attacks occurred August 30 and 31, September 5 and 6, as well as September 19 and 20, 25 and 26, and 27.

The occipital pain had now become less; the musculocutaneous nerve was not so large. Only a few headaches followed during the months of October, November, and December. After November 3 the baths were stopped and the arm was kept wrapped in a warm compress. There was still a certain hyperesthesia, the knee-jerks had become less exaggerated. Massage and mechanotherapeutic exercises were begun. There were no more attacks after September 27.

_Re_ Brown-Séquard’s epilepsy, Lépine remarks that besides the case of Mairet and Piéron, Hurst and Souques have published cases. Lépine himself has observed two cases: one followed a nerve wound in the foot; another, a penetrating wound of the chest. As a rule, such Brown-Séquard epilepsies appear a number of months after trauma; as a result of irritation in the scar. Lépine’s subjects were taken for simulators because they had not received any _cranial_ wound. The prognosis should be guarded, though the outcome in Case 69 appears to have been favorable.

Epileptic episode at 24 years following bullet-wound of hand, in a soldier who had had convulsions in childhood (sister epileptic). Reactive epilepsy? Epilepsia tarda?

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

A man in the reserve, 24, bore the stresses of the war very well in the campaign in East Prussia until he was shot in the hand at Deutsch-Eylau. He had always been well aside from rheumatism, and was discharged with a good record from his military service.

Sent to the reserve hospital for his hand injury, he had, two or three times in the night, convulsions with loss of consciousness and dilated pupils; after which there was a thirty-six hour period of depression with refusal of food. Thereafter this soldier had amnesia for both the seizures and the subsequent depression. He was observed six weeks longer in the Charité Clinic but had no more attacks, and indeed nothing more of note either mentally or somatically.

The history showed that there had been convulsions in the third and fourth years of the patient’s life. There had been, however, nothing epileptoid in the later childhood or developmental years of the patient. However, a sister of the patient had suffered since childhood from convulsions. It remains a question whether this episode is to be regarded as reactive epilepsy--reactive, namely, to experiences in the war--or whether we are dealing with a true epilepsia tarda.

_Re_ this episode following bullet wound, the compiler has placed it after Mairet and Piéron’s case of Brown-Séquard epilepsy, but apparently Bonhoeffer regards his case as probably a reactive one. Unlike the case of Mairet and Piéron, Bonhoeffer’s case had an epileptic soil (convulsions in childhood and epileptic sister). _Re_ the so-called reactive epilepsies, see remarks by Bonhoeffer under Case 57.

Epilepsia tarda in a lance-corporal without hereditary taint or previous history save dizzy spells and excitability.

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

A reserve lance-corporal, 24 years--a soldier from 1911 to 1913 without disciplinary record, and in his second year becoming lance-corporal--was in the campaigns in Belgium, East Prussia, and Poland, making long marches and going through several battles. In the middle of October, 1914, he fell from a horse and suffered a contusion of the thorax, after which blood appeared in the sputum. In November he was brought to the reserve hospital in Berlin, and there had convulsive seizures. Before transfer to the Charité Clinic, a seizure occurred, and he was brought into the clinic in a characteristic dazed state. Thereafter he was clear but often out of humor and irritated. Three weeks later came a brief attack, probably epileptic in nature, with restless half-delirious sleep following.

There was nothing in childhood or in the family history to indicate epilepsy. However, the patient himself stated that from 1913 onward, after his period of military service, he had from time to time felt attacks of dizziness after exertion, and that he had become more easily excitable than before.

The attacks in the lance-corporal are probably not to be attributed to the thoracic contusion, according to Bonhoeffer, because of the long period that elapsed after the thoracic injury, and their development nocturnally without special occasion. According to Bonhoeffer, we are probably here dealing with a late epilepsy.

_Re_ late epilepsy, see also under Case 57. Bonhoeffer makes a considerable point of the lateness in attacks of epilepsy in some of the military cases, pointing out their beginning at the ages of 22 to 27 in the period of peace practice undergone by soldiers. The theory is that cases of severe and long-standing epilepsy are known to the authorities, so that they would not ordinarily be in military service except under conditions of concealment or in case of error. The present case (71) appears to be the nearest that Bonhoeffer has found to a case of epilepsy without heredity and without acquired soil. All that can be regarded as evidence of soil is the dizzy spells and excitability.

_Re_ thoracic contusion, compare remarks of Lépine under Case 69, on Brown-Séquard epilepsy following thoracic wound.

Convulsions by autosuggestion.

=Case 72.= (HURST, November, 1916.)

A private, 27, is described as a typical martial misfit--in private life a music hall falsetto singer, and afterward a valet. He joined the army in 1915 and proceeded to France, and worked in a canteen. A week later, men broke in and threw a mallet at him, whereupon he immediately had a fit, and was dazed, dumb, and unable to walk for two days. Thereafter occasional further fits occurred, with nervousness and insomnia. He was sent home in September, 1916. Discharged to duty, he again in December returned to France, had six fits in the first week--three in hospital, two on the boat, and between two and four for four days after admission. The diagnosis of genuine epilepsy was made in France by a medical officer who had seen one of the convulsions. However, he had never passed urine or bitten his tongue, had no family history, and had never had fits before going to France.

He was hypnotized and given the suggestion that he would have a fit. In the convulsion which followed the plantar reflexes remained flexor, but otherwise the convulsion was quite like the genuine epilepsy. He was told that he would not have any more convulsions, nor did he have any more except on Feb. 16, 1917, when some talk was made to him about returning to duty. Bromides used in France did not help the epilepsy at all. This patient developed a gait and speech defect copied from two patients in the wards. These symptoms, due to autosuggestion, disappeared on persuasion.

_Re_ autosuggestion, Bernheim has returned to the fray (1917) in a book on automatism and suggestion, dealing only in small part with war problems. The most general formula for suggestion appears to be that it is an _idea accepted_. A suggestion offered but not accepted is in effect not a suggestion at all. Any accepted idea, says Bernheim, is from the psychological point of view as well as from the medical point of view, a suggestion. A suggestion may be direct or indirect, reasonable or unreasonable, brought about by

(_a_) mere verbal assertion,

(_b_) hypnotic state,

(_c_) persuasive explanation, rational or emotional,

(_d_) emotion (that is, emotion not the effect of any form of suggestion offered by the physician, but emotion brought about by some event affecting the sentiments of the subject).

Epilepsy of emotional origin.

=Case 73.= (WESTPHAL and HÜBNER, April, 1915.)

A lieutenant without neuropathic tendencies (except that his mother was in a hospital for the insane) was under shell fire for some time. Finally, a shell burst near him, whereupon headaches and transient spells of confusion followed. Shortly upon the news of the death of his Major, he had a spell of violent excitement and confusion, dancing about on the ground and breaking things up. He passed into a stuporous condition with a suggestion of catatonia. There were a few isolated delusions to the effect that he was poisoned. After sleeping a long time, he suddenly cleared up. There was an extensive amnesia covering a period of weeks. He had forgotten the Major’s death and everything thereafter. He complained of headache, difficulty of thinking, and forgetfulness. An agoraphobia developed, as well as great sensitivity to sounds, and a feeling as if the bed and surrounding barracks were moving. There were a few illusions of a visual nature. He had complete insight into his condition. Conduct was normal. There was general hyperesthesia and ageusia.

According to Westphal, this case of deep disorder of consciousness of some duration in a healthy person is probably one of a dazed state following the so-called “affect epilepsy.”

Is Case 73 Shell-shock? Note that, in Case 73, the shell explosion at first occasioned mere headaches and confusional spells. The true occasion of the convulsions appears to have been the news of the death of a superior officer. It is, of course, possible that the transient spells of confusion were actually epileptic equivalents. Lépine remarks that Pierret and others, observing such spells of confusion often accompanied by agitation, have inquired whether manic depressive psychosis is not a kind of epilepsy. This question remains unresolved. These phenomena of epilepsia larvata (see also Case 81 of Juquelier and Quellien) are to be sharply distinguished from attacks of confusion occurring in pronounced epileptics. These latter attacks often follow a crisis and suggest exhaustion; sometimes they last several days.

Fatigue; fear; hysterical convulsions. Visual aura (approaching fire wheel) built up after the third crisis (scotoma after look at sun).

=Case 74.= (LAIGNEL-LAVASTINE and FAY, July, 1917.)

A sapper, 23, with his company under heavy bombardment, October, 1916, was overcome by weariness and fear (he had always been of a timorous disposition). The order for the rear came, but the convoy was hardly en route when the sapper felt a griping in the pit of the stomach and the blood going to his head; whereupon he lost consciousness and went into convulsions.

This incident seems to have made a powerful impression upon the sapper. A fortnight later, while working in the trenches, he had more epigastric sensations with vague discomfort. He thought about the earlier crisis and about his wounded comrades, and again fell down and had more convulsions lasting a quarter of an hour. The tongue may have been slightly bitten in this seizure. In the genesis of this second seizure we may consider that the feeling of discomfort and the epigastric sensations served to recall the first seizure, so that the second one may be regarded as due to autosuggestion--that is, as hysterical.

A little later, on a hot day in the trench, while working, the sapper turned to a comrade and saw a great black spot on his face. He turned toward another and saw another great black spot on this face also. He was frightened, felt strange sensations, fell, and had a third convulsive crisis. The black spots that he saw were due to a scotoma, the result of a transient glance at the sun.

After this scotomatous episode, his crises always had a visual aura. He would feel rather uncomfortable, leave the supper table, feel a gastric sensation, warmth in the face, and oppression. He would go out in the cold for the air, look about for something, appear frightened, fix his gaze upon a certain point, and cease to reply to questions. His head would jerk back suddenly, and he would utter strangled cries of fear. He was now evidently prey to a terrifying hallucination. In ten minutes, everything had gone again, leaving him trembling with emotion. He would then relate how, after the epigastric sensation had begun, he tried to see if he could make out something abnormal; whereupon a little fiery wheel would appear and roll up nearer and nearer, so as to almost touch his eyelids. He could see his comrades to the right and to the left of the wheel; he could hear questions but could not answer. Just as the fire wheel was about to blast him, consciousness was lost and the fits came on.

War strain; anxiety; confusion; fugue. Demotion and detail to the interior.

=Case 75.= (BARAT, November, 1914.)

A lieutenant, 25, an officer in a regiment on active duty near the front, was called before a special board charged with desertion in the face of the enemy. He had been assigned to a certain position but not only had not complied with the order, but had wandered off to the British sector and been arrested there as a spy.

The prisoner was well developed, without stigmata; heredity, negative. His career in the army had been courageous and he had been advanced several ranks and was about to be given a medal for bravery. He said that he had been under a severe strain for several days.

One evening he had been given the order to attack. The artillery opened fire. He found that the Germans had erected barbed wire defences. The loss of men was terrific. His order was to shoot all who held back. A poor territorial crouched down and would not go forward--supplicating the prisoner not to shoot him. The prisoner spared him.

The next night the order to attack the German trenches was again given. This time he was overcome with anxiety and discouragement. The last he remembers was the order to attack. Next day he felt sick and his mind was foggy. He remembered leaving his regiment and wandering round for several days until he fell into the hands of the British and was arrested. Then he understood what he had done.

The prisoner asked to be allowed to return to the front. The testimony of one of the lieutenant’s men verified his statements. On the day before he left the front he had been anxious, had cried often, and would speak to no one. On the day he left the trenches without permission, he was nervous and disoriented.

There was no doubt that simulation could be ruled out; the differential diagnosis lay between a “confused state of emotional origin” and an “epileptic dazed state.”

For epilepsy there was a history of attacks with falling to the ground and loss of consciousness, without involuntary micturition or biting of tongue, during the time when he was a sergeant. Moreover, irritability and unwarranted suspiciousness had been present at these periods. However, there were no other epileptic symptoms; these two attacks were isolated and of quite long duration, leaving no headache or malaise after them. Also there was no basis for the diagnosis “epileptic dazed state,” since there was no abrupt commencement; the loss of consciousness was never complete (the subject was able to converse with persons while the attacks were on); and some remembrance was present of incidents during the attacks.

For Barat, the important points are that the attacks were preceded by long periods of anxiety and the disturbances resulted more from moral than physiological causes.

The importance of the psychological factors lead the author and his colleagues to the diagnosis “Mental confusion of emotional origin.”

The board decided to return him to the interior and give him a barracks position at the reduced rank of drill sergeant.

A solitary epileptic episode in an artillery officer (slight concussion of the brain two years before) following extraordinary campaign stress (38 artillery battles in two months).

=Case 76.= (BONHOEFFER, July, 1915.)

A first lieutenant of artillery, 35, was able to count 38 artillery clashes in which he had taken part in two months of very strenuous, almost daily fighting. Then appeared headaches, anxiety, dizzy feelings, insomnia. Finally one day suddenly, after eating, the lieutenant sustained a loss of consciousness with convulsions, which sent him to his home reserve hospital. The officer had felt nothing before his convulsions came on. The medical report, however, yields no doubt of the epileptic character of the attack.

When he was examined, there was a slight psychopathic depression with a feeling of insufficiency, anxiety, insomnia, restless dreams, over-sensitiveness, and a pessimistic outlook on the future. There were no epileptic traits whatever. There was nothing alcoholic, luetic, or arteriosclerotic about the officer. There was nothing in the childhood or youth of the patient, though there had been a fall two years before, with phenomena of concussion without sequelae. In fact, this fall with concussion had led to no medical examination.

As to the relation of the concussion two years before to the epileptic attack, Bonhoeffer is inclined to interpret the case as one of genuine “reactive” epilepsy on the basis of continuous overstrenuous work for a period of weeks. He regards the previous concussion as soil for this epilepsy.

_Re_ amount of stress occasionally required to bring out epilepsy, compare Hurst’s Cases 64 and 80. It may be recalled that Bonhoeffer is decidedly of the belief that exhaustion has not brought about any actual psychoses, calling attention to the remarkable absence of psychoses among the Serbians after their exhausting campaigns. A general review of war experience indicates, according to Bonhoeffer, the marked power of resistance of the healthy brain.

Nocturnal narcoleptic seizures accompanied by spells of somnolence in the day, both to be regarded as due to the “brain fag” of trench life.

=Case 77.= (FRIEDMANN, July, 1915.)

A tradesman, 23, had been in the German infantry since the beginning of the war. Never sick, he had been, in a general way, nervous; and a brother had had, at the age of 30 years, some sort of severe brain disease, in which he became blind, dying a year later.

The man was for a long time in the trenches and proved himself a courageous and stalwart soldier. He went to hospital after a slight bullet wound of the leg, with a benign paralysis of the peroneus.

In the hospital he began to show a somewhat pronounced emotional depression, with a nervous tachycardia.

Friedmann reports the case on account of certain peculiar seizures which, upon the man’s own story, had begun five weeks before, in the field, although he had told no one about them. He had never felt anything like them before. At first, they came three to five times almost every night. He would suddenly wake and find himself unable to move, to speak, or even to think. These seizures, however, were not accompanied by any feeling of anxiety or any respiratory distress. Consciousness remained clear, and after 10 or 15 seconds, he could begin to think normally again. It was clearly a question of psychopathic absences of a mild narcoleptic type, occurring, however, only at night.

Daytimes, also, throughout the whole period in which the nocturnal absences occurred, there were seizures of another description. During the many hours in which he had to sit in the trench, about twice a day for half an hour long, he would plunge suddenly into a sort of irresistible lethargy. Without any external occasion whatever, there would be a feeling of great fatigue. In the spell he could not move or think, would lean his head upon his hand. He was unable to overcome the feeling of weariness and became convinced that he was ill, and that the fatigue could not be natural. However, he did his work like the rest. Friedmann interprets these spells as a kind of imperfect sleep.

The patient was physically healthy and stalwart, mentally not excitable, and tolerably tranquil in the midst of shell fire. He would never have been reported sick had it not been for his wound. Aside from the tachycardia, of which he himself complained little, nothing wrong was found in the hospital. There was, to be sure, a feeling of discomfort without any hysterical tinge, and sleep was restless. Aside from the peroneus palsy, the injury made a good recovery. The nocturnal attacks persisted; bromides and even luminal failed of effect. There was, however, no longer any somnolence by day. In fact, for the five weeks of observation, there was no change in his condition.

Friedmann states that mild emotional alterations are not infrequent in the trenches with minds disposed thereto, although emotional shock, especially in shell fire, is the most frequent cause. However, these particular seizures are quite unusual. The stresses of field service lead to a sometimes complete paralysis of mental power, interfering transiently with service. There is no evidence of sudden circulatory disturbances such as would bring about dizziness, pallor, nausea, or fainting spells. According to Friedmann, the regulative brain functions, especially those that maintain consciousness, become weak on account of a condition which he terms _Gehirnmüdigkeit_, or, as we should say in English, brain fag. The situation forbids due completion of sleep. Thus, the explanation of the daytime attacks follows rather obvious lines of brain fag. The accidental awakening it is, which at night produces the absences; the wakenings are due to the general restlessness of the patient. The general weakening of cerebral function produces the disorder at the moment of wakening, since the regulative factors of consciousness are already out of order. The condition in the absence rather closely resembles the state of consciousness just before going to sleep, and also perhaps the state of consciousness during the process of awakening. It is as if the process of waking were somehow delayed a few moments. Friedmann is interested to show the relation of such absences to the so-called _gehäuften kleinen Anfälle_, originally described by him in 1906 as occurring in children, and distinguished from epileptic attacks. These attacks, after lasting for years, finally disappeared completely. The same sort of thing in adults was symptomatic of some other disease, such as neurasthenia, and was not a true entity. In children these attacks failed to be attended with any mental injury, nor were there any pronounced epileptic phenomena. Bromides had no effect upon them, and they already showed a somewhat striking and peculiar appearance, involving interruptions ten seconds long of capacity to think, speak, or move, without disturbance of consciousness or automatic movements. Sometimes the attacks occurred from six to 100 times in the day, without in any respect interfering with the general condition of the child. The occurrence of such series of mild seizures is nothing but a syndrome. To be sure, some cases turn out to be cases of genuine epilepsy with an eventual degenerative process. Some forms belong in the spasmophilia group, and some among the hysterias. However, according to Friedmann, there is a narcoleptic _petit mal_ that is an entity by itself, proceeding after a period of years to complete recovery without complications. It is this form which may be regarded as a peculiar kind of brain fag. The case of the soldier may be supposed to be one which will prove to have this benign outcome.

Sham fits.

=Case 78.= (HURST, March, 1917.)

An unwilling conscript developed numerous fits on board ship coming from Jersey, three days after enlisting. _Fifty_ more developed during two days in hospital. He was sent to Netley.

On the hypothesis of hysteria or malingering, he was hypnotized. A fit was suggested to him, but did not come off. The Sister was informed in the patient’s hearing that the man was clearly shamming, as in all genuine cases a fit would occur after this treatment. A fit with marked opisthotonos immediately occurred. This fit immediately stopped when he was ordered to stop it and to wake up.

The man after waking promised to have no more fits.

Epileptoid attacks, controllable by will.

=Case 79.= (RUSSEL, August, 1917.)

A man was received in No. 3, General Hospital: Diagnosis, epilepsy. He was shortly sent to the convalescent camp and then returned, having had two attacks. Russel watched for another attack, felt it was not genuine and “put the situation up to” the soldier whose story was as follows: He had been at the front without leave for twelve months since the German retreat. Leave was due him. A sister’s letter said his brother was severely wounded and his mother was praying for his return. When he thought these things over an attack came. He could, however, control the attacks. Russel told him, if he would play the game, he would be sent to the base with a recommendation for leave. In ten days the man was remarkably changed and had no further attacks.

Hereditary epileptic taint brought out by two years service with eventual shell-shock and burial thrice in one day.

=Case 80.= (HURST, March, 1917.)

A private, 24, in the army from 16, never epileptic (sisters epileptic), was wounded four times in the war from September, 1914. Shell fire did not worry the man, but he gradually became depressed after his father and five brothers had died in active service. He was blown up and buried three times in one day in July, 1916. He was unconscious for two hours after the second blowing up, but carried on for two hours more until blown up for the third time.

After this, he became nervous and shaky, and began to sleep badly, and a month later had a typical attack of major epilepsy. Fits occurred with increasing frequency. As many as 19 occurred in a single day. Rest and bromides caused the fits to cease, and there had been none for six weeks at the time of his discharge.

_Re_ the extraordinary delay in the bringing out of this epileptic’s taint, refer back to Case 76 of Bonhoeffer, with its discussion, and to another case of Hurst (64).

_Re_ Shell-shock and its relations to epilepsy, see below, discussion under Cases 82-84 of Ballard, who has erected a theory of Shell-shock as in some sense epileptic.

Shell-shock: Epilepsia larvata.

=Case 81.= (JUQUELIER and QUELLIEN, May, 1917.)

A soldier, 29 (father alcoholic, died in hospital for the insane), a decorative painter without plumbic history, non-alcoholic, non-syphilitic, was wounded once, September, 1914, but returned to the front in 1915.

May, 1915, a shell burst near him. He lost consciousness, regained it a few days later at Brest, and was so far recovered that he could go on leave in seven days. While on leave, he had short attacks of delirium, followed by a total amnesia; there was, however, no crisis, fall, or convulsion. After the first attack, he had for 24 hours malaise and headache, but got well and went back to his dépôt. Shortly afterward more attacks of this sort recurred, and he went to hospital and thence to the neurological centre at Tours. Whence, August 9, 1915, he got a two-months’ leave for “mental disorder post-confusional, _second état_, probably hysterical (_commotio cerebri_), and organic hemiparesis.”

November, 1915, after returning to the dépôt, there were more spells and he went again to hospital. Invalided December, 1915, he passed a year at home, but the spells continued. Although the epileptic nature of these attacks was maintained by Francais at Évreux, he was placed in the auxiliaries, December, 1916, but had to go to hospital almost at once, and, February 28, 1917, entered the neurological centre of the 9th Region for the second time. Here, when called to be examined two days after admission, he was observed in an attack. He suddenly rose from the bench, made a few steps, seemed to be listening and anxious, as if he ought to be on guard. He looked up, seemed to be looking for something whose noise was approaching, lowered his head, made a slight jerking movement, and said, “Poum!” as if to express the noise of an explosion. He took a few more steps, the same movements were repeated, and the same “Poum!” was uttered. This lasted for about a quarter of an hour, during which the patient was unaware of his surroundings. He could be guided all about the hall without resistance, but did not respond to orders, commands, noises, or contact. In short, the patient was in the midst of a hallucinatory dream at his post in the trenches, undergoing a bombardment. He was placed in a chair; remained motionless for a few seconds, woke up, and answered questions. “Where am I? Oh, yes; I must have been sick because my head feels bad.” In answer to the question. “What did you see; what was there?”, he said, “I don’t remember anything. I never remember. I don’t know.” The patient was dull and weak after the spell.

These spells varied in number but occurred once a week. The patient was able to tell of certain attacks that had occurred while he was out of doors at home.

Now and then, there was another theme in the hallucinatory delirium, namely, a pencil drawing of a woman’s picture, of no great artistic worth but carefully done, at which the patient was much astonished on awaking.

It seems as if auto- and hetero-suggestion can be eliminated from the genesis of these attacks. Neither hysterical nor epileptic crises have preceded or ever alternated with these seizures. Nevertheless, on the organic side, the patient had a general increase of tendon reflexes on the left side, most marked in the knee-jerk, and fell to the left in voltaic vertigo. There was a left hemiparesis, apparently of organic origin, which had been determined as far back as July, 1915.

There was no true dementia. Past memories were but slowly recalled, and inattention interfered with the fixation of recent memory. He complained of troubles in his sleep and dreamed of war experiences somewhat analogous to those in his attack of amnestic delirium. After the seizure, there was a marked hebetude and mental inactivity, torpor, and a severe headache. The case was presented to a special commission as one of epilepsia larvata in a person hereditarily predisposed who had never before presented epileptic signs, suffering from a disease characterized by frequent short attacks of hallucinatory and delirious automatism, following shell explosion which had at the same time produced a slight left-sided hemiparesis and mental inhibition.

To illustrate an epileptic theory of Shell-shock; three cases:

1. Fugue; minor symptoms: later, epilepsy.

2. Epileptic confusion eight months after explosion.

3. Mine explosion: stammering replaced by mutism; mutism
replaced by epilepsy.

=Case 82.= (BALLARD, 1917.)

Atmospheric concussion from shell explosion, October, 1915, was followed by unconsciousness in a soldier described by Ballard.

Blindness for a month followed recovery of consciousness. “Neurasthenia” (anxiety neurosis) after return of sight. Apparently nearly complete recovery after latent period of a few weeks. Return of blindness in one eye in December. Five days automatic wandering (the man was found in a west country town five days after leaving home to rejoin his dépôt and seen by a medical officer who reported that he was dazed and amnestic for that period); admission to second Eastern General Hospital, December 15.

On admission he proved to be suffering from minor hysterical symptoms such as an inability to open his eyes and to see clearly when the lids were raised. The symptoms rapidly cleared up under suggestive conversation and did not return except for amnesia and slight emotional depression. He remained well until December 25. On that day he began for the first time to have definite epileptic fits and nocturnal epileptic delirium. In January he was discharged as an epileptic. There was no epileptic temperament or feeblemindedness. Finally, there had never been any personal or family neuropathic or psychopathic history.

=Case 83.= (BALLARD, 1917.)

A soldier was blown up, April, 1915, and had a spell of unconsciousness. Later, pains in the head, slight amnesia and a condition of asthenia developed.

He was eventually admitted to the second Eastern General Hospital at Brighton, January, 1916. At the time of admission he was semiconscious, stuporous, confused, disoriented, anxious in a dull sort of way, talking about his expectation of “a sailor with a card.” Speech was intelligible, though fragmentary and infrequent. The man obeyed commands but gave no replies to questions. The mental processes were slow and impaired.

According to Ballard, we have here a case of epileptic confusion, eight months after the initial concussion. This particular attack ceased three days later, leaving amnesia for the attack and a certain amount of mental retardation. The man was not epileptic in temperament and his personal and family history proved negative.

=Case 84.= (BALLARD, 1917.)

A soldier was buried in a mine explosion, October, 1915, and for several days thereafter was unconscious or semi-conscious. He emerged deaf and subject to stammering and a condition termed “neurasthenic.” The stammering was soon replaced by mutism, which lasted several weeks. The mutism was then supplanted by epileptic fits.

He was observed by Ballard in a dreamlike, disoriented and inaccessible state, in which he was anesthetic to pin pricks, lay awestruck, dumbly following with his finger hallucinatory airplanes. Flexibilitas cerea was also shown at this time.

Next day he emerged from the dreamlike state with mental processes somewhat slowed, disorientation for time, amnesia for the attack, memory disturbance and a return of the stammer. On the next day following, all these symptoms had disappeared except amnesia for the attack. Another spell of epileptic fits occurred later. It seems that the man had had a convulsion thirteen years before and occasional convulsions since. In fact, he, seven years before, had had what was called “a stroke” and residuals of a slight hemiplegia were still present. (There is no statement in the case report relative to syphilis.)

Emotion; shell fire: Epileptic equivalents.

=Case 85.= (MOTT, January, 1916.)

A man, 19, suffered from shock due to emotional stress and shell fire. He had terrifying dreams. After a short time, he developed paroxysmal attacks of maniacal excitement. Just before the first attack he had been helping in the kitchen, lay down on his bed, went to sleep, woke, startled, flushed, and sweating, and made for the door as if terrified. He remained in this state as if suffering from hallucinations of sight and hearing, and without ability to recognize his wife, the doctors, or the Sisters. When two strangers in uniform came in to observe him, the adjutant became violent, as if the uniforms had started terror anew. The attacks lasted from a few hours to a few days, coming on suddenly, without apparent cause. One day he tried to get over the wall of the playground. He came back and buried his head in his hands. Major Mott spoke to him, whereupon he got up, looking terrified, made for the door, and four orderlies were required for his restraint. At Napsbury Hospital, to which he was sent, he made a complete recovery.

Mott suggests that we are dealing with a psychic equivalent of epilepsy.

_Re_ epileptic equivalents, compare notes from Lépine under 58 and 59.

IV. PHARMACOPSYCHOSES

(THE ALCOHOL, DRUG, AND POISON GROUP)

Pathological intoxication.

=Case 86.= (BOUCHEROT, 1915-6.)

A Territorial infantryman, aged 37, was in the habit of drinking a good deal without getting drunk, and at the front drank a good deal of bad brandy. He had just taken a considerable quantity when his regiment got the order to charge. The charge was hardly over when the man became greatly excited and hallucinated. He thought he was surrounded by Germans and tried to transfix his comrades with the bayonet. Howling and struggling he was carried to the rear.

He was soon brought to the asylum at Fleury after howling all night and seeing the Boches and animals fighting among themselves. His hands and tongue were tremulous and there were cramps in the calves of his legs. On the 6th he expressed astonishment to find himself in hospital and was found to have but slight memory of what had happened. He remembered, however, that he had tried to kill his comrades. With the deprivation of alcohol he became rapidly normal and was sent back to the dépôt in a few days.

_Re_ alcoholism under army conditions, Lépine remarks that alcohol has played in this war a rôle analogous to that of malaria in the epidemiology of some countries. Many of the victims are, to start with, unbalanced subjects and _détraqués_ who are hereditary alcoholics. Alcoholism, according to Lépine, dominates the pathology of the interior and has a marked bearing upon conditions at the front. In fact, alcoholism would have been disastrous in France had not measures been taken against it; measures still insufficient (1917). More than one-third of 6000 cases studied by Lépine during three years have shown alcohol as a sole or, at all events, principal cause of the difficulty. It would be within reason to state, according to Lépine, that if we throw in cases in which alcoholism was a partial factor, more than half, or even more than two-thirds, of the mental cases had been strongly influenced by alcohol. Lépine thinks there may be effects like those of anaphylaxis. Certainly, the startling and sudden effects in so-called pathological intoxication, as in Case 86, suggest the critical and vehement effects seen in the sensitized anaphylactic subject.

CHART 4

PHASES OF WAR PSYCHIATRY IN FRANCE

I. Antebellum phase of PSYCHIATRIC NEGLECT: Groundless fear
that recruiting would be disorganized by psychiatric
sifting processes.

II. Phase of ALCOHOLISM OF MOBILIZATION: Hospitals unprepared.

III. Phase of the MARNE: Alcoholism restrained by law;
psychoses few; psychiatrists optimistic.

IV. Phase of TRENCH WARFARE: Overemotionality; and of HIGH
EXPLOSIVES (January, 1915); now psychiatric services were
systematically established along evacuation lines.

V. Phase of SYSTEMATIC WAR PSYCHIATRY: Filterwise system of
management (_a_) near trenches, (_b_) in main body of
army, (_c_) on evacuation lines, (_d_) special hospitals.

Chiefly from data of Chavigny, 1915.

Pathological intoxication: criminal prosecution stopped.

=Case 87.= (LOEWY, 1915.)

An orderly, in private life a teacher, one day about _noon-time_, when going on duty, called the commanding officer to account because he (the orderly) had had to wait. He said he had been ordered to come at _two_ o’clock and it was already long thereafter! He was severely reprimanded but addressed a number of the officers present with questions having no relation to military service. In fact, he seemed to have forgotten entirely that he was on military service.

This was the more remarkable as the teacher-orderly had many times distinguished himself upon dangerous patrol expeditions and in critical situations, winning the confidence of his superiors and the likelihood of promotion to corporal. He had been a discreet, earnest, and clever soldier.

Loewy observed him during this affair and noticed that he did not by language or movement suggest intoxication or hilarity but merely a certain excitement. He was entirely oriented for time, place and person, and his outward behavior was correct enough except for his military rank.

Sent to his quarters near by, he gave the impression to his immediate superior officer of deep drunkenness. He murmured something and soon fell into a deep sleep. After waking, he had an almost complete amnesia, knowing only that something disagreeable had transpired. He remembered that he had been offered several little glasses of cognac brandy by a comrade, and that he had drained them off quickly before going on duty. He said that he had never drunk cognac before, and in fact had drunk nothing for a long time.

The diagnosis of pathological intoxication was made, and the soldier was thereby cleared of his dangerous situation; a criminal prosecution was not instituted. He thereafter behaved with entire sobriety and modesty, and he achieved his corporalcy and later became file leader.

Desertion in alcoholism may deserve the term “pathological.” Case of fugue.

=Case 88.= (LOGRE, July, 1916.)

A “deserter” said: “I went because I drank a glass. I just went, _comme ça_, without any motive.” He was somewhat feebleminded and, in explaining the impulsivity of his act, he added: “I went like a broken-down beast. I walked straight ahead, without knowing where I was going and if I had been going to be killed, it would have been all the same to me.” He could not that afternoon remember very well; but next morning, after having slept, he regained full consciousness. He said that he then found himself in a field near a cemetery. He had carried his gun and equipment with him, but had lost them somewhere, and from a military point of view, his desertion was complicated by loss of effects. On coming to, he said to himself, “Where am I? How foolish after fifteen months in the line! Probably I have deserted again.” In fact, he had a month before left his post under exactly the same conditions in the midst of a period of alcoholic excitement.

This alcoholic fugue is typical: drunkenness, impulsive and subconscious ambulatory automatism, with partial amnesia, disorientation, with mislaying of objects, followed by sleep and immediate return to normality.

_Re_ fugue, see discussion under Cases 58 and 59. The French military code cannot excuse victims of fugue even though executed in a quite unconscious state, if the fugue is due to alcohol. There was a certain procursive suggestion in the fugue of Case 88, who went “like a broken-down beast,” straight ahead, without knowing where he was going.

Alcoholism: Amnesia experimentally reproduced.

=Case 89.= (KASTAN, January, 1916.)

February 15, 1915, a German soldier drank beer in the canteen and at roll-call appeared tipsy. He then went to bed, but rose an hour later to go to town. A quarter of an hour later, he went to a clerk’s house and asked for paper, on the ground that the next day he was going to march to Warsaw. The clerk gave him no paper, which he then tried to get by force. A policeman arrested him and he said, “You just wait, lame dog!” Upon examination he denied that he had ever been guilty of any crime but had been in institutions on account of delirium. In point of fact, this man had grown up in very bad surroundings, amongst quarrels and disputes of his parents, who kept a disorderly house. At 19 he had been convicted of incest. He finally admitted having been convicted for rape. It was found that he had once run out into the front trenches; had been removed by an advance guard to a stable, and then wondered why he was not in school. He described a number of attacks of delirium although he had not drunk more than moderately.

He was given an experimental dose of 50 c.c. of alcohol, and in ten minutes became excited, tried to get out of bed, attacked other patients without reason, and was able to speak neither spontaneously nor in response to questions. In a period of two hours he became clear and asked what the trouble was. He knew only that he had taken alcohol.

_Re_ the experimental excitement produced in Kastan’s case by the exhibition of alcohol, it is of note that Bérard has been much impressed by the agitation that surgical cases of alcoholism undergo when anesthetized. It may be that the anesthetics act similarly to the experimental alcoholism of Kastan’s case. According to Bérard, these phenomena of the anesthetized wounded (who are men recently evacuated from the front and other hospital cases) are of larval alcoholism brought out by the anesthesia. Bérard wonders whether rum issues at the front are at all responsible therefor.

Desertion, drunk. Contributory factors.

=Case 90.= (KASTAN, January, 1916.)

Gottlieb S. left the barracks, January 25, 1915, met friends and drank with them, remaining all night in the railway restaurant and waiting room. He was promptly arrested.

According to the patient, he had always drunk a good deal and had once fallen from his horse in the campaign, and become unconscious. After this fall, he said he had been able to stand less alcohol than before.

There is doubt as to the syphilis of Gottlieb. He said he had been infected once, but his further statement that he had six relapses is, of course, questionable. As to the hypothesis of feeblemindedness, it appears that in childhood he had learned badly and had been a stammerer. He had been a herdsman, and after that a laborer. He finally became a travelling man for a specialty photographer.

He had previously been convicted of an embezzlement, brawling, and breach of the peace.

As to his military crime, he said he had been celebrating the emperor’s birthday the last three days, being urged on by acquaintances and drinking whiskey. He was, in fact, on a spree and did not eat properly. He had met a student in the railway station and had forgotten all about his military service. He remembered having spoken with the waiter, remembered telling the student that he was going to commit suicide, and the student had drunk seltzer with him. January 29, he for some reason drank no more, and then it occurred to him that he ought to go back to duty. He remembered that he was easily led astray. He had once thought of becoming a tanner but had been dissuaded from the trade because of its bad smell.

The analysis of this case must consider, first, syphilis.
Supposing, however, that this hypothesis is not substantiated
by laboratory findings, the hypothesis of feeblemindedness
might well be raised. It seems possible, if not probable,
that this patient was in the subnormal group, lying between
normality and feeble-mindedness proper. The value of mental
tests would here be extreme. There seems to be no evident
epilepsy, and the majority of the phenomena can perhaps best be
explained by alcoholism. Possibly the case is one of so-called
pathological intoxication. The patient’s own story that,
although he had been always subject to drink, he had been less
tolerant of alcohol since a fall from his horse, seems to be
entirely consistent with the post-traumatic history of numerous
cases, so that it would hardly be wise to consider that alcohol
accounts for the whole story. We must raise then in succession
the hypothesis of syphilis, feeblemindedness, alcoholism, and
coarse brain disease, bearing in mind also early stammering.
As to the utilization of such a man, it would appear that a
supervision of him with absolute countermanding of alcohol in
view of the decrease in tolerance of alcohol since the fall
from his horse might perhaps preserve this man for some form of
military service.

_Re_ German and French war alcoholism, Soukhanoff remarks that the conditions in these countries were in strong contrast to those in Russia. In Russia there was a great decrease in the number of cases of acute alcoholic psychosis; particularly at the time of mobilization, there were few cases of alcoholic psychosis. He says that during the Russo-Japanese war, alcoholic psychoses constituted a third of all the mental cases observed. This figure corresponds with that quoted above from Lépine (see under Case 86). Soukhanoff, writing in 1915, had not observed personally a single case of alcoholic psychosis. Incidentally, the number of cases of psychosis in the Russian army had remained in general small.

Desertion by mild alcoholic dement.

=Case 91.= (KASTAN, January, 1916.)

Emil S. made a number of statements when he came for examination. He had once had a treatment by injections. Both his mother and his grandmother had been insane. He said that his brother was an officer in the navy, but this statement was found to be false.

According to his story, he had lost touch with his troop at the end of September, 1914, and had lived in several lodgings in T---- up to October 19, when he was arrested. He said that he did not know that a man who had lost touch with his troop had to report.