Although the American toll of war syphilis has not yet begun and although the crop of neurosyphilis due to war infections may not arrive until the mid or late twenties of the century (witness German experience in the eighties of the last century), it seems proper here to give a number of abstracts re neurosyphilis as it has developed in the war. Available reports from English, French, and German sources have been levied upon for the years 1914–16.

It is clear that all the armies have had their share of neurosyphilitics, some clearly diseased before enlistment, some developing symptoms as a result of training, stress, or shock, others hastened or made worse by war conditions.

There are important questions of pension, retirement, and compensation for neurosyphilitics. No previous war has had the benefit of the Wassermann reaction and other exact tests bearing upon the nature, progress, and curability of neurosyphilis.

That we shall have our fill of pension and other problems can already be seen from continental reports. Thibierge,^[22] for example, states that syphilis has become a real epidemic among the French soldiers and mobilized munition workers.

Hecht^[23] of Austria claims that no less than an equivalent of 60 army divisions have been temporarily withdrawn from fighting on the Teutonic side for venereal diseases. He commends Neisser’s idea that salvarsan and mercury should be given in the trenches. While hundreds or thousands of Austrians are sick with syphilis, sound and healthy men are being shot down in their stead. The diagnosis of syphilis, according to Hecht, ought to be a signal for sending the men to the front. He makes even the somewhat bizarre suggestion that special companies of syphilitics should be formed, for convenience of treatment, on the firing line.

Not only is the syphilis problem in the army of importance to the military authorities, but also to the civil population, and perhaps to them a greater problem. With the great increase of venereal disease that is the result of the conditions of army life in war time, there will be a considerable percentage of cases developing neurosyphilis a number of years after discharge from the army, but caused by the infection acquired during service. In addition many men will bring the disease back to America in an infectious stage and spread it. We would advocate that the names of all soldiers who had acquired syphilis and were not considered cured at time of discharge should be given to health organizations in their home states that they may be given further care.

These practical and several theoretical questions are raised by the following fourteen cases which we have condensed from their sources.

Case A.^[24] 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.

1. Is this a case of traumatic paresis? From the somewhat meagre account it would appear that Donath’s lieutenant should rather be termed “shell-shock paresis,” in the sense of a paretic neurosyphilis liberated by shell-shock (using shell-shock in the sense of a shock without direct brain injury).

2. What compensation is due such a man as Donath’s lieutenant? The ordinary principles applicable to traumatic paresis are not here in point, since no symptoms pointing to trauma of brain ever supervened. See discussion under Case G.

3. How frequent is paresis in armies? R. L. Richards in White and Jelliffe’s Treatment of Nervous and Mental Diseases writes as follows (of course concerning peace times):

“The French estimate that paresis cases are 7 per cent of all their military cases. The German estimate is 6.6 per cent. In our own army at the Government Hospital for the Insane, of 490 cases of mental diseases among officers and enlisted men, 37, or 7 per cent, were paresis. During the Russo-Japanese War, in the Russian Psychiatric Hospital at Harbin, the percentage of paresis was 5.6 per cent among the cases developing at the front.”

Case B.^[25] A French soldier was buried by effects of shell explosion September 8th, 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).

The patient was estimated to be “40% incapacitated,” according to the French “Échelle de gravitÉ” of conditions. A full pension would not be justified in the opinion of the French authors.

1. Is there evidence of an increase or exacerbation of tabes dorsalis in the war? Birnbaum,^[26] reviewing German war neurology, quotes Weygandt as believing that the war has probably had to do with the production of both tabes and paresis in many instances. Other cases, however, have merely been made worse by the war stress. Thirdly, there are cases in which the war stress has done no harm whatever. Westphal has seen both tabes and paresis develop in men who had never before shown any mental or physical symptoms whatever, and accordingly, Westphal must be counted among those who regard war stress as a liberating factor for these diseases. Redlich and Donath are cited in the same connection. (The case of Donath is the case presented above as Case A.)

A very interesting claim was made by Cimbal to the effect that he found many examples of paresis developing in the early period of the war, particularly in November and December, 1914. Later, according to Cimbal, cerebrospinal syphilis and tabes became more prevalent.

Case C.^[27] 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. In the phrase of the Canadian Pension Board the German commission would probably have rendered a report “aggravated on service,” not “by service.” (See Canadian cases D, E, and F.)

1. Has paresis increased in the war? Both French and German figures controvert the claim. Marie, for example, found not a single paretic amongst the skull injury cases at the SalpÉtriÈre. Most authors are found demonstrating cases which they clearly regard as in some way produced or unfavorably influenced by the war. There seems, therefore, to be a little inconsistency between the general statement that paresis has not increased in the war and the somewhat frequent cases described as occurring in and modified by the war. However, Bonhoeffer, on the basis of nine months’ war experience, also holds it to be probable that paresis is no more frequent in the field than in the home population.

2. Is the old syphilitic especially liable to break down under war conditions? According to Richards, Shaikewicz says that in the Russo-Japanese war paresis was noted especially among the officers and non-commissioned officers, and that it was undoubtedly hastened in its development by war conditions. Steida says that while ordinarily we find paresis developing twelve to twenty years after the primary sore of syphilis, in these cases it developed in five to ten years after the primary sore. Some of the cases progressed with unusual rapidity. It was also noticed that among soldiers from the front, under treatment, evidences of syphilis were present in 20%, while among the other soldiers under treatment, evidences of syphilis were present in 1.6%. Undoubtedly the old syphilitic is especially liable to break down under war conditions.

But, on the whole, the German authors in this war find no evidence favoring Steida’s claim of the hastened post-infective outbreak.

3. How did it come about that the efficient German system permitted this alcoholic and weakminded syphilitic to enter the army? As will be seen, he was a volunteer. In general, the German system has been supplied with army surgeons who have been trained, not by brief and “brush-up” courses, but by longer periods, sometimes two years in duration.

Case D. 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, dyspnea.

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. (See Case E, “aggravated on service.”)

1. In view of the fact that the majority of the cases here abstracted happen to be in common soldiers, is there any evidence bearing on relative incidence in officers and men? Quoting R. L. Richards:

“The percentage of paresis cases among officers alone is variously estimated from 50 per cent in the German army (Stier) to 58.9 per cent in the Austrian army (Drastich). Since paresis is a disease of more advanced life, it is but natural that the percentage of paresis among officers, non-commissioned officers, and older soldiers should be higher than among the whole military body, where the average age is, as we have seen, well below thirty years. Hence the above figures do not mean a greater prevalence of syphilis among those classes, but that we have no means of knowing how many of the others develop paresis. If anything it shows that these ‘soldiers by calling,’ have a more stable mental make-up, since they succumb chiefly to an exogenous toxin.”

Rayneau at the 19th Congress of French Alienists and Neurologists at Nantes in 1909, discussing the insane of the army from a medicolegal point of view, states that the most frequent mental disease amongst officers and soldiers is general paresis. At least, this disease is the most frequent basis of invaliding, retirement, or placing in the inactive list. He states that French and foreign statistics are at one upon this matter, quoting Christian as finding 32% among the soldiers interned at Charenton; Gamier at Dijon, 59%; Meilhon at Quimper, 42% and Talon at Marseilles, 33.8%. Grilli found 31 of 40 officers interned in Florence, Sienna and Milan victims of general paresis. Stier’s German statistics indicate about 50%. Rayneau himself found 16 of 20 officers paretic and 17 out of 27 subalterns and gendarmes.

The Neurological Society of Paris held a conference December 15, 1916, with the chiefs of the neurological and psychiatric military centres of France, and discussed a variety of questions concerning invaliding, incapacity, and compensation in neuroses and psychoses of war. DuprÉ dealt especially with the psychoses of war as caused by trauma, strain, infection, and intoxication. General paresis is regarded by DuprÉ as the most important of the dementias found in the army. The medicolegal point of view is, of course, that general paresis is necessarily related to an old syphilis, but its late development leads to misinterpretations as to its probable cause, both by the family and friends and even by magistrates. The war acts in the French nomenclature as an agent revÉlateur or as an agent accÉlÉrateur. Although its cause is prior and exterior to the war, general paresis in a majority of cases is brought out (revÉlÉ) by the lack of adaptability of the general paretic to the novelty and difficulties of his surroundings and duties in war. Trauma, strain, and alcohol in a certain number of cases accelerate the progress of a general paresis. The aggravation of paresis is produced by these same factors, but especially by violent cerebral trauma. According to DuprÉ, the Val-de-Grace statistics show that the number of paretics has not been increased by the war. Medicolegally, the victim of general paresis, like the victim of traumatic or infectious chronic mental disorder, may be assigned an incapacity of from 50 to 100%, and these patients are invalided under RÉforme No. 1,—a permanent invaliding.

LÉpine of Lyons also discusses the compensation question in general paresis. LÉpine thinks that, although syphilis is indispensable in paresis, yet the truth is that syphilis plus something else unknown to us is responsible for general paresis. This something else is neither a special kind of virus nor is it a particular kind of prepared soil alone. Trauma, physical, intellectual, and moral strain, and insomnia are the factors to which he calls special attention as adjuncts in the production of general paresis. As to the responsibility of the State for the production of general paresis, according to LÉpine, the maximal responsibility should be 40% on account of the very considerable predisposition to paresis created by pre-existent syphilis.

Marie remarked that, although there had been thousands of head cases at the SalpÉtriÈre, there had not been a single case of general paresis. DuprÉ agreed with Marie that trauma was not a frequent etiological factor; strain and alcohol were more important. The Society agreed that in exceptional cases, where an encephalic trauma could be regarded as accelerating or aggravating the disease, the degree of incapacity might be set at from 10 to 30 per cent.

Case E. A laboring man, 44, acquired syphilis at a time unknown. Ten months after enlistment this man developed symptoms on the firing line. He was inattentive, irrational, incoherent. The diagnosis was then “mania.”

There were, however, scars at angle of mouth and on lower lip. Occipital glands were palpable, fine tremor of hands. The W. R. was +++.

Later the patient became violent, destructive, untidy, disoriented. Auditory hallucinations are recorded.

He was “boarded” for discharge five months after the first symptoms. The board agreed that these symptoms would have appeared in civil life. In view of a difference of opinion as to the part played by stress of service, his condition was set down as “aggravated on service” (not, it will be noted, by service, see Case D).

1. Under what conditions should pensions be awarded for disability resulting from venereal diseases? According to a personal communication from Dr. J. L. Todd, Chairman of the Board of Pension Commissioners for Canada, pensions are awarded for all disabilities appearing during service, unless they can be shown certainly to be due to the men’s own fault and negligence. It would appear that during service covers both aggravations by and on service. There remains some doubt as to whether contraction of venereal disease constitutes negligence.

2. What have been conditions in the small inactive American army of the past? Richards has made a study of statistics at the Government Hospital for the Insane, Washington.

“The leading features of this mental disease were well exemplified in our cases the past year. They formed 7.5 per cent of the total number. They averaged forty years of age, and Ziehen says 80 per cent of all cases are in the fourth or fifth decade of life. They averaged ten and a half years’ service, which would indicate that the military life was their calling. Only one had any serious hereditary defect. Stigmata of degeneration were infrequent, averaging only two for each case. 66 per cent had good schooling, considering their opportunities. Physical signs were frequent in each case. Only one showed normal light reaction. Ziehen says the light reaction is retained in only 20 per cent of the cases. Patellar reflex was absent in one case and normal or exaggerated in five. The speech defect was slight in four cases. Other physical signs were present in the usual proportions. Memory defects existed in all the cases. In four the onset was with excitement. One began with a character change as the most marked feature. In only two were the transfer diagnoses correct. One, beginning as a quiet dementia, was diagnosticated paralysis agitans, because of a marked tremor. One was excited and euphoric and was called a manic-depressive psychosis. One with an obscure onset was diagnosticated as a neurasthenic. The other one was first observed in this hospital. The physical signs should have led to a correct diagnosis in each of these cases.”

Case F. 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 of examiners. This board reported that:

“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.

Case G. 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 were found.

The serum and fluid W. R. were positive, albumin in fluid, 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.

1. 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.

2. What is the duty of the military authorities relative to so called traumatic paresis? Medicolegally speaking, Froissart, quoted by Rayneau, states that a victim of traumatic paresis may or may not have presented mental disorders before the accident, that is, that the paretic symptoms may develop out of a clear sky as a result of the accident. The accident itself must be of a serious nature. The accident must be followed by phenomena pointing to brain injury of traumatic nature. These phenomena need not be characteristic symptoms of general paresis at the outset. The period elapsing between the trauma and the supervening condition of paresis must be occupied without notable interruption, at first by phenomena of a purely traumatic nature, later by signs indicating the onset and evolution of general paresis.

The French invaliding process called RÉforme No. 1 with pension is granted according to the governmental instructions only to officers, subalterns, and soldiers whose disease is due to trauma. In view of this governmental regulation, the military surgeon must write out certificates describing every cranial trauma, however slight, which might have a bearing on the development of paresis. However, he should not too readily admit trauma as a cause of paresis. If a long period of quietude, a period in which the trauma itself seems to have undergone a complete recovery, supervenes, then general paresis should not be reported by the surgeon.

LÉpine has recently noted the following features as desirable in board reports concerning paretics: nature of trauma, length of service, fatigue endured, insomnia, date of infection, treatment, W. R.

Case H. A soldier, 35, was sent to the Centre Neurologique with a hospital ticket reading:

“Neurasthenia, general weakness following intoxication by gas.”

The soldier was thought at first to be a neurasthenic. But he soon showed signs of more pronounced mental trouble. The voice was suspicious. There was a slight irregularity of pupils.

An epileptiform attack occurred, followed by aggravation of symptoms.

Lumbar puncture showed pleocytosis. The W. R. of the serum proved positive.

Yet the evident neurosyphilis, possibly paretic (de Massary’s diagnosis), was preceded by a neurasthenia and the neurasthenia was preceded by “gassing.”

De Massary believes the patient and his family would perhaps be justified in believing the condition produced by the injury. De Massary is not clear as to the financial deserts of the patient. It is not a manifest case of aggravation of antebellum symptoms, even if it be neuropathologically an instance of acquired loss of resistance to pre-existent spirochetes in body or brain.

1. What adjuvant factors have been recognized in military paresis? Aside from syphilis, Rayneau finds that alcoholism, malaria, sunstroke and various intoxications serve as causes for paresis. Rayneau points out that the apparent integrity of the mind in general paresis may be such that they last in the army some time and have their oddities ascribed to misconduct or breaches of discipline. In fact the Legrande du Saulle called this early period in general paresis the medicolegal period, showing, as it so often does, thefts, outrages against decency, frauds, assaults, exhibitionism and the like. To be sure these acts are absurd and infantile and not difficult to recognize as of psychotic origin.

Case I.^[28] A man of 35 in the Landwehr acquired syphilis some time in the summer of 1914. He was a good soldier, passed through several clashes, and was promoted to Unteroffizier.

To understand what followed it must be stated that he had been a bed-wetter to 11, had been practically a teetotaler (Bonhoeffer’s point is perhaps that otherwise epilepsy might have developed sooner?), and, when he did drink, vomited almost at once, and had amnesia for the period of drunkenness. His father had been somewhat of a drinker. His sister had suffered from convulsions as a child.

February, 1915, the Unteroffizier lost appetite, got headaches, and went to hospital for a time. Upon getting better, he was sent on service to Berlin. In a Berlin hotel he had his first convulsions and unconsciousness, biting his tongue. He was confused for several days, and, when he had become clear, had a pronounced retrograde amnesia together with a tendency to fabricate a filling for the lost period.

This retrograde amnesia is uncommon in epilepsy and suggests organic disease. No sign of organic disease was found on neurological examination. The patient had no signs of the epileptic make-up. The serum W. R. was negative. On the whole, Bonhoeffer regards the epilepsy as “reactive” to the syphilis, as a syphilogenic epilepsy.

As to the amnesia, it is of interest that alcohol should long before have been able to cause amnesia in this man in the same way as does now the syphilitic epilepsy.

1. In view of the fact that this Landwehr man appears to have acquired syphilis while on campaign, what is the responsibility of the government for treatment? The Canadian authorities, as stated under Case E, are in doubt whether contraction of venereal disease constitutes negligence on the part of the soldier. It would appear to us that where a government does not take suitable steps to prevent the acquisition of syphilis by the soldiers, the government must assume a measure of responsibility for the syphilis incurred. The government’s responsibility would be still greater in equity, it would appear, if commercial opportunities for the acquisition of syphilis are maintained under more or less close government supervision or (even as has been claimed for certain encampments on our own Mexican border) if shelter for illicit sex relations is afforded within the limits of a military camp. In a certain community, “E,” for example, it is claimed by Exner,^[29] the district for prostitutes was “situated within the lines of military camps and protected and ‘regulated’ by the military authorities.”

But even if the government has no legal responsibility in this regard, it would be well to consider the ultimate results of the syphilis that will probably be acquired by great numbers of soldiers under campaign conditions. Aside from the ravages of syphilis outside the nervous system, it is well known, as Weygandt intimates for German conditions, that the aftermath of war will be a high proportion of cases of neurosyphilis.

Weygandt remarks in his review of the influence of the war upon psychiatry, that the opportunity for syphilitic infection in the campaign is considerable. In the war of 1870, the conditions in this regard were extremely unfavorable, and writing in 1915, Weygandt remarks that at present there should be a prophylaxis against syphilitic infection by the soldiers, which prophylaxis should be the most energetic possible. Continence on the part of the soldiers and the isolation of infected women, with examination by specialists, have been advocated by Neisser and by Mendel. In the ’80’s a great number of cases of locomotor ataxia developed in Germany, which were due to syphilis acquired by the soldiers and officers in the war of 1870.

Case J.^[30] A soldier in the reserves, 23, was, subsequently to his being brought to hospital, described by his wife as a rather over-sensitive fellow, who could hardly look at blood and was meticulous about the household. He had always been subject to headaches, especially after hard work. However, he had passed through his military training well in 1910, not even having been bestraft.

He began service in October and fought at Dixmude on the 19th. On the 24th in the trench and while being carried back, he had several spells of pallor, falling stiff, and then having convulsions. Brought finally to the CharitÉ in Berlin, he had more spells of sudden pallor, collapse with brief convulsions, tossings in bed, and absences, post-convulsive headaches, and mild bad humor.

There were numerous attacks several days apart in the first seven weeks. The patient was not of an “epileptic” disposition, though he was rather readily dissatisfied. Headaches also occurred without relation to convulsions.

The serum W. R. was positive. Treatment by mercurial inunctions. No further convulsions. Prognosis as to the possibility of a constitutional epilepsy unknown.

Case K. 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 SalpÉtriÈre 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. Signs of disorder at one time or other affected the first lumbar distribution of the third lumbar and first and second sacral nerves.

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 has 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.

Case L. A German Jew in London passed into the Paretic form of Neurosyphilis shortly after the outbreak of war under conditions suggesting that the stress of emotions directly or indirectly lighted up the neural process.

The man was a bank-officer, 52 years old, and married. He had lived many years in England and was in fact a naturalized citizen. He had been under treatment for syphilis by Sir Jonathan Hutchinson, 29 years before, namely, at the age of 23. Subsequently, Sir John had given him permission to marry.

It proved that for years the man had had fixed pupils, absent knee-jerks, and a perforated ulcer of the foot. However, there had been no other mental or nervous symptoms preventing bank-officer’s work.

At the outbreak of war the man was discharged from the bank. He grew worried and sleepless. He began to charge himself with sex irregularity. He went down to the city and burned trust documents belonging to others.

From worry and self-accusation he passed into depression and agitation. He developed a belief that not only he but also his German wife were to be executed. He thought he was a criminal and was to be hanged.

The depression then altered to a condition of hilarity and loquacity.

In addition to the fixed pupils and absent knee-jerks, a speech disorder shortly developed.

The patient was placed under care, but quickly (a few months?) passed into an advanced stage of paretic neurosyphilis and died.

Case M. June 19, 1915, a shell exploded some distance from Lieutenant R. He remembers the gaseous smell, the bursting of several shells nearby and a sensation of being lifted into the air. When he recovered consciousness, he was in hospital at Paris-Plage, covered with bruises and scratches. They told him he had been delirious and had vomited and spat blood.

June 24, his wife came to see him, but this visit he could not remember. Nor could his wife at first recognize him, he was so thin. He roused a few moments and recognized his wife, but relapsed into torpor again. Speech was difficult and ideas confused.

A few days later he was able to rise; but his mental status grew worse, especially as to speech and writing; the latter quite illegible. There was insomnia, or, if he slept, war dreams.

August 7, he began a period of five months’ convalescence passed with his family, depressed, given to spells of weeping, confined to bed or couch, unable to “find words,” conscious of his state and troubled about it, speaking of nothing but the war, and afraid to go out for fear of ambuscade. There was at first a slight lameness of the right leg. Although he could walk, he felt pain in the knee on flexing the right leg on the thigh. He walked holding this leg in extension.

On going back to the colors, he was immediately evacuated to the Centre Neurologique at Bordeaux, January 20, 1916.

Examination found a bored, impatient, irritated man, vexed that a man who was not sick should be sent up “comme fou.”

Omitting negative details, neurological examination showed slight lameness as above, body stiff and movements jerky; difficult, unsteady gait. The lieutenant could stand for some time on either leg, tongue and face tremulous during speech. Limbs moderately tremulous, especially in the performance of test movements.

Knee-jerks and Achilles jerks absent. Other reflexes, including pupillary, normal. Segmentary hypalgesia of right leg, especially about knee. Tremulous speech and writing. Patient would stop short in speaking for lack of words.

Malnutrition. Appetite good, but a bursting feeling after meals.

Skin dry, scaly on legs, fissured on fingers.

Serum W. R. negative. Fluid not examined.

Mental examination. Conscious and complaining of his troubles, Lieutenant R. claimed persistently that he was not sick. Memory for recent events was in general poor. Errands easily forgotten. Lost in the street. Complaint of corpse odors round him. Everybody is looking at him and making fun of him. He was apt to insult bystanders. He was afraid of German spies. Things in shops angered him as they seemed to him to be of German manufacture.

There were frequent periods of depression, with pallor and no spontaneous speech for some hours to a half-day. Headaches coming on and stopping suddenly.

As to diagnosis, the first impression, say Pitres and Marchand, was that of general paresis. The progress of symptoms after the shock was consistent with this diagnosis. The mental state and the physical findings seemed consistent, although the pupils were normal. His partial insight into his symptoms was not inconsistent with the diagnosis. He had a characteristic self-confidence. There had been four stillbirths (two twins) two children are alive, 11 and 13. Typhoid fever at 30. Syphilis denied. No mental disease in the family.

The patient had never done military duty, having been invalided for “right apex.” But he had volunteered and been accepted in September, 1914.

1. Was this diagnosis, general paresis, at any time justified? The spinal fluid should of course have been examined. The peculiar lameness of the right leg was certainly not characteristic of general paresis, and was perhaps hysterical. (There was no limitation of visual fields or any other definite sign of hysteria.) Presumably some quality of speech defect, the amnesia, and the euphoria, together with absent knee-jerks, led to the diagnosis general paresis. By the 20th of March, 1916, the knee-jerks had become lively; the Achilles jerks normal. At this time the patient had gained in weight, could walk though stiffly, had headache (especially right frontal) and a feeling of lead in head, less tremor, lack of desire to undertake anything. He still wanted to go back into service. He still saw spies about. Dreams terrible; devoured by spiders, leggins instruments of torture. Skin still atrophic. June 4 there was no more tremor of speech or face. Symptoms largely disappeared except a few ideas of persecution. Recovery October, 1916.

2. How was Lieutenant R. cured? Apparently by rest in the Centre Neurologique. Pitres and Marchand do not speak of the subtle relation between mental state and the idea of non-return to military service. This motive might still work even if Lieutenant R. kept protesting quite sincerely that he wanted to go back into military service.

SHELL-SHOCK PSEUDOTABES (non-syphilitic, serum W. R. positive). Improvement. Case from Pitres and Marchand of Bordeaux.