Elmer Ernest Southard

“E perÒ leva su, vinci l’ambascia

con l’animo che vince ogni battaglia

se col suo grave corpo non s’accascia.

“PiÙ lunga scala convien che si saglia:

non basta da costoro esser partito

se tu m’intendi, or fa sÌ che ti vaglia.”

“And therefore rise! conquer thy panting

with the soul, that conquers every battle,

if with its heavy body it sinks not down.

“A longer ladder must be climbed:

to have quitted these is not enough;

if thou understandest me, now act so that it may profit thee.”

Inferno, Canto XXIV, 52-57.

In previous sections we have already become acquainted with many therapeutic successes and failures: indeed it was almost necessary to detail treatment in certain cases to show the nature of the disease in hand or the correctness of a given diagnosis. In the present Section we approach the question more systematically.

After presenting a few examples of various spontaneous and non-medical recoveries, we bring into contrast the types of medical recovery that may be termed rapid (or miracle) cures and those that fall under the general head of reËducation. Admixed are cases of failure as well as of success: if it be remarked that the case method puts forward the best foot, it is probable that the same is true of almost any therapeutics as reported in early articles. As we go to press, trench reports indicate that at least one part of the profession is far more hopeful of successful psychotherapy even in the physiopathic group of disorders than their expounder, Babinski, could concede. The true statistical evaluation of the results must come years later.

Some neuropsychiatrists have been fond of saying that there is nothing new in Shell-shock, that specialists have long been familiar with the psychoneuroses, etc. Yet in the past, specialists have not learned overmuch about the true inwardness of the psychoneuroses. Even a casual inspection of the various therapeutic efforts here described shows how much novelty of observation and ingenuity of plan must eternally be shown in these ever-so-simple psychoneuroses!

Shell-shock: Deafmutism. Spontaneous cure.

Case 473. (Mott, January, 1916.)

A British soldier, 25, a coal miner, had had a bicycle accident five years before, after which he was unconscious for 2½ hours, and gave up work for five weeks, with headaches, fainting-fits, and nervousness ever after and with a tendency to imagine he could see things when there was nothing to be seen.

September 19, 1915, he was under shell fire in trench and dugout. A sergeant and three men working with him were killed by an explosion, and he remembers his cap being lifted off his head. He came to in 46 Rest Camp, some time later, unable to see clearly, or to hear or speak, and with headache and insomnia. He brought a paper from a hospital in France, saying, “Doctor, I had an awful dream last night again; I was dreaming that I was in the trenches; I could see the men falling and the great big shells exploding. I could see the light from the bursting of the shells very plain. They fairly lighted all the place up. I woke up very anxious I can tell you. I wish I could give over dreaming, and I keep having pains in my head right across my eyes.”

October 15, while sitting by himself outdoors, he felt a slight crackling in his head, noticed that he could hear sounds faintly, and in a few minutes he could hear fairly well.

October 17, he was heard making inarticulate noises in his sleep. The corporal next him told him about the noises in his half drowsy state; he tried to speak and said, “Mother.” He then felt queer all over, with pain in his head, and afterward became able to talk very well with slight hesitation.

Re spontaneous cures, Elliot Smith and Pear cite the cure of two mutes on hearing that Roumania had entered the war, and the cure of another by seeing Charlie Chaplin’s antics. Some workers (for example, AimÉ), treat the functional mutes by simply leaving them to themselves, and maintain that they secure numerous spontaneous recoveries, regarding these as superior to cures by isolation, psychotherapeutic treatment, and the like.

Chart 16
METHODS OF PSYCHOTHERAPY

• HYPNOSIS
• Verbal Suggestion
• Fixation
• Fascination
• Various
• SUGGESTION (WAKING)
• Verbal
• Drug
• Apparatus
• AUTOSUGGESTION
• DISTRACTION
• TERRORISM
• INFLICTION OF PAIN
• PERSUASION
• WILL TRAINING
• OCCUPATION THERAPY
• ISOLATION
• PSYCHOANALYSIS

Re mutism spontaneously or non-medically cured, see also cases 476, 480, 481, 482. For various medical methods of treatment, see, e.g., cases 516, 518, 520, 526, 544, 579.

Mott had a case which had been mute more than six months, unable to whistle, phonate in coughing, or blow out a candle, though heard to shout in his sleep: This patient recovered his speech when pitched out of a punt on New Year’s Eve. The condition was in one sense physical enough, as the X-ray showed that the man’s diaphragm hardly moved even with the greatest effort. Mott regarded the inhibition of the breathing movements, especially the phonation, as caused by fear. Mott speaks of a case that recovered on being told by a comrade that he had talked in his sleep. The man was so astonished by this statement that he said, “I don’t believe it.” Other instances of cure under quasi natural conditions are related by Mott: In the presence of a functional mute, Mott speaks loudly to the patient’s sister so that the patient may hear: “This man must be kept on a No. 1 diet, and when he can ask loud enough for you to hear, he can have a bottle of stout and a mutton-chop.” Several mutes are reported to have gotten well the next day under this treatment.

These effects shade imperceptibly over into the manifestly suggestive, and probably no sharp line can be drawn between the effects of medical suggestion, non-medical heterosuggestion, and even autosuggestion. Adrian and Yealland rather decry the Micawber line of waiting for something to turn up. Zeehandelaar, a Dutch professor, studied Berlin methods (Lewandowsky), and found numerous cases (both of mutism and of deafness, paralyses, contractures, and tremors) lying about without special treatment. According to this observer, the expectant treatment was sometimes successful, and sometimes not; if unsuccessful, the soldier was sent home, and re-examined a year later; whereupon he might be found to have profited by this long waiting and to have gotten well enough to return to army duty.

A decorated officer, evacuated for Shell-shock on the third day of the Aisne, after four days returns to the front. Evacuated a second time, after weeks returns to the front without relapse.

Case 474. (Gilles, 1916.)

A young officer, with many decorations for brilliant Colonial service, was in the battle of the Marne, under six consecutive days’ shell fire, smoked phlegmatically a cigarette no matter whether walls were crashing or horses disemboweled beside him, and was uniformly able to stimulate his men to the heavy work by humor or heroic phrases.

A week later, on the third day of the Aisne, he had to be evacuated. He was another man—wild-eyed, shivering, jumping at the least noise, unable to eat or sleep, given to battle dreams. He had to be carried away from the battle zone and put in a bed in a town in the rear and given chloral. The nightmares continued. On being awakened he would ask where he was. He was kept in bed, given strychnine cacodylate, and dieted. He went back to the front in four days. Two days later he had to be evacuated a second time. After some weeks more in the rear, however, he went back to the front, and thereafter had not relapsed (April, 1916.)

Re relapses, Wiltshire thinks their causes and frequency prove the psychogenic nature of Shell-shock. Ballard states that a severe case lasting six months does not recover in the army. Many that are said to recover in hospital break down at dÉpÔts, often with symptoms quite unlike those which they originally presented, and it will be remembered that Ballard has an epileptic theory of the nature of Shell-shock. See Cases 82, 83, and 84 in Section A, III, Epileptoses. But another portion of Ballard’s contentions relates to a causation through fear suppressions released by perturbing events. According to Ballard, if the man endeavors to re-suppress the released fear, the fits occur. Ballet and DeFursac note the frequency of relapses—fewer after treatment at the front.

Vicissitudes in fifteen months of a Shell-shock case with mutism and amnesia. Attacks of mania. Hyperthyroidism?

Case 475. (Purser, October, 1917.)

An Englishman, 21, in a rifle regiment, arrived in May, 1915, at the Dublin University V. A. D. Hospital, being dumb, impaired as to vision and hearing, having dilated pupils, tremors, restlessness and weakness, and giving the impression of visual hallucinations. Although suspicious, he was treated kindly for a few days, recovered his hearing, and wrote the few things that he remembered about home and the war, now and then tremulously and perspiringly writing down, “Asylum; do not lock up; I am not mad.”

With the idea of hypnosis, his bed was surrounded by screens, whereupon he grew so perturbed that the attempted hypnosis could not be executed. He learned the letters PP, TT, SSS, A-OOO, and finally AA-SS, AA-TT, T-OO, and after many weeks SS-SST-R and B-TT-R. His father visited him and probably was recognized.

At the end of September another dumb Shell-shock case recovered speech upon being given ether. Maj. Purser asked the sister to arrange for a like treatment for the first case, explaining that an examination of his throat might be painful. The cure of the second case by anesthesia got into the papers and before he was treated the account was possibly seen by the hitherto gentle rifleman. At any rate, he was seized with a sort of spasm, became furious and could only see Germans coming and carrying off his machine gun. He shouted for help. A half grain of morphine was given him and when it began to take effect the fighting spirit gave way to despair. He trembled over the loss of the gun, and remained in this state of despair for three days, remembering his regiment number and the like, but amnestic for his life during the past few months. He could not read now because print was indistinct. Words, when he had spelled them out, conveyed no meaning. He had a functional alexia. When he saw a picture of a bunch of flowers in a notebook of his, he had another spell of excitement and regained his power of speech, remembering about his experiences only that he had been locked up. He had now completely forgotten his father, who came to call.

By the end of October he was stronger, but his horizon was still limited to the hospital surroundings and a little newspaper reading. Headaches and impaired vision persisted. Sight temporarily left him early in November, and there was a suggestion of an epileptic fit one day early in that month. Tonic and sedative drugs and suggestive remedies were of no avail. Hypnotism made him worse, and psychanalysis was, perforce, ineffective through the amnesia. At the end of November depression and suicidal thoughts set in, with an elevation of blood pressure to 178 m.m., pulse 80 to 90. Maj. Dawson then thought he was a suicidal melancholic. Rest in bed and thyroid extract were given, but the latter threw up his pulse on the fifth day to 140. He grew better mentally on the treatment, however, and his blood pressure fell to 140 in three weeks. He was now over-emotional, unable to stand or walk or feed himself or to pull on his socks.

For change of scene he was transferred to Mercer’s Hospital in February, 1916. He suffered from astasia-abasia. The tremor became jerky, coarse and persistent. The thyroid gland grew a good deal in size during the spring and the pulse went up to 120 per minute. There was also well-marked dermographia and there was a suggestion of the clinical picture of Graves’ disease. Even a quarter grain of morphine had little or no effect upon an ineradicable insomnia.

Maj. Purser gave the case up as a bad job and the man was discharged and sent home September 2, 1916. During the next two months at home he improved in steadiness, though he flushed if dealing with strangers, and improved as to memory. He began to be able to read better. He had begun to be able to get about on his feet without so much support. The ultimate outcome could not be reported by Maj. Purser.

Shell-shock: Mutism. Cure after killing a snake.

Case 476. (Jones, 1915.)

An Australian soldier of 20 went to Egypt, thence to Gallipoli where, on July 29, 1915, he was almost completely buried by earth from the bursting of a high explosive shell. He was admitted to hospital August 5 and transferred to Malta, where he did not speak, stared into space and sometimes made, impulsively, attempts to get away. About September 17 he began to assist the orderlies and played draughts.

The diagnosis there was cerebral concussion. He was sent back to Australia by transport and had to be put in a padded cell on November 1, having become violent, noisy and destructive. He would assault anyone who beat him at the game of draughts and threw anything he could lay his hands on out of the porthole. Hyoscine he resented and threatened the givers by signs. He was at times restrained. He threatened to throw himself overboard. Diagnosis: Melancholia.

At Melbourne he was found in good physical shape, but dazed, mute, apparently deaf, indicating his wants by signs. With pencil and paper he would draw a ship or a gun and would copy any question put to him in writing. He played draughts intelligently and made friends with one of his shipmates. In four days’ time he began to communicate in writing, answering simple questions correctly. Asked to put a question, he wrote “Do you think I am mad?” On the appropriate answer he shook hands with the physician heartily.

He was then sent to a military convalescent home at Highton. Here he communicated often in writing, and had an appreciation of sounds without distinguishing words. At a picnic on December 4 he killed a snake. While returning in the dark he began to whistle a song the rest of the party were singing. At the end of the song he clapped his hands and said, “What is the next item on the program?” Thereafter he was able to hear and speak. Seen four days later he asked to join the officers’ training school. However, he was discharged as permanently unfit for the service.

Course in hospital of an oniric delirium.

Case 477. (Buscaino and Coppola, January, 1916.)

An Italian gun-maker, 27 (father neurotic; grandmother and mother, alcoholic; patient excessive onanist), was called to arms June 14, 1915, and went into artillery service in the Tolmino, early in September. Some time later, a shell burst about 30 meters away and killed his lieutenant. The patient, however, was not hurt and did not even fall. He became mute and inaccessible, and was sent to a military hospital, and thence to an asylum in Udine, where he was restless and hallucinatory. October 2, he was sent to Florence on two months’ leave for convalescence. He was still hallucinated, always seeing his dead lieutenant. He spoke rarely, slept little, and his conduct became more and more queer. Now and again, he would act exactly as if he were at the front. November 5, he started off to find his brother, but was met by a hospital attendant, who promptly took him to a clinic. Here he was inaccessible and lived in a hallucinatory way a soldier’s life at the front: in continual movement, shielding his eyes with his hands as if looking far into the distance, bending down to turn an imaginary lever, apparently taking part of his aim, crouching in a corner, clapping his ears with his palms, and obeying hallucinatory commands: “Ready,” “Fire,” and the like. As to his interpretation of the actual surroundings, he would give a military salute at the entrance of the physician, as if he were the lieutenant. Another patient near by was interpreted as a spy. Hypodermic injections, November 6, were interpreted as military antityphoid injections. On succeeding days he piled dry horse-chestnut leaves for a parapet, which became the scene of battle. November 12 he had become a little more lucid. November 14, he evidently heard whistling and made the leaves ready as a bed for horses. November 15, he rolled up his blanket in a military fashion and hid in a cell corner. He explained, November 16, that he was a sentinel and had not been relieved by the corporal. He had saved everybody’s lives by signaling from a tree the presence of four airplanes. He could not be convinced he was in an institution for the insane. November 20, he was virtually recovered but amnestic for what he had done since commitment. Headaches and dizziness. November 21, he remembered some of his dreams, especially one of being blinded and another of being tied by a German to a tree. By November 29 he had become lucid and oriented, but there was an amnestic gap for his stay at the clinic. Early in December the fields of vision were contracted; polyopia and a glaring and burning sensation before the eyes (after each test conjunctival and tear duct inflammation).

December 21, discharged well.

Re the nature of oniric delirium, see discussion under Cases 333 and 450, Chavigny had but two cases out of 260 in which a rapid curability was noted (90 per cent finally curable). Chavigny’s treatment consists of rest in bed, quiet, purgation if necessary, and warm or cold shower baths. Chavigny remarks upon the extraordinary transformation from apathy to lucidity in the course of a few minutes, brought about by arranging a slight but definite emotional shock to the patient, namely, by mentioning in his presence something about home or family. One bit of technic was to get the patient to write or dictate a letter home.

RÉgis remarks that battle dreams of this nature occasionally affect alcoholics in garrison or at home. The victim ought not to be hastily committed to an asylum, but should be treated in a military neuropsychiatric service with isolation chambers and open wards. RÉgis organized early in the war at Bordeaux a central psychiatric service along these modern lines. He remarks that the central service ought to receive not only patients from the military hospitals, but also patients from the temporary auxiliary hospitals of the city and district round about. A pooling of the military and civilian issue upon rational lines is here indicated.

RÉgis and others have remarked upon the necessity of differentiating these battle deliria from toxic and infectious psychoses.

Shell explosion: Deafmutism, recovery of speech with electrical treatment; deafness cured by suggestion in writing.

Case 478. (Buscaino and Coppola, January, 1916.)

A fusileer, 20 (mother neurotic, brother hemiparetic from infantile disease; patient had extreme otorrhea from an early otitis media), entered the army January 15, 1915. He was sent to the Isonzo in May and was slightly injured in the nape of the neck and the left calf by fragments of a shell that exploded near by. He was picked up unconscious and taken to the hospital at Servignano. There he was given electric treatment, and in a period of 18 days recovered his speech, passing through a phase of stammering. He was sent to a special hospital in Florence, still deaf, and passed into a state of mental excitement with visual hallucinations of soldiers. He was given chloral and bromide. He insisted that he was incurably deaf. August 22, he was admitted to Buscaino’s clinic, completely deaf, slightly stuporous, somewhat indifferent, and innocent of any effort to make himself understood (contrary to the habits of an organically deaf person). Simulation could be excluded. It was possible to awaken the patient during sleep by auditory stimuli, whereupon he opened his eyes but could not hear. He talked well and spontaneously, telling about his accident, reading and answering by signs. He was assured,—always in writing,—that upon the following Sunday his hearing would be restored. Upon that day, during the visit of a lady,—one of the patient’s friends,—hearing was suddenly and almost completely restored in the left ear. The patient was so moved by this that he cried when the physician came. Upon the following day, he gradually began to hear with his right ear. A slight diminution of hearing in the right ear persisted, however, until September 24, and was associated with headache and pains in the left ear—pains which the patient compared to his ear pains in childhood (remains of otitis with retraction of the tympanic membrane).

Paraplegia: Cured by administration of Iron Cross.

Case 479. (Nonne, December, 1915.)

After heavy shelling a soldier fell for two days into a clouded state from which he waked with complete paraplegia of the lower extremities, and total anesthesia from the pelvis downward (reflexes and electric excitability normal).

On the third day after his reception in Nonne’s wards, he was about to be hypnotized when news came that he had been promoted to a lieutenantcy and had received the Iron Cross. He fell forthwith into hysterical convulsions, in the midst of which the hitherto paralyzed legs worked perfectly well! Even after the hysterical attack was over, the man could still move his legs in bed normally, but had absolute astasia-abasia. Next day, with deep hypnosis, markedly improved. After eight more days of hypnosis the new lieutenant got back his normal gait.

Shell-shock, burial: Mutism. Cure by getting drunk.

Case 480. (Proctor, October, 1915.)

A patient, 25, nine years in the service, was buried in a dugout by an explosive shell at Ypres, June 17, was taken out unconscious, and eventually reached the hospital at Versailles. Consciousness had returned a few days after the injury. There was ringing in the ears, difficulty in hearing, and inability to speak. He arrived at the Duchess of Connaught’s Hospital at Taplow, July 12, when, aside from the above-mentioned symptoms and a rapid heart action (108 at rest), he seemed perfectly well. About August 14, he began occasionally to refuse solid nourishment and remained in bed, eyelids closed but twitching at times, especially when spoken to. He resisted having his eyelids opened.

August 27, he was allowed to go to the village with companions, and got drunk, found his voice, for two days talked and sang incessantly. Discharged September 9, cured.

Shell-shock and burial: Mutism. Cure by work in a vineyard with wine to drink.

Case 481. (Anon, May, 1916.)

A correspondent of the British Medical Journal reports a case of cure of emotional mutism. This robust young soldier at Verdun was buried by the explosion of a shell and was thereafter found unable to speak. A week later he arrived at the ambulance in the interior, and was still mute. He could understand what was said to him without difficulty, and was able to reply by signs. He did not even move the lips when requested to pronounce such words as mamma and papa, but was eventually induced to whisper these words.

The laryngoscope showed complete paralysis of the vocal cords, which were in extreme abduction (it was possible to see several tracheal rings). There was no reaction on the part of the pharyngeal mucosa upon stimulation.

A fortnight passed without restoration of speech, though at one time, not having bolted the closet door, the patient was startled when a nurse rushed in, and he said, “Oh, pardon, Madam.” The mutism persisted. He was then given work in the vineyard, plenty of wine to drink, and hard work. After a time (not specified) speech suddenly returned. According to this correspondent, “this indeed is a universal experience, namely, that hard manual work is the best remedy for such functional incapacities of traumatic origin.”

Re Cases 480 and 481, compare cures by anesthesia with chloroform, nitrous oxide, and the like.

Re gradual cures as opposed to sudden ones, Dundas Grant deprecates violent measures in the treatment of mutism during the period of exhaustion after Shell-shock. However, Dundas Grant does not advocate an expectant treatment, but employs a gradual reËducation of the voice through imitation of the teacher. The voice is sometimes restored at a sitting, sometimes gradually; see, for example, Case 578 of Briand and Philippe, and Case 586 of MacCurdy.

Shell-shock, unconsciousness: Deafmutism: Spontaneous recovery of speech and gradual recovery (several months’ isolation) of hearing.

Case 482. (Zanger, July, 1915.)

A musketeer was deafened and stunned by a near-by shell explosion. On coming to, he found no wound, but was deaf and dumb.

Speech returned after ten days, and hearing partially, but there was a tonic stuttering. He had to hunt anxiously for words, talked like a child in infinitives and telegram style, although he could express himself in writing perfectly well.

Hearing improved on the right side very quickly, but on the left side conditions varied from total deafness to subtotal deafness. There was a general hyperesthesia of the skin, pain on pressure on the temples, exaggeration of skin and tendon reflexes, marked tremor in both hands. The man was anxious, depressed, and irritable. During caloric tests of the vestibular apparatus in the course of the next few weeks, the man had an hysterical attack of crying twice, following which all the phenomena got worse.

Rest and isolation from all such influences procured an almost complete recovery in several months.

Re differential recoveries, see also Case 585 of LiÉbault, in which speech was recovered by suggestion and reËducation, and hearing by a process of reËducation alone.

Re isolation, Roussy and Lhermitte remark that in all the psychoneuroses of war, isolation is a valuable and indeed an indispensable aid to psychotherapy. The application of this old classical method of Weir Mitchell reinforces the persuasive talk of the doctor on the day of admission, allows the man to think over the promises made to the doctor, and permits longer observation. It depends on the case, whether rigorous isolation on limited diet shall be employed. See below a general discussion of the psycho-electric and reËducative method employed in French centres.

Marches; battles; slight shell wound of left upper arm: Hysterical anesthesia of the arm and tremors (NO paresis). Causes slight—disease obstinate (partly explained by furloughs among sympathetic friends).

Case 483. (Binswanger, July, 1915.)

A soldier, 26, without heredity, always well, in long marches and several battles early in the war, August 23 sustained slight shell wounds of thighs and left upper arm. He was unconscious about five minutes. In eight days, the wounds were healed, and all movements were free.

Immediately after the trauma the arms trembled, and at times the legs. Treatment was instituted (baths, drugs, massage, electricity), but without result. After a month’s treatment and a furlough at home, the patient was sent, January 3, 1915, to the Jena Nerve Hospital. He was a powerful man of middle size, with some small movable scars on the left upper arm, remains of the shell injury; two similar scars of the gluteus maximus. The deep reflexes were slightly exaggerated, as were the skin reflexes. The touch and pain sense in the left arm was absent as far as the shoulder in typical segmental fashion. Arm movements were free; there was an occasional tremor in both arms, especially the left. This tremor would pronouncedly increase upon intentional movements and with emotion.

He said that about two weeks before, at home, he had waked up in the night and lain down on the floor beside his bed, feeling giddy in his head. In a week the tremors had diminished, leaving only a very slight tremor of the left hand. The patient went to considerable pains to conceal his tremor, holding his hand in a military position at the seam of the trousers, on the medical visit. Sometimes he would succeed in making the tremor quite disappear. February 5, he was busy about the ward work, going errands and carrying trays. He would intentionally spare his left hand in this work. Upon trying gymnastic exercises, the tremors of the left hand and also of the right reappeared. After a few days these tremors again disappeared, only to come back on the 12th, when there was a constant tremor also when the patient was at rest. He had been affected when observing another patient (8[7]). Accordingly, he was separated from this patient and put in a psychiatric ward. The tremor remained of varying intensity, sometimes being absent for hours together.

Request for furlough at the beginning of March was refused with the statement that it would be granted when cure was complete. The patient was inaccessible to psychotherapeutic influence. He was always of a friendly, modest demeanor, sleeping well, and performing all bodily functions properly. On any exertion the pulse ran to 134. The heart was normal. There were outbreaks of perspiration.

March 26, he renewed his request for leave, desiring his Easter furlough. He was told he might expect it. March 31, the tremor was found to have quite disappeared. Upon his return, April 12, there was a marked tremor of the left arm, especially of the wrist joint, which again disappeared after some days. The middle of June he was released as capable of garrison duty with the recruits.

If there was a mechanical factor in this case, it must have been the shaking-up of the body by the shell explosion. His skin lesions were slight. The main factor was doubtless the emotional shock. The tremor supervened upon a very brief period of unconsciousness. It is hard, according to Binswanger, to explain the localization of the cutaneous anesthesia without the development of a corresponding paresis. May it be, inquires Binswanger, that the wound of the left upper arm at the moment of the setting-in of unconsciousness, or perhaps at the moment of waking from unconsciousness, directed the mind forthwith upon the left arm and in this way produced localized disorder of sensation? If so, why did the wound of the gluteal region not produce corresponding disorders of feeling and sensation of an hysterical nature? The obstinacy of the disease stands in striking disproportion to the slightness of the causative factors at work.

According to Binswanger, this is perhaps due to the long furlough which the patient had. According to Binswanger’s experience, as that of many others, home works badly for these hysterical patients; their friends sympathize with them too much.

Re furloughs, Ballard states that severe Shell-shock cases should get analogous treatment to that of civilian psychoneurotics, namely, a complete removal from the environment in which the illness began. He advocates three months’ leave, after which the man is to be sent to a convalescent home, and thence to a command dÉpÔt. He states that if a relapse then occurs, such a patient will never be a soldier. Ballard would allow the men to walk about with their “pals (not with escorts).” Cimbal remarks that German data show that home furloughs should be avoided in every instance where possible. Fiessinger remarks, on the basis of English experience, that a Shell-shock patient treated by rest, suggestion, and manual occupation may go back to the line “and on a subsequent occasion prove a hero.” (See Case 474 of Gilles.) But Forsyth remarks that it is probably injudicious to send any cases of Shell-shock, with few exceptions, back to the firing line, because their fighting value has been permanently deteriorated, and because, if the fear of return to the trenches is removed, recovery is more rapid. The experience here is not unlike that of industrial accident board cases with rapid recovery after the decree of compensation.

War stress in a volunteer banker: Hysterical seizures. Treatment by hydrotherapy.

Case 484. (Hirschfeld, February, 1915.)

A banker, a volunteer (articular rheumatism at three years; at 18, some form of lung and tracheal inflammation; tendency to fainting spells on cold days—heart disease was said to have been found), as a result of the strain and excitement of the war had hysterical attacks during a fortnight before observation in hospital, consisting of sensations suddenly developing in the region of the heart, stiffness of the whole body, disorders of movement, without loss of consciousness.

November 23, 1914, he was examined in bed in the dorsal position, with the muscles of the legs, back, and neck in a state of tonic contraction. He was unable to answer questions. The pupil reactions were normal in the seizure. The attack ceased in two minutes, as the result of hitting heavy blows on the chest with a moist handkerchief and the threat of a strong and painful application of the electric current. The patient then got out of bed at request, walked about a little incoÖrdinately for a time, but after a few minutes was able to walk perfectly and to talk once more.

Examined, November 25, he was found to be pale, fairly well nourished, with a somewhat accelerated pulse, and a melancholy, slightly apathetic expression. A systolic murmur at the right apex; accentuation of secondary pulmonary sound; increased knee-jerks; trembling of the lids (Rosenbach).

By December 12, the patient was completely well. The seizures had not recurred. The treatment was by hydrotherapy. A preliminary treatment is advocated by Hirschfeld, to insure peripheral circulation, either by light baths, hot douches, or packs. More important than this preliminary treatment is the cooling off process by means of tepid douches or partial baths. These partial baths are given at 28°C. for the intense effect of the cold. Sometimes this treatment can be concluded with a dry pack. The patients are treated by Hirschfeld three times a week with both the warming and the cooling procedure.

Re hydrotherapy, Mott has found the continuous warm bath of great value in Shell-shock cases coming back from France. He keeps the patient in the water from a quarter to three-quarters of an hour, or longer. A warm bath and a drink of warm milk at bedtime may permit a man to get on without hypnotics, or to get on with lesser amounts of hypnotics. The effect of these baths is doubtless largely somatic. Some writers stress the suggestive value of hydrotherapy as well as of electricity, radiant heat baths, and the like (Ballard). A neuropsychiatric center properly equipped with a hydrotherapeutic plant can do therapeutic work by means of the suggestion afforded by a cold shower, which may act quasi miraculously, like electricity (Roussy and Boisseau). In fatigue and exhaustion cases, along with adrenalin and strychnin, AimÉ gives mild hydrotherapy without other sedatives. Laehr’s free sanatorium at SchÖnow treats the arrhythmia and tachycardia cases with rest and hydrotherapy.

Brasch reports rather poor results with hydrotherapy in the cardiac neuroses. Weichardt has used the continuous bath as a form of psychotherapy and permits the symptoms of psychoneurosis to subside therein.

Shell-shock: low blood pressure: Pituitrin.

Case 485. (Green, September, 1917.)

A lance corporal of the Expeditionary Force, 26, went to France feeling very fit, February, 1916. He was blown up by a shell July 1, and faintly remembered crawling out of some water. He came to in a dugout, dumb and partially deaf, and was blind for a few minutes. August 17, he was admitted to Mott’s wards at Maudsley, mute but with hearing normal. The hands were dusky, sweating, cold, and slightly tremulous. He was given to battle dreams and used to wake in a sweat and terror after a pantomime of bomb-throwing. He had headache and was depressed. He complained of feeling cold and the surface temperature was subnormal. The blood pressure was also subnormal (according to Green, nightmares are most marked in cases with low blood pressure; these are, in fact, severer cases of Shell-shock than cases with high blood pressure; only 10 of 27 cases with blood pressure above 120 showed nightmares).

September 25, he was able to speak in a whisper. The dreams had become less terrifying. The other symptoms had been slowly improving.

November 25-28, all of the symptoms returned upon hearing the death of his brother in action.

The man was now put on extract of pituitrin gr. 2, t.d.s. (better results are claimed by Green from pituitrin extract than from pituitary fluid injections, as these sometimes cause dizziness, of which no case treated with extract complained). As in other cases, the extract was immediately followed by an increase in blood pressure, a general improvement and a diminution of headache and depression. The bomb-throwing pantomimes still persisted, but the patient was less weak on waking. The treatment was continued for seven days, whereupon the surface temperature began to rise and the patient himself felt that he was much warmer. The pituitrin was discontinued after a month’s treatment, yet the improvement persisted. The man was boarded out of the army and in March, 1917, wrote that he was still feeling better.

Various treatments of a contracture of hand.

Case 486. (Duvernay, November, 1915.)

A chasseur, 22, received a bullet wound in the anatomical snuffbox, the bullet emerging under the styloid process of the radius, having traversed the back of the hand without striking bone. Healing was rapid, but the hand assumed a peculiar position. The second and third phalanges of the fingers were extended, whereas the first phalanx was flexed. The four fingers were as if glued together. Both phalanges of the thumb were flexed, the wrist was in extension, and the tendon of the palmaris seemed contractured. The fingers could not be moved and the wrist was very mobile. There was pain on attempts to move the hand passively, and small clonic contractions were made by the fingers. There were no sensory disorders, but there was a maceration of the interdigital spaces.

Mechanotherapy accelerated the contracture, and massage, motor reËducation, bromides, and sedative drugs, had no effect. Under kelene-anesthesia the contracture would disappear. In January, 1915, the hand was put up in plaster in a position opposite to the contracture. The intense pain of the first days was treated by opium. The patient was sent on leave, and, at the end of two months, the plaster was removed; but the hand at once resumed its faulty position, and attempts to alter its position again provoked pain. Elastic traction was then tried for six weeks, and the bad position was somewhat modified but not improved by hyperextending the second phalanx on the first, and putting the third in slight flexion on the second. Hot compresses were unsuccessful also. May 14, 1915, the position was still irreducible; there was no R. D. or electrical hyperexcitability. This was not a question of radial paralysis, since finger extension was distinct; nor a paralysis of the median, since the thumb was flexed. The contracture, in fact, does not affect a special nerve territory, and the disorder is in the ulnar, radial, and median territories.

Orthopedic case.

Case 487. (Sollier, November, 1916.)

A patient suffered from a rupture of the peroneal nerve in its lower part, September, 1915, and had operation scars before and behind the external malleolus. He was immobilized for 45 days at first, and then for 30 days, with the foot in extension on account of the pain produced in the endeavor to put it into normal position. A 6 cm. atrophy was then found to affect the calf, and there was a fibrous retraction of the tendo Achillis and of the calf muscles. There was no anesthesia, the toes moved easily, the foot was fixed in equinus, with about 7 cm. of the heel above the ground. He was placed in various orthopedic institutions and was treated with mechanotherapy, but without result.

At the neurological center, however, in six weeks, he was got to walk, with his heel on the ground, by means of massage and manual mobilization. The atrophy diminished a centimeter and the foot became mobile in all directions.

According to Sollier, mechanotherapy by means of apparatus is apt to be ineffective, especially in contractures, because its action ceases the moment it ought to commence, namely, when the patient is beginning to react a little painfully after recovery from anesthesia. In cases of retraction, mechanotherapy with apparatus does not allow the proper combination of massage with progressive mobilization.

Re orthopedic cases, Jones classes the conditions that create an orthopedic case under four heads (note especially the fourth):

1. Mechanical injury to bone, joint, muscle, or nerve.

2. Atrophy and disease of these structures primarily due to the injury.

3. IncoÖrdination of movement due to disease of the brain—a result of atrophy and disease of peripheral structures.

4. Psychological conditions which can be overcome by reËducational processes.

Favorable effects of lumbar puncture.

Case 488. (Ravaut, August, 1915.)

An accountant, 20, in the 135th infantry sustained shock from mine explosion near his trench, March 6. He was kept two days at the relief station. March 8, at the ambulance, he did not appear to understand questions and had a fixed stare. He complained of a violent headache and kept pressing his head between his hands. He kept looking about him anxiously, and the slightest noise made him jump. He would mutter a few incomprehensible words, and in reply to a question would give only the last phrase which he happened to have been saying. Lumbar puncture showed a very slight excess of albumin. Next day, he answered his name. March 12, he could speak in monosyllables, and he began to understand what was said. After the lumbar puncture, the headache disappeared and did not set in again. March 13, he began to be able to write and say short phrases. March 16, expression was good though hesitant, and the patient wrote a letter to his parents, telling about his shock. Lumbar puncture showed that the albumin was now normal. From the rear, April 5, the patient sent Ravaut a postcard in perfect form, telling how he was ready to go back to the front.

Re lumbar puncture, Imboden quotes Podmanizky as having used lumbar puncture as a method of suggestion for the cure of abasia. See also cases 560 and 561, in which Claude cured two cases of dysbasia by the device of stovaine anesthesia of the spinal cord. Pastine also has a case in which a slight improvement was produced on removal of cerebrospinal fluid, and a sudden and complete cure was brought about by the second puncture, a very painful tap. Pastine’s case is thought by him (1916) to be in part at least organic.

Bullet wound of forearm: Hysterical clenching of fist. Recovery by fatiguing the flexors.

Case 489. (Reeve, September, 1917.)

A soldier, 28, was thrice wounded between August 18, 1914, and July 14, 1916. The third time, a bullet passed through the fleshy part of the forearm, whereupon the hand became clenched and remained so after the wound was surgically healed. As a case of war neurosis, the man was treated by electricity, massage, passive movements, and fixation in a straight splint during a period of nine months, without result. He was admitted to Maghull Military Hospital, April 18, 1917.

Two days after admission a treatment was given whose principle consists in producing a condition of fatigue in the muscles responsible for contracture. This fatigue is produced by continuous passive movements in a direction opposed to the normal action of the muscles in question. Many hours of forcible movement are sometimes necessary in the case of the more powerful muscles before the limp, toneless fatigue condition is brought about. Relays of men are told off for this purpose. Patients are got to assist in the work, particularly such as have been cured by the treatment. Also, the patient is himself told about the nature of spasms and the relief which the method will bring. This patient was told that after the flexor muscles were fatigued they would no longer be able to pull the fingers into the clenched position, whereupon the antagonistic muscles on the back of the forearm would begin to work.

The fingers were forcibly opened without interruption for six hours, in each case as soon as the fingers closed into the palm. In a few hours they began to return more slowly, and at the end of the six hours remained extended. The extended position was still found the following morning. The extensor muscles were feeble in action, but improved day by day. The spasm did not return. The patient was discharged July 2, 1917, about two and a half months after admission to Maghull. The hand was now strong and useful.

Bullet through shoulder girdle: Hysterical adduction of arm. Treatment by induced fatigue.

Case 490. (Reeve, September, 1917.)

A man, 29, was in hospital more than two years before the Reeve fatigue treatment was applied to a functional contracture. This man had a bullet pass through the right scapula and out the pectoralis major, June 4, 1915, was (according to patient’s story) operated two months later, then further operated for drainage of septic wounds, and from August, 1915, had his arm fixed to the side, going into spasm at any attempt to move it passively. The elbow was extended and at first the fingers were tightly flexed and wrist extended. The finger flexion and wrist flexion cleared in March, 1917, and recurred in May. Electrical massage in June, 1917, yielded free movement, but the spasm returned.

The man was admitted to Maghull, June 12, 1917, that is, a little over two years after his injury. The arm sprang back to the side like a clasp knife on being released. The wrist and fingers were moved freely. Three days after admission the elbow was forcibly flexed for some hours, whereupon the spasm disappeared. Next day the arm was forcibly abducted and reabducted: for four or five hours the arm could be voluntarily abducted. Two assistants were necessary, such was the force of the adductor contraction. At the end of a week the patient was found able to lift his hand to the back of his head. There was no longer spasm.

Re abrupt treatments, amongst which Reeve’s treatment by induced fatigue may be counted, Babinski and Froment consider that abrupt treatment is far superior to slower psychotherapy combined with isolation, whether or not we are dealing with a recent or an old disease. So far as psychotherapy goes, Babinski wants to obtain a definite improvement, if not a cure, on the first application of treatment. According to Babinski, the patient’s faith in his physician’s power to cure him is most active at this first meeting, whose emotionality favors the cure.

Burial and bruises of back: Hysterical cross-legs. Treatment by induced fatigue of contractured muscles.

Case 491. (Reeve, September, 1917.)

A man, 32, was buried by a shell and bruised about the back, August 2, 1916. He was bedfast until February, 1917. Every attempt to move the legs brought on tremors. He was then allowed up; but the attempt to walk caused one foot to knock the other, and his ankles became bruised, necessitating cotton wool pads for feet.

He was admitted to Maghull, June 12, with one leg crossed over the other and the thigh adductors spastic, especially on the right.

The fatigue treatment was carried out in dorsal decubitus, each leg being pulled by a man, and the separation repeated when necessary. Four hours a day for three days of this work finally reduced the spasm so that the patient was able to walk with assistance. On the sixth day he walked a mile without assistance. The spasm has not returned.

Re leg contractures, BÉrard got successful results by continuous extension combined with injections of 1 per cent novocain into the sciatic nerve trunk and the contractured muscles. According to Babinski and Froment, there ought to be an almost certain cure of any genuine hysterical state. They quote the observations of Souques, Meige, Albert Charpentier, Clovis Vincent, Roussy, and LÉri as proving this claim.

The Reeve method, so far as it is psychotherapeutic, bears a resemblance to Clovis Vincent’s first stage of what the poilu calls torpillage, namely, the stage of crisis and of intensive reËducation. But Clovis Vincent uses in his direct and forcible reËducation the galvanic current.

Bullet wound of neck: Hysterical torticollis. Treatment by induced fatigue.

Case 492. (Reeve, September, 1917.)

A soldier, 20, had a bullet pass through the back of the neck, July 10, 1916, and returned to his dÉpÔt surgically well October 1. A fortnight later a Zeppelin raid turned his troop out in the middle of the night, and on the morrow the man’s neck was twisted around and inclined upon the left shoulder.

Treatment followed in various hospitals, with fixation in the corrected position by plaster of Paris but without result. The patient was admitted to Maghull, April 18, 1917, with spasm of left trapezius and right sternomastoid muscles. Under hypnosis the deformity could be easily corrected. Unfortunately, it returned.

The fatigue treatment described by Reeve was started a week after admission to Maghull. The neck was forcibly straightened and restraightened upon return to its twist. In a few hours the contracting muscles had become fatigued; the neck was straight.

The next day the deformity returned slightly. The fatigue treatment was repeated. The patient was discharged well, July 2.

Burial by shell explosion: Abasia, tremors. Claw foot persistent two years cured by induced fatigue.

Case 493. (Reeve, September, 1917.)

A man, 24, buried by a shell, February, 1915, had had a functional “claw foot” for more than two years, cured by the Reeve fatigue treatment in less than a week. According to Reeve, claw foot is perhaps the most common of the war contractures, particularly intractable, and often seen out of hospital with an “inside splint.”

After his burial this man could not walk, had tremors, was in bed for four months and on getting up showed strongly inverted foot. Three months’ splint treatment, strong faradic currents, massage, passive movements, special boots with leather wedges to tilt the foot over, were methods of treatment tried, but unsuccessful. At Maghull from November 18, 1916, he was treated by exercises, passive movements, suggestive and reËducative measures, and after a few months got about without sticks.

The claw foot continued. Toward the end of June, 1917, the feet were forcibly flexed and everted for eight hours. The deformity disappeared, but returned slightly next day. Further fatigue treatment for eight hours caused the spasm to cease permanently. He was discharged quite normal, July 20, 1917. Reeve remarks that this fatigue method might be applicable to certain hysterical contractures in civil practice.

Skull trauma over right eye: Delirium, febrile? post-traumatic? exhaustive? Operation: Epileptiform excitement. Later, explosive diathesis: Operation: Euphoria. Seizures and slight mental change.

Case 494. (Binswanger, October, 1917.)

A soldier (brother choreic, sister infantile palsy) had had measles at 13 and in his fever climbed out of bed upon a couch, fell from the couch and was found by his mother lying on the floor. He was of moderate intellectual grade, of an emotional, passionate Saxon nature and had now and then been intoxicated.

In September, 1914, he was wounded over the right eye. He did not lose consciousness but concluded that he could not get back to his own lines on account of the enemy fire. Using a knapsack to cover his head, he lay down for twenty-four hours, until rescued by a passing body of the sanitary corps who were about to leave him for dead when he called loudly to them.

He was very weak in hospital and, towards the evening of the day after receiving his injury, he must have fallen into some sort of psychotic state lasting ten days. For this he remained quite amnestic, although he was told by comrades that he had hallucinations and had scolded and yelled, hearing voices. Apparently there were situation-deliria—the call to go over the top. Temperature, which had run to 38.8, after ten days sank to normal, and consciousness cleared up.

Was this a case of protracted febrile delirium? Or of psychosis due to commotio cerebri, that is, an effect of heightened intracranial pressure? Or was it exhaustion-delirium following loss of blood, sleep and food?

But this was not the end. The wound suppurated, and in May, 1915, eight months after the injury, operation was performed to relieve this abscess. Temperature immediately rose to from 38.4 to 38.6, the fever lasting three days, and a second psychotic phase with complete amnesia entered. He went into this phase immediately after recovering from the operative narcosis, looking wildly about and cursing the sister. The patient was violently excited and was put in a straight jacket on the second day. This phase may be regarded as one of epileptiform excitement with delirium. The operation may have played a part in the psychosis.

There were no further psychotic phenomena which could be attributed in any way to commotio. There were, however, attacks of cortical origin and emotional seizures. The patient became emotionally excitable and lost all inhibitions against expression of emotion, such as crying. Once he actually tried to suppress his emotion with a noose about his throat. He became seclusive and withdrew within himself—a victim of Kaplan’s explosive diathesis, or of Bonhoeffer’s emotional hyperesthetic defect condition.

A second operation was performed in September, 1916, to loosen the brain scar, and a large splinter of bone was removed. During the operation, under local anesthesia, there was a severe cortical seizure with complete disappearance of the reflexes. Ether was then administered. Later, in the same day, there were several minor cortical attacks.

After this operation the man’s emotional status changed; he was no longer irritable or exclusive, but became slightly euphoric and contented. He received during the next two weeks four tablets of Sedobrol and for a long time thereafter two tablets daily. There were never any phenomena of bromidism or any suggestive effects of the bromides.

The first attack after the second operation came in November, 1916, and was followed by slight dysarthria. Repeated attacks followed which were attributed to contractions in the scar. Accordingly, a third operation was performed and an attempt was made to bridge over a defect in the right frontal bone. The man’s emotional status remained good after the operation, but further attacks appeared six weeks later and there were spells of dizziness. Occasionally, in process of thinking, he said something stuck in between his thoughts. Sometimes thinking broke off sharply as if he had cut through a wire with an electrical current in it. There was a slight reduction in attention and a slightly increased fatiguability.

Hard service; shell explosion with loss of teeth: Vomiting. Cure by restoration of self-confidence.

Case 495. (McDowell, January, 1917.)

A married reservist was called up at the outbreak of the war and went through Mons, the Marne, and the Aisne and was finally blown up by a shell at Ypres. Early in November, 1914, he lost his speech but got it back in time to get home for Christmas. A number of teeth had been lost in the injury. Vomiting began first in England. While on leave at home he vomited at every meal. Asked whether it was his food or his thoughts, he said, “You are quite correct, Sir, you know I have always been with thinking.”

Under medical care, June, 1915, he was found suffering from hesitating speech, general tremulousness and emotionality. He worried a great deal on account of money matters at home. He lay awake thinking. A child became ill and died, and all the while he got worse, “thinking all the time.”

It was explained to him that the vomiting was a matter of emotions. The lost teeth were replaced by false ones. As he began to get control of his emotions, he vomited less and increased in weight. Finally he was boarded for discharge and was sick again on the day of the meeting. A fortnight later when sent to sign discharge papers he vomited once more.

According to McDowell, the vagus may possibly be incriminated as a cause of these gastric disturbances. Practically, the vomiting is a result of emotional stress. The cure is to produce insight on the part of the patient, the removal of worry and the restoration of self-confidence.

Michell Clarke cured such cases with milk diet.

Roussy and Lhermitte find hysterical vomiting to be relatively common and as a rule without difficulty in diagnosis; but they remark that there is often some underlying organic condition to be sought for and treated after the neuropathic element has vanished. They remark, also, that there is no tendency to spontaneous cure of the disease. They advocate a strict dietetic rÉgime and psychotherapy.

Cure of self-accusatory (“started retreat from Mons”) and other delusions by “autognosis.”

Case 496. (Brown, January, 1916.)

Capt. William Brown, in the discussion at the Section of Psychiatry of the Royal Society of Medicine, January 25, 1916, speaks of a method of treatment which he calls autognosis—a method of giving the patient self-knowledge, by revealing to the patient through his own confessions the cause of mental change leading to his symptoms. One of Brown’s examples is that of a sergeant in the firing-line during the retreat from Mons. He was admitted to Maghull with the delusion that people thought he had given the signal for the retreat from Mons on a silver whistle, a shooting prize of his. German officers used silver whistles that made a note like his own. In fact, he had other like delusions, such as that people thought him responsible for an Edinburgh railroad accident in connection with his troop-train. A German spy might have heard this.

In the process of procuring autognosis, Capt. Brown found that at the age of 12 this man had been falsely accused of stealing pork pies from a shop, and had been brought before a magistrate. In point of fact, he proved an alibi, but he was greatly worried by the charge. According to Capt. Brown, this incident of the insistence of the false accusation was the beginning of his tendency to delusions. In two months’ time there was a remarkable improvement.

Re psychoanalysis, autognosis and various modifications, Forsyth remarks that when the acute stage is passed, the Shell-shock case becomes an everyday neurosis in which war experiences are merely the latest phases in the patient’s life, and that psychoanalysis may then become necessary. Eder regards the “mechanisms” of what he terms “war shock” as the Freudian mechanisms of hysteria, and has commended psychoanalysis for a few cases, preferring hypnotism for acute cases. Adrian and Yealland decry psychoanalysis on the score of time limitations.

Deafmutism in three men shell-shocked at one time.

Cases 497, 498, 499. (Roussy, April, 1915.)

There were three Zouaves in a first-line trench north of Arras, January 14, 1915, who were blown up by a bomb thrown from the enemy trench some hundreds of meters away, by a mortar, a crapouillaud. This projectile burst with a great noise, louder than that of a bomb, and made a very strong windage. A dozen men were blown under the trench wall, just after entering the trench; two were killed; and the others, most of whom had been buried to the neck, were pulled out and carried, trembling, to the nearest relief post. Two of the three Zouaves were bleeding at nose and ears, and all three were absolutely deaf and mute. Evacuated to an ambulance, and thence to Paris, they arrived at Val-de-GrÂce, January 17, that is to say, three days after the shell burst. They communicated with the attendants by signs; one got hold of paper and wrote several hours in the day rapid notes about the accident. However, hysteria or pure simulation was suspected in these three Zouaves, and they were placed in small separate rooms. They were informed through the physician’s remarks to his staff that these were cases of nothing but simple nervous shock such as we had often observed, and the claim was made that they would be completely well either on the morrow or the day after.

On the morrow, two of them partially recovered hearing and got back their voices. They became loquacious and began to tell about the battle. The day after, the third patient began to speak. Two of them showed traces of auricular hemorrhage, and in fact, actual ear lesions were found in all three. One had a suppurative right middle ear, with perforation; another had both drums perforated and a suppurative middle ear, also on both sides. The third, who recovered his speech after the others, had perforation of the left tympanum with a little suppuration of the right ear tympanum and a slight tear of the right tympanum. In April, 1915, the hearing was cured.

These men had been under fire several months, and had taken part in the battle of the Marne. It was not a question of their first baptism of fire, and in fact, each of them had been previously wounded. According to Roussy, the story is, that the shell-burst produces by displacement of air tympanic perforation, and at the same time a violent nerve shock with loss of consciousness for a few minutes. The men come to, but the ear lesion, probably exaggerated by the nervous status of its bearer, creates a complete bilateral deafness. This deafness produces an absolute hysterical mutism.

Re case groups of war neurosis, several writers speak of dangers of contagion, but also emphasize the values of contact of patients with one another in the securing of therapeutic results. What Mott has termed the atmosphere of cure was no doubt present in the three instances of Roussy just cited. The cure of one may act heterosuggestively to produce the cure of a second, and so on. Functional deafmutes are somewhat refractory as a rule. H. Campbell states that there is some danger attached to allowing large numbers of functional cases to consort together too closely. He suggests making use of small wards and screens, and a process of sorting out patients so that they shall not affect one another injuriously. Steiner especially stresses the value of individual rooms in preventing psychic infection, of which, he says, the danger is large in open dormitories. The psychic contagion is as a rule that of hysterical seizures and tremors; but complaints about faulty hospital arrangements are also readily spread. Steiner advocates never questioning a nervous patient concerning his troubles in the presence of other soldiers. To reach 60 to 70 patients, Steiner had one examining and treatment room. Roussy’s institution at Salins in 1917 had a service limited to traumatic hysteria, from which, in three months’ time, 200 subjects had been discharged cured (see Boschi).

Dysentery: Milk diet persisted in: Vomiting, incontinence, inability to walk. Cure by persuasion.

Case 500. (McDowell, December, 1916.)

A soldier, 25, a low menial when war broke out, developed “dysentery and gastritis” at the Dardanelles, although even before the dysentery his nerves had gone bad. He had diarrhoea and vomiting, was sick every day, found himself unable to walk, and found himself always wet with urine dribbling day and night. Arriving in England and treated in a hospital, he still had vomiting. He had lived on milk and custard and been kept in bed.

Capt. McDowell convinced the patient that his legs were not as weak as he supposed. He was encouraged to walk, put upon light diet and then upon ordinary diet. He became an active worker in the ward, later going for five-mile route marches. Two months later he went back to duty in good health, weighing seven pounds more than before. This man was weakminded and, when his dysentery was cured, did not dare to start eating ordinary food. He was a victim of hospital rÉgime. Individual attention would have obviated much of the subsequent state.

Re vomiting, see remarks under another case of McDowell (Case 495).

Re incontinence, see Case 384, of Guillain and BarrÉ.

Officer dies in convulsions: Servant develops hysterical convulsions, which vanish on being explained as such.

Case 501. (Hurst, March, 1917.)

An officer and his servant were blown up by a shell. The servant ran to fetch a stretcher for the officer, to whom he was much attached, but on his return the officer made a few convulsive movements and died. Immediately after, the servant had a fit. During the next two months he had eleven more. Hurst made a diagnosis of hysterical fits resulting from emotion, explained his idea of their origin and nature to the servant, and the convulsions then ceased completely.

Re hysterical convulsions, see remarks under Case 443.

Course of a case with crises of trembling.

Case 502. (Roussy, April, 1915.)

A soldier in the artillery, who had been in the lines from August as a kitchenman, looking after the food of the first line trenches, with which his shelter was connected by communication trenches, 800 meters away, was on January 17, 1915, with three other men placed in the shelter kitchen of the trenches but a short distance away from the French artillery. The firing passed over the heads of these men but they could feel the windage, which obliged them to lie down each time. The evening of that day, several hours after firing had ceased, the kitchenman had a shivering spell, with trembling that lasted all night; after which these crises came on every day. He had finally to be evacuated to the rear.

According to Roussy, such patients always have neuropathic taint and a history of previous crises. Such a patient ought to be handled with rather severe discipline. In this way, according to Roussy, the reappearance of a severe attack of convulsions can be prevented. But these patients cannot go back to the front.

Re tremors, see Cases 224 and 225.

Two cases of lameness cured by persuasion: Russel.

Case 503. (Russel, August, 1917.)

A man on crutches, paralyzed completely in the right leg, partially in the left, developed paralysis in the right arm from the use of the crutch. There were marked vasomotor changes in the right leg and arm together with anesthesia to pinprick. Assured that he could move the legs perfectly he said that he had tried and failed. After a persuasive talk in private he began to use the arm, and to walk perfectly. It seems that in the trenches he had a sharp pain in the right knee, after which he did not use the leg and it gradually became more and more useless. It had been paralyzed for three months. The reason he did not use this leg was not on his own account, but on account of his mother at home. He seemed really grateful for the cure.

Case 504. (Russel, August, 1917.)

A sergeant in hospital for a year for shell-shock still had a marked shaking of the right leg whenever he raised it from the ground. He walked in leaning on a silver headed cane. The functional nature of his shaking was explained to him by Russel, whereupon he walked out normally saying he could do without his cane. Russel suggested that crutches and sticks thus given up were often donated to the shrine. The sergeant whose cane must have cost at least three pounds beat a hasty retreat carrying the cane in front of him.

Re Russel’s general point of view concerning malingerers and psychogenic cases, see under Case 458.

Hard patrol work: Delirium; head tremor augmented by excitement: Virtual recovery on bandaging neck, isolation, open air, to-and-fro transfers to mental and nervous wards.

Case 505. (Binswanger, July, 1915.)

A metal moulder in civil life, 29, in military service 1907 to 1909 (no hereditary taint, moderately good scholar), became unconscious for a half hour after taking a cold drink following a somewhat long practice march, at some time during his first year of military service.

He was in several skirmishes in Belgium and Northern France early in the war, being once surrounded in patrol work (November 11) by Turcoes and Zouaves. There was a lively exchange of shots, in the course of which five of the eight men on patrol fell. The three survivors hid themselves for three days in a quarry, and on the fourth were found by the advancing troops, and immediately went into battle.

But during a pause while on the point of taking coffee, the man suddenly fell sick, tried to carry on, but lost consciousness and apparently remained unconscious for about three-quarters of an hour. It seems that he raved and shouted and tried to bite his fingers, being held with great difficulty by several comrades. He was removed to a dressing-station three km. distant.

At the dressing-station, his head began to shake, although he was unaware of this until his attention was called to it by his comrades. He said that he felt restless and that his head ached almost continually. He was carried to the reserve hospital, and from thence, December 9, 1914, to the nerve hospital at Jena, where he was unaware of the shaking of his head (which had now lasted for three weeks), and said that he felt a thick fog in his head (to say nothing of headaches), and was only free and clear in his head while standing in the open air.

His sleep was restless and poor; there were war dreams almost every night. In the process of getting to sleep, his arms and legs frequently twitched. He would soon tire and feel weak. Also since his dangerous experience, he had noticed a change in his speech: always fluent before, it was now hard for him to speak because one had to exert one’s head so much in speaking.

This head tremor was in fact the most marked symptom of his illness. It would increase on every active motion of the head, but ceased almost entirely when attention was diverted. The head would then be held bent to the right.

During emotional excitement, the shaking spasm would spread over the entire upper part of the body, but would remain more severe upon the right than upon the left side. The forearms would fall into a lively shaking movement of pronation and supination. The hands and fingers would be attacked by a less marked tremor. After calm had set in, a fine tremor of the right hand would remain plainly noticeable. The musculature of facial expression would frequently fall into spasmodic movement, the left corner of the mouth twitching, the lips set for whistling, or the upper lip making movements as if snuffing spasmodically.

Physically the man was of medium height, strongly built, with adherent lobules, and a somewhat pointed skull. The teeth were defective and irregularly placed. Both deep and skin reflexes were increased. Marked dermatographia and mechanical excitability of the muscles: periosteal reflexes strongly developed; numerous pressure points in the head. The right temple and back of the head were painful on percussion. The patient showed no disturbance in touch and pain sensibility. Outstretched tongue showed marked fibrillary twitching; speech was difficult, being slow, awkward, stumbling, and sometimes hesitating (suggesting the speech of general paresis). At other times, the speech was of a peculiar sighing, tremulous nature, reminding one of the speech of children complaining or asking for pity. Rest was secured by injections of salt solution. A few days later, the treatment was continued by a bandage about the neck. After this the tremor grew slighter and would even remain absent for some hours. The patient was told to rest in bed and not to speak much; being “seriously ill,” he was kept alone. He was often irritated, querulous, and subject to outbursts of profanity. He took food well and slept well, receiving sodium bicarbonate.

The bandage was changed after five days. The tremor was very marked. The patient was furious because visitors were refused to him. He was especially angry with his nearest relatives and his betrothed, and wrote defiant letters to all of them. He became one of the most troublesome patients in the psychiatric division of the hospital. He complained sometimes of anxiety and feelings of unrest. He received treatment by pantopon. He continued to be a very disagreeable patient, feeling himself opposed and not properly considered. He thought himself seriously ill, behaved much like a spoiled child, and was of the opinion that he would not get well in the hospital because they were grieving him so. His appetite became bad; he complained of pains in the loins and of rheumatism in the legs. A cord was found hidden in the bed. The patient expressed suicidal thoughts at various times.

At the beginning of January there was marked improvement. The headshaking ceased almost entirely; the patient walked in the garden some hours daily. However, in the middle of January, on refusal of furlough, the head-shaking began again markedly. At his request a bandage was placed on the head again for a few days. He seemed emotionally very tender; his head would shake at the sight of a dead rabbit.

He was transferred to the nerve division of the psychiatric clinic at the end of January. He had recently begun to complain of flickering before the eyes. The ophthalmologists established an existence of a choroiditis disseminata. The eye examination had a markedly depressing effect upon the patient, and the shaking spasm of the head appeared again. Upon being told that he would have to be sent back to the psychiatric section of the clinic, the shaking immediately disappeared (24 hours after it had begun).

Thereafter slow improvement followed. He stayed in the open a great deal and walked. March 2, he showed a vehement outburst of anger, quarreling and using violence with a comrade. He was brought back to the psychiatric section, and in transit had a severe hysterical attack with unconsciousness, crying fits, and stepping movements of the extremities. He was promptly taken to a section for those seriously ill. The next day, upon his assurance that he could control himself, he was put in a more quiet division. He began to take part in gymnastic exercises, worked as a coachman, and then as an experiment was sent to a gentleman’s estate for recreation. At last accounts he was feeling well except that he occasionally had headaches during work. He could not work so hard as before on account of the rapid onset of fatigue, especially when working in the sun. The head-shaking recurred but seldom and lasted for a few hours only when the patient became angry or when there was much noise about.

Rationalization of war memories: Returned to duty.

Case 506. (Rivers, February, 1918.)

A young English officer was wounded just as he was extricating himself from burial in a mass of earth. He became nervous and sleepless and lost his appetite. After the wound had healed, he was sent home on leave, which had to be extended as he got worse. An out-patient in London for a time, he was finally sent to a convalescent home, still troubled with insomnia, battle dreams and concern about his recovery. He made light of his condition and was on the point of being returned to duty by the medical board, when his sleeplessness led to his being sent to Craighlochart War Hospital.

He could not sleep without a light in the room, else every sound attracted his attention. He tried hard all day long to banish all unpleasant and disturbing thoughts, but at night it took him a long time to get to sleep and then came vivid dreams of warfare. He did not, himself, feel that he could ever forget the war scenes.

Rivers, in general believing that the attempt to banish such experiences absolutely from the mind is poor psychotherapy, narrated his views to the patient. Rivers advised him no longer to try to banish the memories, but to try to transform them into tolerable, if not pleasant, companions. The war experiences and anxieties were talked over. That night the man had the best night he had had for five months, and during the following week the sleeplessness was no longer so painful and distressing. If unpleasant thoughts came, they had to do rather with home life than with the war. General health improved; insomnia diminished. He was at last able to return to duty.

Rationalization of war memories.

Case 507. (Rivers, February, 1918.)

An English officer was buried by shell explosion and developed severe headache, vomiting and disorder of micturition, yet remained on duty for more than two months. Collapse came when he went out to seek a fellow officer and found the body blown to pieces, with head and limbs severed from the trunk. This vision haunted him in dreams. Sometimes the officer appeared as on the battlefield; again as leprous. The officer would come nearer and nearer in the dream, until the patient woke pouring with sweat and in utmost terror. Accordingly, he was afraid to go to sleep, and spent all day thinking painfully about the night to come. Advice to keep all thoughts of war out of mind merely brought the memories in sleep upon him with redoubled force and horror.

Rivers’ therapy was to draw attention to the fact that the terrible mangling proved conclusively that the officer had been killed outright and without pain. The officer said he would now no longer attempt to banish the thoughts and memories of his friend, but would concentrate on the pain and suffering his friend had been spared. No dreams at all came for several nights, but one night in his dream he went out into No-Man’s-Land and saw the mangled body, but without horror. He knelt down, as he had in the original experience, and woke as he was taking off the Sam Browne belt to send to the relatives. A few nights later came another dream in which he talked with his friend. There was but one more dream in which horror occurred.

Rationalization of war memories: Eventually unfitted for military service.

Case 508. (Rivers, February, 1918.)

A young English officer, after doing well for a period, was rendered unconscious by shell explosion. The first thing he remembered was being led by his servant towards his base, thoroughly broken down. He had headaches, sleeplessness, war dreams and spells of terrible depression appearing with absolute suddenness, unlike ordinary “blues.” For ten days in hospital no such attack appeared, but one evening he came to Rivers pale and anxious. A few minutes before, he had been writing a letter in his usual mood, when this causeless depression came on. In the afternoon he had walked about on some neighboring hills. The letter dealt with no depressing matter. In ten minutes the depression vanished. Nine days later another came as he was standing idly looking out of a window. The attack lasted for several hours, as no physician was present to meet the issue. If he had had a revolver he would have shot himself.

Rivers was inclined to interpret these gusts of depression as due to a forgotten but active experience. As there was no definite tendency to dissociation, Rivers hesitated to plunge in with the hypnotic method, nothing short of which, however, served to recall the incident. The man was gravely apprehensive about fitness for further service, and was repressing his fear, as he thought it either was cowardice or would be called cowardice. The patient, by his discussions with Rivers, had already become familiar with the idea that the gusts of depression might be due to a submerged experience. Perhaps, however, there had been no experience, and the patient was advised that possibly the thing repressed was the idea about fitness for service. Accordingly, the patient agreed to face the situation. One transient attack of morbid depression occurred, after an operation. Then the man fell into a state of anxiety neurosis such that he was passed by a medical board as unfit for military service.

Rationalization of war memories: Commission relinquished.

Case 509. (Rivers, February, 1918.)

An oldish English officer lost consciousness while looking at the havoc wrought by shell explosion. Probably there was a second shell that sent him off. He was eventually admitted to an English hospital with paresis and anesthesia of legs, severe headache, sleeplessness and terrifying dreams. Hypnotic drugs and advice neither to read nor to talk about the war were the measures adopted and after two months in hospital he was given three months leave. He buried himself in the heart of the country, away from relatives, with aspirin and bromides. He began to sleep better and had less headache. When the president of the medical board asked a question about trenches at the end of his period of leave, however, he broke down and wept. He again repaired to the country for two months’ leave, for the chosen treatment by isolation and repression.

An order was then given that all officers must be either in hospital or on duty. He was sent to an inland watering place and treated by baths, electricity and massage, whereupon he rapidly became worse, especially as to sleep. He was transferred to Craiglochart in an emaciated state, with an expression of anxiety and dread, paresis of legs, sleeplessness and war dreams.

He was now advised to give up repressing, to read and talk a little about the war, and to accustom himself to thinking about war experiences. He did this but half-heartedly, as he thought the ideal treatment was what he had so long followed. Nevertheless, he got distinctly better and the content of the war dreams was altered to home scenes. He was still loath to acknowledge his improvement and thought that he would have recovered if he had not been taken from his retreat and sent to hospital. As it was obvious that he would be of no further use in the army, he was allowed to relinquish his commission.

Rationalization of war memories, without redeeming feature as nucleus.

Case 510. (Rivers, February, 1918.)

An English officer was flung by shell explosion so that his face struck the ruptured and distended abdomen of a dead German. The officer did not immediately lose consciousness and got distinct impressions of taste and smell and an idea of their source. After a period of unconsciousness he came to, vomiting and much shaken. He carried on several days, still troubled by vomiting and haunted by taste and smell images. Several months later he was observed by Rivers suffering from horrible dreams, in which the battle experience was faithfully reproduced. He got no relief except when he went into the country, far from every suggestion of war. Rivers’ psychotherapeutic plan of finding a redeeming feature in the experience, upon which the patient might concentrate, failed because there was no redeeming feature. Accordingly, it was thought best that the man should leave the army and seek the conditions that had given him slight relief.

Re psychoanalysis and its modifications, see remarks under Case 496, under which several favorable opinions were mentioned. Boschi in his report on French conditions gives no reference concerning psychoanalysis or hypnosis. Bruce has found blended with the war dreams many episodes quite alien to the war, and considers that the patient’s ante-bellum history is of importance, since ante-bellum emotions may be revivified by the war. Craig states that he has not been impressed favorably by the results of psychoanalytic treatment. Arinstein from Russian experience gives preference to Dubois’ psychotherapy over hypnosis and psychoanalysis. Nonne states that the data of the war prove that hysteria is neither a degenerative disease according to classical theory, nor a disease based upon Freudian principles.

Post rheumatic “paraplegia” (or abulia?) cured by removal of crutches, after question of discharge “unfit” had been raised.

Case 511. (Veale, November, 1917.)

A soldier, 23, had fever with swelling of several joints and temperature in 1915, and was furloughed to England. He complained of pains in the limbs and shortness of breath, and was put in hospital. As he did not improve, he was sent to a special hospital for baths and electricity. There he remained from August, 1915, to March, 1916, with D’Arsonval baths, cataphoresis, electric treatment and massage.

He was now sent to the second Northern General Hospital to see whether he should be discharged permanently unfit. Here he shuffled along on two crutches, very tremulous, and sweating, and suffering from palpitation on exertion. He wanted to take poison if he could not be cured.

The crutches were taken away. He was asked to walk up and down. He had to be supported at first and fell several times. The exercises were continued. Massage and drugging were stopped. The next day he was able to stand alone. In twenty-four hours he walked by himself. The other patients in the ward encouraged him on account of the genuine exertions he was making to get well. April 7, he returned to duty, smart and well set up.

Babinski and Froment always give the suspected subject the benefit of the doubt, never uttering the word simulation in the presence of the soldier, and proceed to psychotherapy; for psychotherapy will act to cure simulation or exaggeration just as it acts to cure hysteria. They say that in their experience, all these disorders of doubtful nature—that is, that lie diagnostically between hysteria, exaggeration, and simulation—are as a rule cured by resort to psychotherapy provided that the due amount of energy, tact, and perseverance is employed. See also remarks under Case 453. Veale’s case (511) never showed mauvaise volontÉ, and nothing more than aboulia.

“Trench foot,” “neuritis,” a year of astasia-abasia or at least of complaint of inability to stand or walk. Treatment by a “cruel though justifiable” process.

Case 512. (Veale, November, 1917.)

A regular army man, 38, well built and muscular, in Flanders the first winter, returned to England in January, 1915, with “trench foot.” “Neuritis” then developed, with loss of power to walk. Baths, electricity, massage, sympathetic wheeling about in a chair by women, all failed.

January 11, 1916, he still complained of inability to walk or stand. The reflexes were exaggerated. He was able to get into a wheel chair from bed by jerks, associated with palpitation, tremors, flushing and sweating.

He was told that he had now recovered from the neuritis. Crutches, sticks and wheelchair were removed. He flopped about and then lay on the bed exhausted. In a few days he began to shuffle about and was put on the stationary bicycle. January 29, he left the hospital well, remarking that though the treatment at first seemed cruel, it was fully justified.

Re genuine polyneuritis, Mann gives German experience regarding neuritis as somewhat frequent and affecting a special form which he terms polyneuritis neurasthenica. He states that the commonest instances of mononeuritis developing in the war are the sciatic and trigeminal. The neuritis often outlasts the other symptoms. The treatment was rest, tepid baths, and electricity. Naturally, alcohol and syphilis must be excluded in the diagnosis.

Nonne also described non-alcoholic, non-syphilitic, and non-infectious polyneuritis in neurasthenics, which he, however, finds most common in the ulnar, median, radial, anterior crural and posterior tibial nerves.

Re “spa” treatment, Turner thinks there may be easily too much massage, electricity, bathing. He prefers segregation in special hospitals to “spa” measures in general hospitals, prefers occupation to rest, and calls attention to the stimulating value of the gratuity to be paid on leaving the hospital.

Shell-shock paraplegia: Treatment by bed, cigarettes and chocolates altered to isolation, no tobacco, no visitors, faradization. Recovery.

Case 513. (Buzzard, December, 1916.)

Early in the war, a lad, 19, was blown up by a shell. He was sent home paralyzed from waist down, and was seen by Capt. Buzzard after he had spent ten months in various hospitals, “carefully nursed, on the water bed, constantly using a bed urinal, smoking innumerable cigarettes, and eating countless chocolates.” He could not move his legs. They were wasted and flaccid. The knee-jerks could be got with difficulty. Plantar reflexes flexor. Complete anesthesia from umbilicus downwards, but preservation of abdominal reflexes. The navel did not shift downwards when the patient attempted to sit up. The incontinence was not real; urine was passed into the urinal at appropriate intervals.

Buzzard directed treatment “not to his spinal cord but to his mind; isolation; the stoppage of tobacco and all visits; the assurance that he would rapidly get well, together with some suggestive faradization of his legs.” This brought about a cure in a very short period. The atrophied legs eventually grew strong enough to walk.

Re cigarettes in Shell-shock, Mott decries the over-liberal gifts of cigarettes that induced cigarette habits in both officers and men. Of course, the cigarettes are still more detrimental to cases of soldier’s heart than to other cases of neurosis. Mott remarks how over-frequent are the social tea-parties, joy rides and drives given by well-meaning ladies for the “poor dears,” actually perpetuating neuroses.

Re atrophy, Babinski and Froment again bring up the question whether muscular atrophy can be brought about by a hysterical motor disorder. In point of fact, Charcot and Babinski were the first to describe the true hysterical amyotrophy, but this hysterical amyotrophy is exceptional in hysterical paralysis, and is slight when it occurs.

Shell-shock blindness, mutism, deafness: Blindness spontaneously vanished, 24 hours. Mutism, 2-3 months. Deafness cured by “small operation.”

Case 514. (Hurst, September, 1917.)

A lance corporal, 26, became blind, deaf and dumb, though without losing consciousness, when blown up by a shell, August 29, 1916. His sight returned next day. On reaching England he talked in his sleep. Encouragement, electricity, etherization failed to effect improvement. One night in November he woke up and asked the sister for a drink; thereafter he talked normally.

Seven months after the shell explosion he was transferred to the neurological section at Netley, March 21, 1917. Deaf to air and bone conduction, a loud noise behind him caused a slight tremor of hands, with blinking and dilatation of pupils; but further stimuli of the same sort failed to produce such reactions. Normal nystagmus and giddiness on functional tests of vestibular nerve and canals. The internal ear was then probably free from organic changes. Since shell-shock mutism is always hysterical, it was probable that the deafness was hysterical. Under hypnosis (staring at lines for fifteen seconds) he showed no change. During natural sleep, also, a shout of “Fire” and metallic noises failed to wake the patient or to produce contraction of eyelids. Electric suggestion (despite the patient’s belief in electricity) and reËducation failed.

April 16, he was told that a small operation would have to be done April 20. To this he readily consented. Two small incisions were made behind the ear under light ether and suture was inserted. A loud noise was made during the “operation”; he heard this noise and jumped from the table. To his intense delight normal hearing returned in a few minutes. Next day hearing was tested and found normal to air and bone conduction. He was discharged to duty three weeks later and on his way to France, June 29, demonstrated his normal hearing to the physicians.

Deafness: cure by stimulating vestibular apparatus.

Case 515. (O’Malley, May, 1916.)

A private, 20 years of age, lost speech and hearing after the battle of Neuve Chapelle. Eight days later he came under the care of the laryngologist in a very excited state, pointing to lips and ears and carrying a note with information concerning his deafmutism.

Dr. O’Malley wrote on a piece of paper that he would restore the patient’s speech and hearing. Dr. O’Malley then used the mirror until the point of retching, and wrote, “You can speak now; count up to ten loudly.” He did.

Dr. O’Malley next used the cold water douche to the right ear to the point of giddiness, then shouting through a speaking-tube (see description below). The patient then found he could hear and the tears streamed down his face. Thereafter he was able to converse freely. Dr. O’Malley writes:

Bullet through mouth; Hysterical mutism. Treatment by operative manipulation.

Case 516. (Morestin, January, 1915.)

A Colonial infantryman, 32, was wounded December 17, 1914, at the Boisselle, being struck by a bullet which entered on the right side in the upper part of the neck and came out behind the left side of the mouth, having traversed the tongue, broken two teeth, and caused a good deal of hemorrhage by mouth. The patient felt his tongue swell, and from this time on he could not pronounce a word. He was sent to the ambulance, then to Mien, then to Saint Germain, and finally to Morestin’s surgical service. With wounds by this time healed, the patient found it hard to open his mouth. There was no trace of fracture of the lower jaw. The tongue could be only incompletely examined. The man swallowed liquids easily but could take no solid food. He tried hard to speak, made pantomime movements, grew emotional and lachrymose.

On the whole, however, it seemed that his inability to articulate sound could not be due directly to the lesion. There must be either simulation or hysteria. For four days he was attentively watched, and not once did he pronounce a word. He grew more and more stricken and humiliated by his plight. Rigorous diet did not cause his mutism to cease. Isolation and ennui did not decide him to talk. Accordingly, it was announced, in the man’s hearing, that an operation was to be done to restore speech. January 9, 1915, his face was copiously washed with alcohol and ether. Cocaine was injected to secure anesthesia and resolution of the muscles of mastication. Six c.c. of a 1-100 solution on each side. Shortly the surgeon began to open the jaws, against decreasing resistance. The tongue, which was not spastic, was seized with a tractor and rhythmic movements were executed with it. After a few of these movements, joy was painted on the features of the patient. He said that he wanted to speak and that he was about to speak. He shook the surgeon’s hands effusively and said, “Merci.” Although the first words came hard, little by little speech became free and a perfectly sincere elation at having recovered speech set in.

This man was neuropathic, having always been a rather strange, irritable and restless person, and given to nervous crises in anger, in which he lost consciousness entirely.

Re pseudo operations as forms of disguised persuasion, almost countless methods have been used. See Cases 514, 515, 518, 519, especially 521, 560, 561. Sham injections under ethyl chloride have been made (Goldstein). See also under Case 484, re continuous bath, and under Case 488, re lumbar puncture. Very close to these methods are the methods of torpillage of Vincent and the methods employed by Yealland in England and Kaufmann in Germany. See under Cases 574, 563, and 564, and 570.

LÉri quotes Babinski as saying, “We cannot fight hysteria in trench warfare; manoeuvres are necessary.”

Re treatment of mutism, Chavigny remarks that the principle of treatment for mutism is quite different from the principles of treatment of paralysis. The reËducation of mutism is psychic. Chavigny claims probably absolute success in the treatment of mutism through faradism to the larynx region simultaneously with a signal given to the patient to make an effort to pronounce the letter A. Garel modifies the treatment (in case the faradic apparatus is not at hand), by a vigorous and sudden blow to the patient’s epigastrium simultaneously with the patient’s endeavor to imitate the movement of the doctor’s lips.

Shell-shock: Impairment of vision (even commanded men to fire on kindred troops!) Improvement by verbal suggestion, faradization, injections.

Case 517. (Mills, October, 1915.)

A sergeant-major, 29, in private life a bookkeeper, said that shrapnel struck the ground in front of him and burst as it struck. Unconscious for a moment, the sergeant-major thereafter saw everything imperfectly, led his men in the wrong direction, and even commanded them to fire in the direction of his own troops.

Seven days afterwards the eyes looked normal, fundi were normal, vision was reduced to the perception of hand movements; with a plus 10 sphere the right eye could count fingers at 5 c.m. and with a plus 8 sphere the left eye could count fingers at 3 c.m. There was a right frontal analgesia.

Treatment: Sweating; rest in bed for several weeks; assurance of complete recovery. There was a slow but constant improvement, aided by faradization and injections of strychnine sulphate into the temporal region, but the prospect of a return to the front retarded the improvement.

Re injections into the temple, see also Case 521 of Bruce. Re cure of blindness, Grasset has a case of a blind deafmute who was cured by a nurse. She put a pencil in his hand and guided the pencil while she wrote a question. The patient replied in very good MSS. In blind deafmutes sight is described as returning first, hearing next, and speech last.

For other cases of blindness, see especially under Section C, Cases 433 to 438, with discussions thereunder.

Re retardation of improvement by the prospect of further military service, Lewandowski has insisted upon the strong factor of the wish in all such functional conditions. Lewandowski wants all functional cases, however, to be sent to duty in the rear or to be discharged as unfit.

Aphonia: manipulation in larynx.

Case 518. (O’Malley, May, 1916.)

A corporal, 28, had a bullet pass through his neck from a point in the middle line at the upper border of the thyroid cartilage to a point behind the right sternomastoid muscle, two inches below the point of entry. The corporal lost his voice at the time of injury, spat up a teaspoonful of blood, and thereafter was able to whisper only. The laryngoscopic examination betrayed no intralaryngeal lesion. Treatment as described below enabled the patient to speak. O’Malley describes his technique as follows:

Re methods for curing aphonia, Muck has a method called the “ball” method. A ball is put into the larynx to cause a temporary suffocation, which produces a reflex that starts the adductors. He would apply the method as soon as the man was well over the shock that produced aphonia. Muck states that he has applied the ball method, not only to cases of aphonia, but to cases of mutism and deafness, with success.

Tilly mentions a case in which the patient refused to open his mouth, so the device was adopted of passing an electrode through the left nostril so that it finally reached the larynx. A spasm was produced, which was carried to the point of considerable cyanosis, but the aphonia was relieved and for the first time in three months the man spoke. Incidentally he began to hear also.

Re treatment of aphonia, Schultz has used the electric current externally over the larynx, all the while carrying on a laryngoscopy. Schultz remarks upon the fatigue that may come during the first few sittings. Roussy and Lhermitte remark that, although aphonia sometimes exists from the outset of shock, it is often a phase in recovery from mutism.

LiÉbault notes that, not only cases of true nervous aphonia but cases of laryngitis, apparently of infectious origin, and cases of true voice strain, may also turn up for treatment. Some men have been improperly discharged from the army for aphonia actually due to voice strain.

Hysterical aphonia in a mechanician (war time contributory?). Cure by suggestive manipulation of larynx.

Case 519. (Vlasto, January, 1917.)

A mechanician was refitting an engine valve, when steam was suddenly put on and the drains were opened out. Some of the steam entered the throat of the mechanician, who rushed up, gasping, unable to speak. Oedema of the larynx was thought of; but there was no complaint except the inability to speak.

A month later he was discharged to the hospital ship at Plassy, where he got faradic treatment, the effect of which was to cause him pain without recovery of voice. The man could whisper well enough and cough fairly loudly. The vocal cords of the larynx appeared normal on laryngoscopic examination, but adduction of the cords was not be properly effected. He was now given rest and constant assurances that he would get well.

Ten days later, another laryngoscopic examination was made, with mild mechanical stimulation of the air passage. The patient remarked that he had never been so near being able to speak since his dumbness came on. The patient was now informed that his muscle of talking was going to be replaced and that the success of the operation depended upon his help, so that he was to shout out as soon as he became conscious of the physician’s working inside his throat. The patient was given ether lightly, into the second stage. When consciousness was about to return, the laryngeal mirror was placed lightly on the larynx. The patient was commanded and encouraged to count out loud and shout. Speech returned permanently.

It is to be noted that there was no specific war effect underlying the phenomena, unless we regard the fact of its being war time as contributory to the shock produced by an incident in every day engine room duties.

Gradual onset of mutism and amnesia without special occasion. Faradism. Dream.

Case 520. (Smyly, April, 1917.)

A soldier was slightly wounded in the arm and returned to the trenches. Later he found himself in hospital at Boulogne, unable to speak and unable to remember what had happened to him from the time he was in the trenches. It appears that his voice and memory had gradually disappeared, according to what was told him by his comrades.

A month afterward, in a London hospital, the patient was roused suddenly from sleep, and then proved able to speak, although there was great difficulty in getting each word out. Two months later, he went to bed, feeling indisposed, in the night had a kind of fit, and remained unconscious until the following night; the next morning, his voice was again lost. The aphonia persisted for a fortnight, and the patient could hear only loud shouting when close to his ear. He was anxious to get well and requested electricity from the physician, Dr. Smyly, having heard probably of another case cured thereby. Dr. Smyly applied faradic current to the larynx externally, instructing the patient to blow at the same time. At first the patient spoke so low that he could not hear himself speak, but on suggestion succeeded in speaking up loudly enough. He was shortly able to speak and hearing improved. The climax arrived with a bad dream one night, from which the patient awoke in a fright and found himself able to hear and speak perfectly.

Re nocturnal spontaneous cures, see observations by Mott under Case 473. Note also in this case the presence of what Mott has termed “the atmosphere of cure.”

Re relapses, see Case 476 as well as remarks under Case 474. Re special cases of mutism, Goldstein has insisted upon a greater individualization of treatment for functional mutes than even for other neurotics, and advocates the establishment of schools within the hospitals and aftercare institutions. He thinks the problem very serious.

Shell-shock blindness: Cure by a course of injections in the temple.

Case 521. (Bruce, May, 1916.)

A soldier from Gallipoli was admitted to the Royal Victoria Hospital at Edinburgh, blind. He had been at Gallipoli from May 1, 1915, until August 12, when a shell explosion blew in his trench and buried him. He was dug out nervous and tremulous. Shortly afterwards there was the bright flash of a second shell, and amnesia set in until he found himself in hospital. He could not see at all with the left eye and the sight of the other was poor. He arrived in Scotland, October 9. He was nervous, excitable and now somewhat depressed, complaining of blindness and pain in the left eye, and headache. The left eyelid drooped. The fundus was normal. He had not been given an anesthetic.

It was explained to him that the eye had not been injured; that it had become weak from the explosion; that he would be given a series of injections into the left temple of a strong drug which would restore the sight of the eye.

Gradually increasing quantities of normal saline solution were given every morning. After four days he said that the treatment was doing him good. A week later he said that the eye was much stronger. After the fifteenth injection he could not sleep. The headache was worse, and there was “moving about inside his head.” Early in the morning he went to sleep after a period of restlessness. He awoke at eight o’clock able to see perfectly, and was overjoyed at the result. There was some blurring and four days later he said he was becoming blind again. More normal saline was injected, causing pain. After that there was no relapse, and the man was sent back to his unit.

Re Shell-shock blindness, Ormond and Hurst recommend a light hypnosis; taking the functionally blind man into a dark room and requesting him to make his mind a blank. Some cases are refractory. An anesthetic may be used with suggestion in the semi-conscious stage.

Deafness, cured by suggestion in writing.

Case 522. (Buscaino and Coppola, 1916.)

L. G., 20 years old; fusileer. (Mother of neuropathic constitution. Father died in 50th year of heart disease. One brother had hemiparesis from infantile cerebropathia.) The patient suffered from infantile otitis media bilateralis, which was followed by abundant chronic otorrhea from his fifteenth year. He relates that for a long time he was obliged to wear a very large handkerchief on his shoulders to receive the pus, which came from an ear. No sex disease. Nothing of importance in the physical anamnesis.

Patient entered the army, Jan. 15, 1915. In May, he was sent to the front (Basso Isonzo). Towards the end of July, while he was in the trench, a grenade exploded a short distance from him, causing slight abrasions at the nape of the neck and in the fleshy part of the left calf. He was picked up in an unconscious state, and taken to the hospital at Cervignano, where he was admitted as a deafmute and was given electric treatments. After 18 days or so, first stammering and then pronouncing with difficulty a few words, he finally regained his speech entirely. Deafness continued, however.

Being transported to a special hospital in Florence, he was in a state of psychic excitement for several days, showing also visual hallucinations—saw “many soldiers,” saw “many soldiers all about him.” He was treated with chloral and bromide. The suspicions of several physicians were aroused by the obstinate declaration by the patient that he was incurably deaf.

On being admitted to the clinic on August 22, he showed complete deafness in addition to a slight degree of stupor; he remained impassive to the glance of his questioner without showing signs of worry about his condition, nor did he make any effort to make himself understood by making lip-movements (which is in contrast to another patient affected by organic deafness, who on the contrary made great efforts to understand anything said to him, clearly showing his great grief over his incapacity).

He failed to respond to auditory stimuli either by air or by bone conduction. It was possible from the beginning to exclude suspicion of simulation; during the day, indeed, it was not possible by any of the repeated attempts to awaken surprise in the patient by means of an acoustic stimulus. At night, while the patient slept, it was possible, however, to awaken him by calling his name, or by making a fairly loud sound; the patient would then open his eyes but was quite unable to hear. Neither confusion nor hallucinations were in evidence.

He was able to converse very well and spontaneously (he remembers having lost consciousness at the explosion of the grenade and not coming to until after his arrival at the hospital at Cervignano); he read correctly both mentally and aloud, and answered by signs the questions put to him in writing. Being face to face with hysterical traumatic deafness, notwithstanding no other hysterical phenomena were noticed, a successful attempt was made with suggestive therapy, the patient being emphatically assured (always in writing) that the following Sunday his hearing would be restored without doubt. The following Sunday, in fact, during the visit of a lady (one of his friends), hearing in his left ear was suddenly and almost completely restored to the patient. He was in profound emotion on account of this, and upon the appearance of the physician he had a hard weeping spell. During the following day, he began slowly to hear with the right ear.

During the latter part of his stay at the clinic, however (until September 24, 1915), a slight hypo-acusia in the right ear persisted, along with severe headaches and pains in the left ear (which the patient compared to the suffering as a child with otitis).

At the otoscopic examination by a specialist, only residuals of the old catarrhal otitis with retraction of the tympanic membrane were found.

Shell-shock story reproduced in hypnosis. Recovery.

Case 523. (Myers, January, 1916.)

A private had been found wandering in a village, in shirt and socks, unable to give name, regiment, or number. He was admitted at a field ambulance, and seen by Major Myers three days later. No Christian name seemed familiar to him. The past was a blank. He was depressed. There was numbness over the occiput. The legs, hands and tongue were tremulous. The left arm and leg and the left side of the face, chest and abdomen were hypalgesic. The knee-jerks were exaggerated; pseudo-clonus of left knee and right ankle. There had been a nightmare of bombs thrown into trenches—one thrown by a German hit him in the neck and woke him up in a cold sweat.

In hypnosis the dream was repeated, and points about his previous life were dragged out piecemeal. Next, the names of village and near-by town, and finally his own name, regiment and number were elicited. After the bomb-throwing, he said, “I must have gone off my head and run away. I must have taken off my clothes in a field. I spent the first night under a hedge. I spent the next two nights in a wood. I ate nothing. The next night I was walking along a road on the outskirts of a village and I was taken to a house by two men.” On waking, he proved unable to remember these things and was promptly rehypnotized, whereupon the memories became clearer and more ample. More powerful suggestion was given, and complete recovery of memory followed the second period of hypnotism. The pupils became larger. The despondency disappeared, together with the occipital numbness and the left-sided hypalgesia. He was transferred to a base hospital, and thence after three weeks to a hospital in England, made an uninterrupted recovery, and rejoined his regiment.

Shell-shock story reproduced in hypnosis. Recovery.

Case 524. (Myers, January, 1916.)

Private, 29, seen by Major Myers in a base hospital the day after entrance, was in a stupor from which he had to be repeatedly roused to answer questions. He could recall neither name, regiment nor age, and was unable to write or read except a few letters in very large type. Twice he said the words war and comrade, and made a gesture as if following. He agreed that a shell came and intimated that he had pains in the forehead. He could not hold his hands out for many seconds without dropping them. Knee-jerks brisk.

Four days later he was very little better, never having spoken voluntarily, but replying yes to the utterance of his name, and was able with great effort to write his name. He still intimated his severe headache. The next day the names of his two children were given. He could not read aloud the figure 2 but held up two fingers. Next day, he gave syllable by syllable his wife’s name from her photograph.

A week from admission he was hypnotized and persuaded to talk about the events that preceded his disorder, breathing excitedly, gesturing, and evidently visualizing the scenes. He had been in the trenches, had been sent to draw water at a camp, and had been knocked down when two or three shells burst over him. He carried out post-hypnotic suggestions.

He was hypnotized again, two days later, and now described how, after shelling, he had lain on the ground, dazed; had risen, picked up the water bottle, returned to the trenches, and then lost all sense and reason. He recalled how his mates had told him he was silly, but had lost all intervening memories. But the full details were elicited by persuasion. Next day he complained that he still wrote with difficulty. Under hypnosis, his speech and writing were restored to normal. He was discharged two days later to an English hospital.

He was then passed for foreign service, being prevented from active service in the field by occasional severe headaches.

Burial after explosion of a “coal box”: Automatism, amnesia, deafmutism: Recovery by hypnosis.

Case 525. (Myers, September, 1916.)

A sergeant, 18, with nineteen months service in the army, 11 months in France, was seen by Lt. Col. Myers at a clearing station to which he had been transferred after three days in another clearing station, with a note “Found in the streets of B——, asking his way to the fire trench; could not be got to speak on admission nor since; seems deaf, but now writes rationally.”

Mute and very deaf at the second C. C. S., he regained a good deal of his hearing with encouraging talk and also became able to cough and utter P, B, F and S, finally whispering name, regimental number, and the like. At the same time he could write fluently. After being buried he had lost himself until he had asked his way of a military policeman at the crossroads in B——. There was amnesia again until he had been 48 hours in the clearing station at B——. The throat hurt as if it were pulled down when he tried to speak, and his head ached when he tried to remember. There was much tremor, especially of right arm. In a quiet room adjoining, the tremors increased and there was much agitation. Lt. Col. Myers suggested cure and encouraged the man, finally inducing a mild hypnotic state in which he spoke aloud, at first hesitatingly, later fluently.

The man eventually remembered what had happened after he had extricated himself. He had run, as he thought, towards the fire trench, taken a wrong direction, and met a Frenchman who gave him eggs and bread, allowed him to sleep on a couch, put him on a cart and drove him to B——. He was then very giddy and asked his way of the policeman. The shell by which he was “terribly shaken” was a “coal box.” Posthypnotic suggestion that the headache would not recur and that he would shake hands with the orderly was successful. He now talked in a proper voice, at first hesitatingly. He looked another man as his clay-colored face resumed a normal aspect. After a good night’s sleep he was evacuated to a base hospital, thence to an English hospital, whence he wrote six days later in gratitude for the successful treatment, stating that he was now nearly well and hoped to be fit for light duty.

Six weeks later he wrote that he was still dizzy. He also remembered certain further details of his experience; how he had wandered into a listening sap in front of the Huns’ barbed wire and had had a tussle with three Huns, after which he was buried during the heavy shelling.

Mutism: Recovery by hypnosis.

Case 526. (Hurst, 1917.)

A transport driver, 31, was run over by a loaded wagon at Gallipoli in May, 1915, and fractured his pelvis. He remained perfectly conscious but unable to speak for three days. At the beginning of August, when he was admitted to the war hospital, he still spoke with great difficulty and with contortions of his face. Even when he did not speak, he had facial contortions and that mental condition characteristic of tic, namely: although he was able to control the contortions by will, he felt uncomfortable during the control and finally gave way to the irresistible impulse.

Under hypnotism, it was suggested to him that he would be able to speak without difficulty and would no longer have the contractions of the face. When he came out of hypnosis he was able to talk quite normally, sang next evening at a concert, and a few days later he took part in a play. The facial contortions persisted in hypnosis and even afterwards, but vanished after a second hypnosis.

Re hypnosis as treatment of mutism, Ballard remarks that a genuine return of speech and a merely hypnotic speech must be distinguished.

Nonne is the great exponent of the use of hypnotism in treatment of the war hysterias. He got as good results from high as from lower classes of men. He remarks that the hypnosis does not protect against recurrence if the patient again falls under the original conditions that brought about the first attack. Hypnosis may be used also as a diagnostic measure between functional and organic cases. Even tics and tremors have been at times cured.

Re employment of hypnotism, Hurst suggests that it may well be used, not only in mutism, but in hysterical deafness, blindness, and occasionally in psychasthenia. It is not a cure-all for the war hysterias, but is to be used as a not infrequent form of treatment. Nonne claims cures of 51 out of 63 cases of hysteria major (28 rapidly, 23 more gradually). Ten of his 63 proved refractory to hypnosis altogether.

Stammering: Cured by hypnosis.

Case 527. (Hurst, 1917.)

An Australian, 22, wrote the following, August 21, 1916:

The abrupt ending of the letter was due to the entrance of Major Hurst. The patient had been hypnotized but his deafness had persisted during the hypnotic sleep, so that suggestions could not be effectively taken. He heard nothing whatever during a very heavy thunderstorm, was unable to make any sign whatever, and could not even cough.

He was now told in writing that his speech and hearing would be restored when ether was given. After a few whiffs, he struggled and before he was under began to repeat the word “Mother.” Etherization was discontinued before his limbs had even become relaxed. As he was coming to, he was requested to repeat various words, and when the anesthetic had passed, he was talking normally and had completely recovered hearing.

Now, however, his memory had become a complete blank. From a short time before his shell-shock up to the moment of his regaining consciousness after etherization, he remembered nothing of his loss of speech or hearing, nothing about the events in his letter, and nothing about Major Hurst, whom he felt he had not previously seen. According to Hurst, this patient had become (a) speechless from fright at the time of the shell explosion, (b) deaf from the noise of the explosion, and (c) unconscious from the windage. After he came to at the time of the explosion, an autosuggestion to the effect that he had lost his power of speech and hearing occurred. Ether broke down this inhibition of speech and hearing by interfering with the control of the high over lower cerebral centers.

Re emotional stammering, Chavigny treats by voice gymnastics, rhythmical breathing movements, sounds spoken by metronome with simultaneous movements of arms or trunk, and by singing. Re hysterical stuttering, Roussy and Lhermitte remark that the symptoms are always very pronounced, come on suddenly, and cease just as suddenly under the influence of electrical treatment. The history will differentiate hysterical stuttering. The effects of treatment will also help. Genuine non-hysterical stammering may, of course, be increased through emotion or shock. Dundas Grant aids the stutterer by having him twist a button or carry out some other muscular movement simultaneously with the attempt to speak. He also has the patient endeavor to expand the lower part of his chest during the effort.

MacMahon notes that Shell-shock stammering is chiefly a difficulty with vowel sounds and voiced consonants, and amounts to a speech inhibition, accompanied sometimes by amnesia for words and suggesting a form of aphasia. Mild cases of such stammering are cured simultaneously. MacMahon relies in part upon especially regulated breathing movements and the attendant sense of repose. The cases of old cured stammering that have come back under Shell-shock are harder to treat.

Two burials; shell-shock: Mutism and amnesia. Recovery aided by hypnosis.

Case 528. (Myers, January, 1916.)

Major C. S. Myers recites hypnotic cure in a case of mutism. He remarks that malingering is sometimes suspected in these cases. There was, however, in this case a severe constipation which lasted five days from the shock, and a retention of urine with catheterization during the same period. This private, 32 years, came to a base hospital, mute but able to read and write as follows:

It seems that he had wandered off with a lance-corporal for three days after the first burial, and neither he nor his comrade were able to find their regiment.

Understanding was slow and look vacant. There were jerky movements of the arms and a snoring sound from the nasopharynx. Voluntary movements were restricted, weak, slowly executed, jerky, and incoÖrdinated, but not tremulous. Station was unsteady; failure in finger-to-nose test. He could imitate the sound ah, and the consonants s and p.

Knee-jerks exaggerated; plantars flexor; abdominal reflexes absent; pupils reacted; eye movements normal; moderate restriction of visual fields on temporal side; watch not heard even in contact with ear; heard better by air than by bone conduction.

In the next two days, the patient became brighter and movements became better. On the seventh day stupor and ataxia had disappeared. Familiar names could be repeated and the next day could be given on request. The patient would sweat profusely in giving replies. There was no spontaneous speech. A week later speech had improved.

Under hypnosis he spoke more fluently though feebly, and became emotional upon being questioned as to trench life, waking up suddenly from hypnosis and wiping the sweat from his chest.

The next day, forgotten events of the second burial were recalled together with what followed. Post-hypnotic suggestion of the performance of eccentric actions was successful.

Next day his memory had returned save in reference to the two days’ wandering after the first burial; and under hypnosis the events of those two days were recalled. He was then transferred to an English hospital.

Re hypnosis for “war shock,” Eder remarks that the usual objections to hypnosis cannot apply because the majority of cases have no neuropathic antecedents. Eder, as psychoanalyst, endeavors to level hypnotic suggestion against the so-called “complexes.” Elliot Smith and Pear commend Lt.-Col. Myers’ results, but regard the results of hypnotic treatment as brilliant but erratic. Colin Russel, regarding hypnotism as an induced hysteria, remarks that a true hysteria can hardly be cured by adding more, although he has sometimes used the treatment with apparent success. Podiapolsky notes that some 17 per cent of his functional cases will, at a word, drop off into an artificial deep slumber. He thinks chloroform should not be given to these subjects without an attempt to secure this artificial deep slumber first. Chavigny, highly commending suggestion, notes that the use of hypnotism is prohibited in military hospitals in France. A remark of Smirnow indicates that the Russian authorities also look with disfavor upon hypnosis, but he notes certain patients whom he cured by hypnosis, so that apparently Russia did not absolutely forbid the use of hypnosis in war cases. Another Russian, Arinstein, prefers the Dubois method to hypnosis.

Roussy and Lhermitte definitely state that the psychotherapy of Dejerine, Dubois, and Babinski beneficially replaces hypnotic suggestion, “which ought definitely to be rejected.” However, if the conclusions of Bernheim are sound, there can be no theoretical claim of distinction between hypnosis and other forms of suggestion.

Fifteen bayonet wounds; recommendation for Victoria Cross: Hysterical contracture of hand, revealed by hypnosis as the bayonet clutch.

Case 529. (Eder, August, 1916.)

A left-handed Irishman, 23, on December 22, 1915, got 15 bayonet wounds, 14 of which were on the right side of the body. He was in the trenches with 23 men, when they were attacked by about 200 Turks. He and a sergeant leaped out of the trench into a bayonet attack with Turks.

He was admitted to the hospital January 26, 1916, for a hysterical contracture of the right hand. The fingers were semi-flexed and could not be passively extended. Col. Purves Stewart noted that there was an anesthesia and analgesia to pin-pricks and cotton wool on the whole of the right arm. “At the beginning of the examination, the patient felt pin-pricks at the wrist; as examination continued, the boundary of anesthesia steadily increased until it reached the shoulder, by which time the previously sensitive spots were now anesthetic.” Later there was a complete right hemianesthesia.

In telling his story, this soldier repeatedly emphasized that “You must clutch your rifle very firmly and never let it up, guarding yourself all the time.” This was the explanation of the contracture. According to Eder, in the unconscious, he was still clutching the rifle, fighting the good fight, and symbolizing the desire by the grasping hand. In hypnosis, suggestion was made that the fight was over and the rifle could be let go, whereupon the hand was immediately relaxed.

The analgesia, thinks Eder, was present during the fight and passed away subsequently. In fact, the soldier said that he felt no pain during the fight and did not know that he was wounded until his attention was called to the fact that blood was flowing from him. According to Eder, the unconscious mind refused to feel pain. At Col. Stewart’s first prick or two “the unconscious took no notice, but as the pricks continued, the former memory was revived and the unconscious became on guard.” He had been recommended for the V. C.

Gunshot of forearm: Hysterical contracture, wrist and fingers: Cure by hypnosis, “indecently quick.”

Case 530. (Nonne, December, 1915.)

An infantryman, without special hereditary taint and previously well, was shot September, 1914, in the right forearm. A paralysis of the hand and fingers persisted after the wound had healed. Several reserve hospitals failed to cure the paralysis.

Eight months after the injury he arrived at Nonne’s clinic at Eppendorf, with a flexor contracture of the right wrist joint as well as of the fingers (exclusive of thumb). The finger tips were deeply sunk in the flesh of the palm. Extension could only be brought about against strong resistance. There was a total anesthesia for all sensations in the hand and fingers. No contraction of visual fields.

The patient, upon suggestion, fell immediately into hypnosis. At first the contracture was released with some difficulty; then, with greater ease, and then without any resistance whatever. During the same hypnotic sÉance the patient finally became able to extend actively both fingers and wrist; and next day, after the patient had convinced himself of his cure, he was able voluntarily to stretch the hand and fingers with normal amplitude and power. The disturbance of sensibility had spontaneously disappeared.

This cure was, from the patient’s point of view, indecently quick. He said everybody must feel he was a malingerer, and in fact he felt so himself. He went back into service, where he had been for several months at the date of Nonne’s report.

Re Nonne’s enthusiasm for hypnosis, see under Case 526. Nonne, contrary to Babinski and Froment, would regard even the severe and obstinate vasomotor disturbances as purely functional and as not even “sub-organic.” The basis of this belief is that hypnosis cures these phenomena as well as various tics and pertinacious tremors. French observers consider that these tics and tremors may even be organic in their nature, basing their ideas upon the non-success of suggestion. (It may be noted [see under Case 528] that the French military authorities do not allow the use of hypnotism in the army.) With respect to the present case (530), of course, the French observers would not deny the power of hypnotism to produce the cure. Babinski and Froment’s Postscript to the English edition of their work on hysteria, remarks that, though Roussy and Lhermitte state that vasomotor symptoms may disappear along with the psychotherapeutic cure of paralyses and contractures, yet Roussy and Boisseau later admitted that improvement in thermal and vasomotor control is at best an exceedingly slow one.

More recent personal communications indicate that there is still room for some question as to the curability by suggestion of such disorders as tic, tremor, vasomotor imbalance, and the like. In short, the true scope of the “pithiatic” or suggestion-curable diseases is still somewhat a matter of controversy.

Shell-shock: “Doll’s head” anesthesia, mutism: Hypnosis.

Case 531. (Nonne, December, 1915.)

An officer, mute for five months following shell-shock, had been for four months treated in a succession of hospitals—field hospital, war hospital, two reserve hospitals.

He had no acquired or hereditary neuropathic taint, but even in the period before the critical shock he had been under tremendous physical and mental strain. The explosion produced a total anesthesia of the skin of the head, face, neck and shoulder region—in short, what Charcot called the “doll’s head” form of sensory disorder. Moreover, there was a marked contraction of the visual fields.

The patient, when treatment was given, fell at once into a deep hypnosis and began to intone, and then to speak isolated words, and finally to speak complete sentences. All that was left of his mutism was a slight over-fatiguability of the speech organs. This also cleared up in the next few days. He was discharged well, and had already been—December, 1915—some months in the field.

Case 531, though an officer, responded to hypnosis well, and Nonne remarks that hypnotizability is independent of the presence of any neuropathic tendencies, or of any loss of resistance through exhaustion. One trouble with the hypnotic method, according to Nonne, is the fatigue of the hypnotizer and his inability to rely upon assistants.

Re Charcot, Nonne remarks that the work of Charcot on hysteria is not sufficiently well-known, especially as civilian practitioners in peace times had few cases. Re taint, Nonne found such tendencies absent in more than half of his cases with careful anamneses. The absence of adequate psychogenic cause is a not uncommon experience according to Nonne. Nonne, finding 26 cases of pure neurosis amongst 1800 cases of war injury, had a considerable number of odd erroneous diagnoses in the group. Not only were cerebrospinal paralyses wrongly diagnosticated, but ischemic paralysis, plexus paralysis, arthritis deformans and synovitis.

A soldier is put in the Landsturm at 22 and later called “unfit” by reason of tremors after mine-explosion (history of tremors at 14 after a fall), but is cured by hypnosis.

Case 532. (GrÜnbaum, November, 1916.)

A Landsturm soldier, 22 (father excitable, family otherwise normal), had a history of being the best scholar in the class and well up to his fourteenth year. At 16 he fell from a tree and though he apparently sustained no injury his head and arm began to tremble. He became unable to learn and gave up his preparations to be a teacher. The tremor, however, disappeared in six months and he went into some technical work. At 16½ years he went as cabin-boy, but in a fortnight he was sent home by the physician. He then began to breed carrier pigeons and got first prizes at international exhibitions. He also went into foundry work and did well as an apprentice. He worked well at home and busied himself with setting up small electrical and other machines. He had never been interested in women and loved his pigeons best, and therefore was regarded by people who knew him as not quite right. He was also non-alcoholic.

After mobilization he was sent back twice but finally was put into a JÄger Battalion. After reaching the front he had to have a hernia operation and on getting well went back to his place and a few days later a mine exploded near him. He was much frightened and fell down unconscious. On regaining consciousness he felt a “running” in the legs and tremors in the hands. The latter grew stronger and began to affect the arms.

After two months in hospital he went to garrison unrecovered, was placed in the Landsturm and did four months station duty in Russia. The tremors persisted and when his comrades played a bad practical joke on him the tremors got so bad that he was sent back home as unfit for service.

He was a stocky looking, well-nourished man of middle height, without visceral disease or sign of organic nervous disorder. The shaking tremor grew much more powerful in any state of excitement but always paused sufficiently to permit the execution of any particular movement. The head movements were continuous, slight rotations. There were a few regions of anesthesia to touch, but these areas differed at different examinations. There was a general hyperesthesia. Conjunctival, corneal and pharyngeal reflexes were absent. The man was slightly excitable, apprehensive, depressed, complained of sleeping badly, did not want to sit or stand and felt as if he wanted to run away, no matter where. In dropping off to sleep he would fall out of bed and talked aloud in his sleep. He thought he was incurably sick. Intelligence and school knowledge were very good.

He was hypnotized eight times for periods of about five minutes each. Hypnosis was extremely easy to accomplish. At the second trial the manual tremor disappeared. After the third trial there was an essential improvement in the shaking tremor. Moreover, his emotional state had become happier. He began to sleep well. He was now free from disease and regained confidence and looked upon himself as well and fit for work. Undoubtedly without hypnotism this man would have been released from service after a few months of inconsequential hospital care without pension.

Re tremors, see remarks under Case 308, concerning the possibly organic nature of many of the so-called Shell-shock tremors; an opinion apparently shared in by Meige and by Guillain. Babinski also found that these tremors were not influencible by psychotherapy. Yet here is an instance in which tremors are reported cured by hypnosis, and moreover, tremors that were recurrent from an ante-bellum attack at 14. See remarks under Case 530.

Shell-shock, slight injury, unconsciousness: Astasia-abasia: Recovery under hypnosis, two sÉances.

Case 533. (Nonne, December, 1915.)

A musketeer, without neuropathic taint and without nervous symptoms before the war (parents both dead of tuberculosis, eleven brothers and sisters died young), saw four comrades killed by a shell October 27, 1914. The musketeer himself was slightly injured superficially in the back. He remained unconscious for three hours and on coming out showed general tremor of the body, felt pressure in the head, was lachrymose and unable to walk or stand. He was subject to insomnia. He was in four different hospitals, finally reaching Eppendorf. Diagnosis rendered at the first hospital and carried on through the others was hemorrhage into the spinal canal.

For two months at Eppendorf he lay in extension. He was then examined by Nonne, who found general neuropathic habitus, pronounced “cramp neurosis” in the lower extremities, psychogenic astasia-abasia, hyperidrosis of the lower extremities, marked cyanosis of feet and lower legs, increased tendon and skin reflexes, pseudoclonus, no Babinski or Oppenheim reflexes. The man complained of pressure in the head, sleeplessness, a feeling of depression and hopelessness. Pulse 120-130.

Hypnosis proved easy. After the first treatment the man stood and walked and showed no tremor. The next day the hypnosis was repeated and the cyanosis of the legs disappeared. Sleep on the second night was good. Appetite returned and the man fell into a good emotional state. Thereafter the patient was intentionally ignored by the physicians and could soon not be distinguished in any respect from the other non-nervous convalescents.

This case is expressly stated by Nonne to resemble in all respects those formerly described by Oppenheim as “traumatic neurosis.”

Crural monoplegia: Cured by hypnosis.

Case 534. (Hurst, 1917.)

A Belgian soldier fell into mud on the collapse of a roof from which he was observing the enemy. It was an hour before he got his left leg out of the mud, and found it fixed in extension. He was sent to England, where for three months the leg remained stiff. The spastic paralysis did not seem organic as the leg was dragged behind. The knee and ankle could be bent only by using much force. The entire leg was in all ways anesthetic. Babinski sign gave additional proof that the condition was hysterical: when the patient lay with arms folded and legs apart and then tried to sit up, the normal leg was lifted and the paralyzed leg remained flat.

According to Hurst, the paralysis and stiffness were due to an autosuggestion from the legs being embedded in mud. The anesthesia was probably a matter of medical suggestion produced in the course of examination during the three months of disability. According to Hurst, Babinski is right in supposing that hysterical anesthesia is almost invariably produced by the observer.

Accordingly a strong faradic current was passed through the leg, and he was assured that sensation and power would be restored. However, he could still walk only with difficulty.

Hypnosis was therefore resorted to and repeated on several occasions. He went back to duty in three weeks, although he still held the leg somewhat stiff when he walked.

Re recurrences after hypnotism, see remarks of Nonne under Case 530. Howland also notes that cases treated by hypnotism must be followed up to prevent relapse. In the above case of Hurst’s, it will be noted that the hypnotic treatment was several times repeated.

Shell-shock, emotional (slight trauma): Tremors and sensory impairment: Cure by hypnosis, thrice repeated.

Case 535. (Nonne, December, 1915.)

A reservist, always well, not neuropathic (mother had had seizures, possibly epileptic, for many years) was wounded in the left calf by a shell fragment, about the middle of December, 1914. He was at the same time, as a result of the shell explosions near by, afflicted with a tremor of the whole body; this tremor gradually increased and proved refractory to all treatment for nine months.

At the beginning of September, 1915, the patient reached Nonne’s wards, showing tremor of head, arms and legs, with pronounced hypalgesia of the whole body, abolition of frontal and conjunctival reflexes, and contraction of the visual fields.

The tremor of the head was completely removed at the first hypnotic treatment. There was a slight recurrence of this tremor two days later, and traces of it could be observed for nine days. A third hypnotic treatment swept away this tremor, which did not return.

The patient was discharged after about four weeks, suitable for garrison duty.

Re traumatic neurosis, Nonne dislikes this term of Oppenheim, because such a term rather tends to connote unfavorable prognosis. As quoted under Case 530, Nonne holds that the war data show that hysteria is neither a form of degeneration nor an affair built on the Freudian schema.

Nonne in fact maintains that the hysterical syndrome may occasionally occur with much greater ease in a normal person than ever has been known before. It is precisely in these cases of normals getting hysterical that Nonne gets especially good results with hypnosis. If the development of the hysterical syndrome had extended over days or weeks, then the hypnotic cure was a slower one. The above reservist developed his Shell-shock gradually and required three hypnotic treatments. But although the number of doses of hypnotism required may be said roughly to depend upon the time which the condition took to come to a head, yet there is no similar rule re duration. A miracle cure may be brought about even in cases that have lasted over a year. This result, if confirmed, would signify that the hysterical condition once fixated did not especially increase in its tenacity.

Re hypnosis in Germany, it should be noted that Nonne is the chief protagonist for hypnosis, at least among the well-known neurologists. Psychoelectric cures, which the Germans term Kaufmann’s cure, are also greatly in vogue in German clinics. Despite the well-based claims of Lt.-Col. Myers and of Eder, some English observers appear to condemn hypnosis as inadequate, or even as dangerous.

A series of relatively successful cases like those here mentioned might yield a wrong impression of the value of hypnosis (see Feiling’s unsuccessful case 369).

Hysterical paraplegia of gradual development: recovery only under repeated hypnosis.

Case 536. (Nonne, December, 1915.)

A volunteer, of nervous parents, had for four years suffered from attacks of uncertain (hysterical or epileptic) nature. These attacks came on again after strenuous marching in the campaign in Belgium and France. Released from service at the front and detailed for guide duty, he proved unsuitable for this work, too, and was sent back to a hospital at home. Here there gradually developed a paralysis of the lower extremities. Treatment proved ineffective.

At the end of January, 1915, he came to Nonne’s wards at Eppendorf with a paralysis that had lasted six months. There was a total paraplegia inferior, with anesthesia for all sensation from the knees downward. The lower legs and feet were cyanotic and cold. The tendon and skin reflexes were lively. There was a moderate contraction of the visual fields on both sides.

Under hypnosis, the patient proved able to move both joints somewhat, but very weakly and slowly. The patient was hypnotized daily for a week, and made slow progress. Only after another week did it prove possible to get him to stand. After four weeks, his gait had so improved as to look like that of a tired old man. Three weeks more of treatment permitted the patient to walk, run and hop normally. Repeated waking suggestion had failed to accomplish anything in this case. The improvement followed only hypnosis. It seems to be a general principle that in cases of gradual development, the recovery by hypnosis will also be gradual.

Re repeated hypnosis for cases of gradual development, see remarks under the preceding case (535).

Struck by rifle butt: blindness of an eye already poor. Shell-shock: dysbasia. Hypnosis.

Case 537. (Ormond, May, 1915.)

A lieutenant, 20 years, managed to get into the army despite the fact that he had never been able to use his left eye, owing to hypermetropia and amblyopia. He was hit on the left side of the head by a rifle butt, and knocked unconscious, in June. On recovering, he found he could not see at all with his left eye, which he had never been in the habit of using. August 10, he was wounded slightly in the left thigh. August 23, while still on duty, with the wound not completely healed, he was blown up by a shell. He regained consciousness on a stretcher. Feeling the pain in his old wound, he thought he should be unable to walk.

On shipboard, he found that he actually could not walk. He kept his left eye covered by a shade on account of headache that would follow exposure to light. He was much excited and had bad nightmares.

After the journey home from the Dardanelles, it was found that the left eye was normal except for the hypermetropia, despite the fact that he was quite unable to see with the eye.

He was hypnotized four times, losing the nightmares and much of the headache after the first treatment; the eye pain on exposure to light, after the second treatment; and the blindness, after the third treatment. He was now able to see with his left eye as well as before he was struck. He was still unable to walk without crutches. Hypnotized the fourth time, he was told he could walk, and did so.

For hypnotic treatment of blindness, see under Case 521. Re blindness of eye already poor, see Cases 294-301 (296 and 297 eye cases). Ormond states that in the treatment of Shell-shock blindness, he first tried rest, tonics, cutting off tobacco, confinement in bed, isolation, persuasion, encouragement, counter-irritation; but that all these measures failed. Suggestion and hypnosis succeeded.

Shell explosion; concussion; retinal hemorrhage: Blindness. Cure by hypnosis.

Case 538. (Hurst, November, 1916.)

An English private, 22, was looking over a parapet, July 18, 1915. He afterward remembered sand thrown in his eyes and a fall backward, hitting his head, after a shell had struck the sandbags in front of him. He was unconscious 24 hours. Upon recovery, he found himself completely blind, save that he could just tell light from darkness with the left eye. His eyes were sore and eyelids blackened; there was also severe headache and partial deafness.

Hearing returned and the headache improved shortly; but the condition of the eye seemed more permanent. On forcibly opening the eyes, September 14, they were turned far upwards so that the iris could scarcely be seen. Some sand grains were buried in the conjunctiva, not in the cornea. There was no inflammation about the sand grains.

In hypnosis, he was told that he would see on waking. The moment he woke, this suggestion was repeated forcibly and his eyes were held open. He cried out that he could see; tears ran down his cheeks; he fell on his knees in gratitude. Three days later, he said he was able to see as well as he had ever seen. There was, however, an opacity of the vitreous of the left eye, the result of a retinal hemorrhage: doubtless the result of injury at the time of the explosion. September 30, he had perfect vision in the right eye and 6/36 in his left.

Re results of hypnotic treatment, Lt.-Col. Myers, summarizing 23 cases of Shell-shock, got apparently complete cures in 26 per cent, and distinct improvement in another 26 per cent. He failed to hypnotize 35 per cent, and got no improvement after hypnosis in 13 per cent. Is the recovery after hypnosis complete and permanent? Lt.-Col. Myers believes that it may be, but others remark the tendency to relapse (see Case 534). Similar objections may be made to the psychoelectric treatment as used by Vincent, Yealland, or Kaufmann. See under Case 535.

Appendix operation: Post-operative retention of urine. Relief by hypnosis.

Case 539. (Podiapolsky, August, 1917.)

A soldier, 32, operated for appendicitis, had a post-operative retention of urine. Hypnotic suggestion was requested to reËstablish excretion of urine before resort should be had to the catheter.

Somnambulistic amnesia was obtained at once and without questioning him P. suggested to him directly that he must feel the need of micturition. The suggestion was unsuccessful. However, bearing in mind psychogenic obstacles of an unknown nature, P. questioned the patient as to sensations and learned that in the operation the skin had been burned about the urinary passage and that the patient feared micturition. Besides this, micturition was painful on account of the wound above the appendix. The patient also feared that the sutures would yield.

Accordingly assurance was given that the burned parts would be insensible and that the bladder could be emptied without effort and without endangering the sutures. Analgesia was produced by a few passages of the hand upon the bed clothes. Complying with post-hypnotic suggestion the patient urinated after a quarter of an hour of sleep, and in thirty-six hours retention was relieved.

With respect to frequency of immediate somnambulism for the first trial, P. states that, although authorities set the percentage of successful immediate somnambulisms at 17-20 per cent, war conditions yield three or four times as high a percentage. The war has produced a suitable soil for hypnotism. Hypnosis is impossible in from 1½ to 2 per cent of cases.

Wound of sciatic nerve: Pains after operation. Relief by hypnosis.

Case 540. (Podiapolsky, August, 1917.)

A German prisoner, 33, was admitted to a Russian Hospital, November 11, 1916, with “a bad wound of upper right thigh, marked pains in right sciatic nerve especially affecting feet.” Morphine and pantopon did not abolish the pain. Insomnia. November 13, the sciatic nerve was surgically freed from a scar and laid in the midst of the femoral biceps. Every evening pantopon was injected; but the pains and insomnia persisted nevertheless.

November 19, he was hypnotized. The pain stopped. He had an excellent night, and the next day felt only a slight pain in the toes.

Curiously enough, while giving him suggestion in the German language, P. had said fingers instead of toes (inadvertently, since the Russian language uses the same term for both). He slept well to November 29 but still felt a slight pain in the toes. On November 29 another hypnotic sitting was given, and the toes this time were named correctly. The next day the patient said, “You have relieved me of all the rest of my pain.” He had no pain thereafter and the morphine and pantopon were dispensed with. Sleep returned.

Incidentally, this patient had his hair grow white in a few months of war.

Ship blown up by mine: Stereotyped explosion dream by survivor: Cure by hypnosis (also of antebellum habitual headache).

Case 541. (Riggall, April, 1917.)

A survivor of H.M.S. T.B. II, blown up by a mine off Harwich, was admitted to the naval hospital at Chatham, March 3, 1916, a well-nourished, nervous looking lad, aged 20. After the accident, he began to dream, always the same dream, of the explosion, waking up with the cry of the ship mates, and then unable to sleep the rest of the night. The knee and ankle-jerks were somewhat exaggerated.

April 15, when there had been no improvement, he was hypnotized. The patient was told to lie back in an arm chair, make himself comfortable and allow muscles to relax. He was told to fix his eyes and concentrate his attention on an electric lamp. The suggestion of sleep was made, and he was repeatedly told in a monotonous voice that he was becoming more and more sleepy. Then in an emphatic voice he was told that the treatment would completely cure him. He had no more dreams after this first sitting.

Hypnosis was continued every other day until April 20, when he was discharged cured. After the first sitting hypnosis was induced by simply telling the patient to go to sleep, which he would immediately do on entering the room, while still standing up. At subsequent sittings, he was made to write twenty times such phrases as: “I feel much better”; “I shall have no more bad dreams.”

Once when a tooth was to be pulled a post-hypnotic suggestion that no more pain would be felt was given, nor was any pain felt. Headache persisted after the first two or three sittings. Accordingly, during hypnosis a pencil was pressed to the forehead with the suggestion that it would burn and that after waking there would be an itching pain for half an hour, followed by recovery from headache. Curiously enough, a distinct erythema of the skin was observed over the point of pressure. Toothache and headache vanished.

Shell-shock from air-craft bomb: Amnesia: Recovery under hypnosis (also removal of a headache dating from childhood).

Case 542. (Burmiston, January, 1917.)

May 22, 1916, a stoker, 26, was found on shipboard in a workshop behind oil drums, refusing to come out, looking dazed, not recognizing messmates, suspicious and complaining of headache. He reached the Royal Naval Hospital at St. Malo, May 24, answering questions “Don’t know,” and physically normal except for diminished knee-jerks. At the end of two or three weeks he would answer questions about his stay at the hospital, but complained of headache or weight in the head. Wassermann reaction, negative.

Special examination on May 26, showed an amnesia for everything up to his arrival at St. Malo. For example, he did not know the name or use of a hammer or a pressure gauge, though he knew the pressure gauge was made of brass and glass, having seen brass and glass in the hospital wards. He had no idea of the nature of a ship. He was sent to the sick bay at the Royal Naval Barracks at Chatham, July 7, carrying a recommendation that he be retrained as a stoker.

He was put under hypnosis, induced by gazing at the brass knob of a paper weight. He went off easily, was told there was nothing to worry about, taken back to the beginning of his illness, and asked what happened. He told about a bomb explosion from aircraft, and how he had lost his memory after a nearby explosion. He told how he was married and had a child 21 months old. During the narrative about bombs falling, his worry was such that he was put in a deeper hypnotic sleep, and was told that he would remember all that had happened. Upon being ordered to wake up, he remained dazed for a few moments, and then said that he was all right. Asked about his marriage, he replied that of course he was married and had a child.

After four days leave, he returned, July 13, without trouble except a headache, from which it appeared that he had suffered ever since a fall when a child. He was again put into a hypnotic state and asked to remember the accident that caused the headache. He was conducted back through the years, and finally described a white house in India, his fall in the area, the black people in white clothes, the cut bleeding head. He was told that he would have no more of such headaches. On being wakened, he said that his headache was gone, and retold the story of the accident. August 2, he said he had never felt better in his life. September 1, he was drafted to a seagoing ship.

Shell-shock, unconsciousness: Convulsions (recollection of childhood convulsions): Cure by hypnosis.

Case 543. (Hurst, March, 1917.)

A New Zealander was rendered unconscious for a few minutes following concussion from a high explosive shell. Convulsions developed, occurring at least once and often several times a day.

As to the origin of these convulsions, it appeared that the soldier had had a few convulsions after falling on his head at the age of 8. According to Hurst, recollection of these childhood convulsions probably led by a process of autosuggestion to the Shell-shock convulsions.

Captain Crabtree hypnotized the man, suggesting recovery. The fits immediately ceased and did not recur.

Recurrent hysterical mutism. Spontaneous recovery in (a) 18 months (antebellum incident). (b) Hypnotic recovery in a few minutes.

Case 544. (Eder, August, 1916.)

A soldier in a mine accident eight years before the war, lost his speech when his brother was killed, and then recovered his speech spontaneously after 18 months.

After a shell explosion in Gallipoli, he was again struck speechless and also deaf.

Six weeks later, he came to Dr. Eder and objected in writing to treatment, saying that he believed in nature’s methods. God had taken his voice away before and had restored it. Eder replied in writing “rather irreverently” that God had taken 18 months, but he could do it in a few minutes. The patient afterward consented to treatment, and speech and hearing were duly restored in the time promised, whereupon Dr. Eder told him that in point of fact his physician was merely the instrument of Providence.

Neurasthenic symptoms: Cured by repeated hypnosis.

Case 545. (Tombleson, September, 1917.)

A private, 24, was admitted to hospital with diagnosis neurasthenia, March 11, 1916. He suffered from vertical headache; general analgesia, more definite on the right side (patient left-handed); loss of smell and taste, also more definite on the right side; paresis of right leg, with dragging of foot (old trench foot); and sleeplessness.

The next day Tombleson put him in a hypnotic state, third stage, and again, March 13, but without results.

March 14, the somnambulistic stage was reached in hypnosis, and next day the man’s headache was much relieved as a result of the suggestion offered. He was again hypnotized and the following day, March 16, the headache had vanished and the man was in general much improved. In somnambulism the disappearance of the analgesia was suggested, and it proved possible to make the man walk about without limp and without dragging the right foot. Next day the analgesia was much relieved. In somnambulism the suggestions were repeated.

March 18, the man said he was quite well, and proved to be so on examination, except that he could not yet taste with absolute normality on the right side. In somnambulism it was further suggested that the cure was a perfect one and included the sense of taste. However, March 25, the expected improvement had not yet occurred in the taste, whereupon further suggestions were given in hypnotic somnambulism, re taste. Next day taste had become normal.

Re hypnosis, Tombleson says that the most successful cases of hypnosis are those of Shell-shock psychasthenia, but that he gets very good results with hyperthyroidism and with neurasthenia also. He goes so far as to say that practically all cases of war neurasthenia and psychasthenia can be cured and sent back to work if treatment by hypnotic suggestion is used in a reasonable time.

Neurotic symptoms: Improvement under repeated hypnosis.

Case 546. (Tombleson, September, 1917.)

A private, 32, was admitted, April 15, 1916, to Tombleson’s ward from the Cottonera Mental Ward with the diagnosis: psychasthenia with paresis of right arm. The man was very suspicious of the medical profession, melancholy, morose and prone to tears. He had been kicked by a horse four years before and showed a depressed and very tender scar in the right parietal region. The right side of the body since that injury had been getting weaker, but the arm was much weaker than the leg. Anesthesia was practically complete on the right side. There was a wasting of the muscles of the right arm and the skin of the hand and fingers was thin and shiny.

Before his transfer the man was placed in the somnambulistic state, with suggestions of happiness and confidence in the coming cure. He arrived at Valletta, April 16, in a cheerful frame of mind, stating that there was nothing now the matter but weakness. Under somnambulism the loss of symptoms was suggested and, April 17, the patient was well except for the loss of power in the arm and leg. Daily training under somnambulism was given for a period of seven days, with suggestions especially leveled at the paretic muscles. He was then so far recovered that hypnotic treatment was stopped. The patient went to England, May 12, 1916, well.

Convulsions, “Jacksonian,” and dysbasia: Cure by hypnosis.

Case 547. (Tombleson, September, 1917.)

A private, 18, was admitted to hospital, March 22, 1916, with the diagnosis Jacksonian epilepsy, with marked functional gait. He had just had several fits—two March 20, two March 21, and several earlier. He was tremulous and could not stand. Much pain. Knee-jerks brisk.

There was a history of a fall into a harbor at seven, followed by bleeding from nose and ears and unconsciousness for a week. Convulsions, involving the face, arm and leg, and attended by unconsciousness, kept recurring until twelve. Five months before admission there had been cerebrospinal meningitis. In February at Salonica he had had pneumonia.

March 23-24 the soldier was hypnotized to the third stage, but he had two fits. A “funny feeling in the right big toe” was brought out and suggested away. March 26-27 the patient was able to walk with a typical functional disorder. Under somnambulism the suggestions were repeated, but on the evening of March 27 two more convulsions appeared. In somnambulism he explained that he “had got round” the inhibition of the aura.

The night of April 2 occurred two convulsions. April 5, the man was placed in the somnambulistic stage to last three days. During the night of April 6 he was observed to be restless for an hour, with some twitching of the right face, yet no fit followed. The morning of April 8 the patient woke feeling well. He was again placed in somnambulism to last two days. Two hours later, however, a fit started. It was stopped at once by suggestion, but the patient woke. He was left awake the rest of the day. April 9, somnambulism: suggestions repeated; sleep to last for two days. That evening there was a slight beginning of a fit, which was stopped at once by suggestion, the patient waking April 11 in another beginning of a fit, stopped by suggestion.

Thereafter no more fits recurred at all. May 12, 1916, well.

Agoraphobia: Cure by hypnosis.

Case 548. (Hurst, 1917.)

A captain was (with one lieutenant) the sole survivor among his battalion officers at Ypres. The captain received the D. S. O. for his gallant conduct in saving the remnant of his battalion. He now felt he could never face responsibility again and that he would disgrace himself if he ever got into danger. He developed a terrible dread of open places and became more and more depressed. When he heard that there was going to be an attack at Neuve Chapelle, he broke down but managed to get through the first day of the battle. He was worse off than ever in the evening, felt that he could not face another day’s fighting, was invalided home, and arrived in a condition of exhaustion and feeling of disgrace. He had bad dreams at night. Rest was insufficient to restore confidence. Hypnosis was followed by rapid improvement, and the man was soon able to get back to duty.

Re agoraphobia, see Section A, XI, Psychopathoses, and also Steiner’s case (182) of claustrophobia, in which shells were preferred to safety in a tunnel.

Stress on Eastern front; cardiac seizures; cellulitis: In convalescence, manual tremors. Treatment eventually by forcing and isolation.

Case 549. (Binswanger, July, 1915.)

A subaltern officer, 24, in civil life a student of mathematics, had serious hereditary taint on both sides (father, alcoholic; maternal grandfather, victim of “severe nervous disease”). As a boy he developed normally, and was a good student. He served as volunteer in 1911 to 1912, but in drill in 1913 he had had to be released from service on account of nervous heart and difficulty with respiration.

However, he was called to the colors at the outbreak of the war, and was subjected to tremendous strain in the eastern campaign; and he was put in the pack train at the end of November for cardiac seizures. He had a cellulitis with furunculosis following, and at the beginning of December there was suppuration of the whole right tibia. He was treated in hospital and slowly recovered.

At the beginning of March, 1915, without obvious external cause, while sitting in a cafÉ, the convalescent officer felt a cramp in his right hand, and strong movements of the hand to right and left followed. He was treated with bromides, but unsuccessfully. The tremors became more marked and then again from time to time grew weaker. Electric treatment increased the shaking to a maximal degree. April 27, the patient was brought to the nerve hospital at Jena.

The patient was a fat and muscular man, of average size, with very small ears and poorly-developed, adherent lobules, and syndactylism of the second and third toes of both feet; reflexes increased; marked dermatographia; a static fine tremor with rapid oscillations. The tremor became a positive tonus if the arm and hand were stretched out horizontally. Face and chest reddened easily.

Whenever any other voluntary movement was carried out (even slight finger movements of the left hand or of the right or left foot while lying in bed) this right-sided convulsive tremor immediately disappeared. The movements could also be made to disappear by slight turning movements of the head or of the tongue. Moreover, when the mind was diverted, as in reading, the tremors ceased. When the patient thought intensely of some mathematical problem, he could bring his shaking to a stop. The left grip was stronger than the right. In the Romberg position there was a marked swaying to the left and backwards.

Subjectively, the patient complained of nothing but a circumscribed headache in the left parietal region and of sleep interrupted by frightful dreams. At first the condition remained unchanged. There was much insomnia, and the slightest noise caused fright. Headaches in the daytime also were produced by any noise, and these headaches were localized in the left parietal region. The tremors of the right hand persisted except as he caused them to stop as above mentioned. He could write well with his left hand. He would drum with his left hand on the table until the tremor of his right hand disappeared. He could play on the piano, playing first with the left hand until the right had become quiet. He was a very irritable man, passing into anger and extreme profanity at the slightest occasion, and it was very difficult to bring him to any kind of orderly activity or persistence in therapeutic measures. These consisted of baths, massage, and gymnastics, but they proved quite unavailing.

As the fellow got more and more intolerable, and as upon May 27 at about 9 o’clock in the evening, he disturbed the quiet of the entire hospital by a severe paroxysm of scolding, he was placed in a single room in the psychiatric department. He was placed in bed, cut off from all communication with others, and forced to carry out his exercises.

For two days he was surly, crabbed and obstinate, but then changed his demeanor completely; he became friendly and obedient. The tremor completely disappeared.

Five days later he was able to carry out all active gymnastic exercises with great energy and without the slightest disturbance in the right arm. At date of report he was busy in the garden.

Five weeks’ field service: Loss of speech. Cure by verbal and electric suggestion in three weeks.

Case 550. (Scholz, December, 1916.)

A grenadier, 21, of healthy stock, physique, and habits, lost his speech, April 15, 1916, five weeks after going into the field. May 5, examination showed him a well-nourished healthy man (lively reflexes and slight dermatographia), able to communicate only by signs and writing. The laryngoscope showed almost complete immobility of the two vocal cords, which lay in the cadaveric position, as in paralysis of the recurrent nerves. In endeavoring to pronounce the vowels a and ee the cords trembled but failed to move toward each other. The patient’s effort to speak was such that his head soon got deep red and sweat streamed from the forehead.

Speech exercises were started by passing the electric current through the larynx during the processes of laryngoscopy. The patient was meantime assured that his larynx was healthy and that he would soon learn to speak again. At the first sitting, the patient felt himself able to cough aloud.

After a few days, the patient was able to speak the separate vowels tolerably well, and was then made to go on with such words as Anna, Otto, Hurrah. The vocal cords began to move better. Fatigue was a feature of the first treatments, of such a degree that words that could be pronounced during the first part of the sitting were lost toward the close.

The grenadier assiduously set himself to say over and over again the words that he had learned, and would come to the sister radiant with joy at his success. In ten days he was able to speak again perfectly, though giving the impression of a slight stuttering. After three weeks hospital stay he was discharged cured and fit for service.

Struck by a rifle butt on right side of head; old wound of right thigh: Hysterical right hemiplegia and deafmutism. Treatment by faradization: Return of speech and improvement of hearing. Full recovery by suggestion. Hysterical CONVULSIONS developed BY HETEROSUGGESTION from convulsive neighbor.

Case 551. (Arinstein, 1915.)

A Russian corporal, 21, was knocked unconscious, September 13, 1915, by a butt of a rifle which struck the right side of his head. He came to in a short time. He was examined in hospital, early in October, and besides a small skin wound of the head, there was evidence of a wound on the anterior aspect of the thigh. There was paralysis of both right arm and right leg, and anesthesia of the entire right side of the body, face and even of the tongue. There were also pains over the whole right side of the body. The abdominal reflexes were present on both sides; the tendon reflexes were in excess on the hemiplegic side; there were no pathological reflexes of any sort. The patient’s hearing was diminished, and he could not speak at all although he could understand the speech of others perfectly.

Speech returned after a single sÉance of suggestion with faradism to the throat. Hearing began to improve. The patient’s suggestibility was a favorable factor in his cure, but there were some unfavorable features. One day, he saw a neighbor go into convulsions and proceeded to develop convulsions himself. These hysterical convulsions continued. According to Arinstein, such undesirable complications appear under conditions of extreme crowding of hospital patients suffering from shell-shock. Progressive sÉances of psychotherapy caused the disappearance of all the signs of paralysis, and at the time of the report, there was no disability, except that the full use of the hand had not yet been regained.

Shell-shock and burial; labyrinthine disease on one side: DEAFMUTISM. Cures, relapses and eventual cure by general anesthesia, more than four months after shock.

Case 552. (Dawson, February, 1916.)

A private, 30, had been 12 years in the service. July 8, 1915, he was partially buried by a shell which killed two companions.

On admission to hospital he spoke a few sentences but was deaf, and next morning could neither speak nor read, nor did he take food for 36 hours thereafter.

Admitted to the King George Hospital, July 18, he was found stuporous, but started violently if touched, made signs indicating his wants, took no interest in surroundings, and resisted efforts to arouse him. He was without signs of organic disease. It seems that he had been a nervous child, with nightmares and fits.

July 24, he was given gas for dental extraction, partly in the hope that he would recover speech; but though he struggled violently, he made no sound. He had by this time become rather intelligent in a childlike manner, being pleased to see his small boy, but taking no notice of his wife. It transpired afterward that he did not recognize her.

Phonation in whisper now began. There was then a relapse, and for a week or more no food was taken. Such relapses with irritation and hypobulia and an obstinate constipation recurred; but improvement came on slowly. He became able to read short printed words, and later handwriting.

For another month there was no improvement and he lost heart and the will to get well, brightening up only when offered a motor drive or something else pleasant. He was transferred to an auxiliary hospital, against his will, September 18.

November 1, he was brought back to the King George Hospital, excited, shouting, struggling and evidently drunk. On a day’s leave from the convalescent hospital he had come up to London, and in alcoholic elation began to laugh and talk. Morphia did not reduce his violence. He insisted on seeing the physician, to tell him the good news. Hearing was still diminished, though if attention were diverted, direct answers were given to some questions. Sleep followed.

The next day he spoke perfectly but could hear nothing. There was no further progress for three weeks, though he occasionally caught sounds. He now became bright and pleasant and had lost all irritability and sulkiness. Galvanic and faradic current had no effect on the ears.

November 27, after elaborate preparation to heighten the suggestive effect, the patient was kept in bed and given gas and ether up to the abolition of the corneal reflex. As he was coming round, the doctor shouted that he could now hear well. He was overcome with joy and had hysterical convulsions. He could hear, but with the right ear only. In point of fact, the left ear on examination showed signs of labyrinthine deafness. He was placed on home service.

Re etherization for functional deafness and mutism, Ninian Bruce maintains that ether is more satisfactory than chloroform. The loss of consciousness in cases of deafness and mutism ought to be a relatively slight one, and the patient should be suddenly roused to the realization that he is speaking. Recovery from chloroform anesthesia is, according to Ninian Bruce, too slow to allow the patient to catch the point that he is now speaking and hearing when he was formerly dumb or deaf. A failure with the method is a bad thing for the patient, as he loses confidence in the method, whereupon some other method must be resorted to.

Re etherization for deafmutism, see technic of Ninian Bruce under Case 553. Penhallow has a case in which during primary etherization the patient reviewed in a loud voice the whole story of his speech loss. He was found to have recovered speech and hearing after coming out of ether.

Re anesthesia by gas, Abrahams has used nitrous oxide for cure of hysterical paraplegia. Proctor also reports the use of light ether anesthesia for bringing out the voice of functional mutes.

Shell-shock functional deafness (five months). Yes-No test. Cure by suggestion on emerging from ether anesthesia.

Case 553. (Bruce, May, 1916.)

A soldier was admitted to the Royal Victoria Hospital, Edinburgh, completely deaf in the left ear. He had been under shell fire a number of times in France and was eventually thrown down and made unconscious by a shell explosion on his left. He did not remember the noise of the explosion or anything until he found himself in hospital. After the explosion he had begun to stutter, and the stuttering had grown worse. Examination of the ear indicated that the deafness was functional. He was given ether and when just under was asked if he could hear anything spoken in his right ear. He said, “Yes.” With the right ear closed he was asked if he could hear when his left ear was spoken into. He said, “No.” This test was repeated several times. After covering his right ear, he gave his name, regiment, etc., in reply to questions whispered into his left (previously deaf) ear. The incongruity was pointed out. He was now suddenly wakened. He laughed hysterically with joy over his recovery.

But the next morning he was again stone deaf in the left ear. Blistering and electricity failed to produce benefit. He was, however, puzzled about himself.

After a fortnight he was again given ether and a little chloroform was added. The yes-no test was again positive. He was allowed to recover gradually from the chloroform, but he had now lost recollection of what had happened. The left ear remained deaf. Ether was again given. He was asked to close his right ear with his finger. While answering questions addressed to his left ear, he was suddenly awakened and immediately said that his hearing had come back. This return proved permanent. He returned to his dÉpÔt. In the conversations under ether there was no stuttering. He had been totally deaf in the left ear for five months.

Blow in neck by rifle butt: aphasia, right hemiplegia and hemianesthesia, and especially (here MEDICAL suggestion) trismus: Recovery by anesthetic and suggestion.

Case 554. (Arinstein, September, 1915.)

A Russian soldier was struck in the head and neck by a rifle butt, and developed paralysis of right arm and leg with loss of speech. After the excitement experienced by the patient when exhibited to the students by the late Prof. M. N. Szukowsky in the neurological clinic of the Military Medical Academy, trismus developed.

The patient spent a year in various hospitals, the most diverse methods of treatment by drug therapy, electricity, and suggestion yielding no results. The patient had to be fed chiefly by nose and rectum, though small quantities of fluids were fed through the mouth through an opening formed by the falling out of one tooth in the upper jaw. The patient became greatly emaciated and weak and was, October 29, 1915, brought into the nervous wards of the hospital.

He showed flaccid paralysis of left arm and leg, together with anesthesia, analgesia and thermanesthesia over the whole left side of the head, extreme general atrophy of muscles, somewhat more marked on the palsied side. The temperature of the paralyzed half of the body was not lowered. No knee or Achilles reflex obtained upon either the affected or the healthy side (general exhaustion?). Abdominal and testicular reflexes lively. The pupils responded well to light. Corneal reflexes lively. The neck was held awry to the left, and the head was inclined somewhat downwards and leftwards; hearing on left side impaired. The jaws could not be opened even with the greatest effort. Wassermann reaction negative.

Patient thought himself incurable. Purves Stewart’s case, in which chloroform and oxide of nitrogen were used, was the basis of Arinstein’s treatment. It was suggested to the patient that he submit to narcosis with the proviso that he would not be operated upon. His consent was secured; with the coÖperation of others, the chloroform was administered November 6. The stage of excitability was not well marked. 8 gr. of chloroform was used altogether, by the drop system. Nevertheless, even with the weak initial excitability, the patient became capable of some movements with paralyzed hand and foot. On opening mouth, the patient yawned yet uttered no sound. Between the jaws was put a rubber insertion and upon awakening the patient was let see with his own eyes that his jaws were open and that therefore food might be introduced through the mouth. Upon repetition of the narcosis, 5 gr. of chloroform was used altogether, and the stage of excitability was this time better marked. To strengthen movements in the paralyzed extremities, the device of pricking the patient with a pin on the unaffected half of the body, with the unaffected hand and leg held horizontal by assistants, was adopted. The patient then made reflex defensive movements in the paralyzed extremities, especially the hand. At this point the narcosis was suspended, and the irritation with the pin was continued until consciousness returned. At this moment, the patient’s attention was called to the disappearance of the paralysis and his restored ability to move the paralyzed extremities.

From that time on, the patient’s condition underwent a sharp transition. Artificial feeding became unnecessary. The patient ate by mouth; the mouth was opened by the leverage of a small stick held by the patient between his teeth. Speech returned gradually. In reading aloud the patient aided the movements of his lips with his hands. At the time of report the patient spoke well, ate normally, had gained in weight, and with some effort could sit down and even stand and walk. All this was attained in a relatively short time after a whole year of paralysis.

The author felt that the success attained in this case gave him the right to use the same method where the cause was not a contusion.

Ten months’ field service; severe FEBRILE DISEASE: Afterward hysterical TRIPLEGIA, MUTISM, “JUMPING-JACK” reactions to stimulation of feet. Cure by anesthesia, verbal suggestion, faradism to palate.

Case 555. (Arinstein, September, 1915.)

A Russian private, 30, brought to a field reserve hospital, June 20, 1915, was in a grave condition diagnosed typhoid. By the end of June the general condition had improved and the temperature had fallen.

July 9, worse; happening to be in the company of a sanitary in a privy, he was observed suddenly to fall unconscious, with both feet and left arm paralyzed. Soon afterward he lost the power of speech. From September 30 to October 19, he lay in field hospital; but was then transferred to the nerve hospital with diagnosis: convulsive paralysis and aphasia. At entrance, complete paralysis of both legs and left hand; loss of speech and aphonia (speech understood). Upon touching a foot, strong convulsions developed with legs rapidly drawn apart and drawn together much in the manner of dancing toys. The mouth was twisted to the left. Though he silently opened his mouth and made rapid movements with the lower jaw, he could not utter a single sound, either vowel or consonant. Left hypalgesia. Hypesthesia of skin of hand and mucosa of tongue. Knee-jerks absent because of the strain of the muscles of the legs. Wassermann negative.

The history showed that the speech of the patient had been incorrect and indistinct from childhood. Moreover, in 1908, in chopping wood in the forest he had fallen under a sleigh and hurt his left hand, which had not since fully recovered. He had volunteered for the war.

The psychogenic character of the disease seemed clear. Suggestion was followed by ether narcosis, during which, on pricks of the healthy side with a pin, the patient made defensive movements with the paralyzed hands, and also moved both legs. Speech was not regained either during or immediately after the narcosis, although the patient gave forth indefinite sounds. Speech was restored on the same day, September 7, with verbal suggestion and faradic brush applied to palate. The patient at once began to speak clearly and distinctly, read his prayer book, and described distinctly and in detail how he went to war. From that moment the convulsive movements in the feet disappeared, the region of anesthesia on the left side narrowed, speech was permanently reËstablished, and the patient began to move with his feet and finally began to walk after six months of paralysis. Before that time no medical treatment had had the slightest effect. The effort to stop mechanically the jerks even temporarily by means of plaster casts had been unsuccessful. In sleep the twitches ceased, but upon reawakening, even before full consciousness returned, the jerkings would resume. It is curious to note that upon falling asleep under the anesthetic the patient would issue always one and same kind of yells—“Help, there goes the German! They are shooting! Russians, do not yield!”

Re chloroform anesthesia, Milligan remarks that the treatment should be carried out in a quiet, single room, with the chloroform slowly administered and the suggestions made by the anesthetist during the optimal phase for suggestion,—just before the stage of involuntary struggling.

Shell-shock; unconsciousness: Mutism and musical alexia. Cure by anesthesia.

Case 556. (Proctor, October, 1915.)

A private, 23, was admitted to the Duchess of Connaught’s Hospital at Taplow from Gallipoli, September 10, 1915. A shell had exploded behind this man. He had been picked up, unconscious, and remained so about a day. He recovered without the power of speech. Cerebration was slow at first but improved steadily.

The man had been a professional musician. Curiously enough, though his ability to read ordinary print was as good as ever, his reading of music was lost with the speech.

September 20, he was etherized, but being of a phlegmatic type, he was not readily excited and took the anesthesia very quietly. After perseverance, however, he was induced to talk. The ability to read music returned with the voice. He was discharged, October 4, 1915.

Re the use of anesthetics for curing deafmutism, Colin Russel rather disapproves of this method on the ground that no attempt is made to get at the genuine pathogenesis of the case and that accordingly there may be a tendency to recurrence.

Re the peculiar musical alexia, see discussion under Cases 353 and 450 of confusion and amnesia. The most highly selective amnesias have been found in confusional cases. However, Case 556 had been a professional musician and the effect may have been a highly specialized suggestion. See also Case 369 of Feiling for differentiated musical disorder. Mott has used the retained knowledge of tones as an avenue of approach in certain mute cases.

Shell-shock; burial (24 hours?); unconsciousness, 13 days: Deafmutism. Chloroform narcosis cured the deafness (!), not the mutism.

Case 557. (Gradenigo, March, 1917.)

An Italian infantryman was buried under Mt. Zebio after shell explosion. After 24 hours he was found and dug out. He remained unconscious for 13 days and came out absolutely deaf and mute.

At hospital he was markedly depressed and cried very readily on being spoken to. The tympanic membrane had lost its sensitiveness to pain. As for the speech mechanism, the larynx proved negative. All the movements of the soft palate, tongue and vocal cords could be normally performed. The tongue was anesthetic to touch, but the taste function was perfectly preserved. The cheeks and various parts of the face were also anesthetic to touch, and the lobules of the ears could even be pierced with large pins without reaction by the patient.

He tried to pronounce labials, opening and closing the lips rapidly; but the expiratory movement was too weak, and not a single sound was made.

At the patient’s request, he was chloroformed. During a very violent excited phase, he did emit groaning sounds. The narcosis, however, did not put an entire stop to the mutism, since only a few inarticulate sounds could be emitted, and those only after great efforts. Curiously enough, however, the chloroform narcosis had caused the deafness to disappear entirely. Another narcosis upon the patient’s insistent request was given but remained without results, and at the time of report, the patient though cheerful and intelligent-looking, was still mute.

Treatment of two cases.

Cases 558 and 559. (Smyly, April, 1917.)

A soldier was out with a bombing party when a shell burst. He came to in a casualty clearing station, and was sent on to Salonica, deaf, dumb and jumpy. Two months later, an attempt at hypnosis failed; faradism of vocal cords failed.

The patient dreamed one night that if he vomited he could speak. Ipecac produced vomiting without speech. The patient, however, wanted a second dose, and while waiting for it, uttered an exclamation, which he did not himself hear, however. In the meantime, Dr. Smyly had been trying to hypnotize a second soldier, dumb but not deaf. This man’s dug-out had been blown in on him seven months before, whereupon the patient became very shaky, but did not become sick for a week. He was then sent to hospital, and his voice gradually disappeared. He suffered from violent headache and spasmodic movements of the arms and legs. Suggestion seemed powerless, and ether was unexpectedly given to the patient. While going under the ether, he said, “Oh dear, oh dear” several times indistinctly. It seems that another physician had already tried to cure the patient of dumbness by removing teeth without an anesthetic.

While this therapy was proceeding with the dumb man, the deaf-and-dumb man disappeared. It seems that the smell of the gas had caused him to take refuge on an outhouse-roof. The next day he had recovered voice and hearing completely, partly from shock and partly through suggestion.

The etherized patient did not recover voice but lost the spasmodic movements and his insomnia. A week later ether was again administered, and the patient was strapped down; as he was coming to, faradism was applied to the head and face. The patient then quickly recovered his voice and still retains it.

Shell wound: Hysterical dysbasia from contracture. Many methods of treatment fail. Success with “a new measure,” e.g. stovaine.

Case 560. (Claude, March, 1917.)

A sergeant was struck in the suprapubic region, December 15, 1915, by a shell fragment and got a large hematoma in the perineal region (shell fragment visible on X-ray). The man was treated a year in a center for physiotherapy and was then treated in a neurological center, where a faulty position of the right thigh maintained in extensor rotation and abduction was found. The patient walked on crutches, legs wide apart, balancing with body.

Upon transfer to Bourges, an intraspinal injection of stovaine (after withdrawal of 2-3 cc. fluid, 1 cc. stovaine, 0.07 to the cc., mixed with cerebrospinal fluid) was made. This reduced the contracture and permitted the patient to place his legs parallel. They were then bandaged in the parallel position. The bandages were removed two days later and the limbs did not reassume their faulty position. The man was shortly able to walk with a cane; progress was rapid. This man was very desirous of cure and refused to be invalided, believing he was to be cured, and had received medal and war cross. Simple motor reËducation in competent hands had been without effect. A new kind of measure, such as stovaine, proved successful.

Re “new measures” for hysteria, see items under Case 516. See also remarks upon cures by lumbar puncture under Case 488.

Burial: Hysterical dysbasia. Treatment by stovaine anesthesia.

Case 561. (Claude, March, 1917.)

A chasseur, buried June 24, 1916, had a number of general symptoms, apparently got well and was given seven days’ leave at home. On the way he felt abdominal pain which he thought due to the jolting of the car. Suddenly he felt his legs trembling on extension. He left the train and went into a hospital where a diagnosis of radicular and spinal lesions was made. Two months later he was sent to Claude who found that he could walk only with knees flexed. If he was requested to stand up and extend his legs on the thigh, a trembling set in suggestive of an epileptoid trepidation. Even in the horizontal position the same clonic trepidation occurred which only stopped if the patient flexed his legs on the thighs.

However, no sign of organic lesion could be found. There was an analgesia limited to the ankles. Psycho-physiotherapeutic treatment was unavailing. January 28, 1917, the stovaine injection method was tried. After anesthesia had set in, it was found possible still to produce the spastic state by extending the legs; but a half hour after injection the spastic state could no longer be produced. The patient was shown that the trepidation was abolished. During the period of return of sensibility, the legs were constantly moved and the patient constantly told to make movements himself. He was convinced of his power. There was no longer any clonus. The patient remained all day in bed without epileptiform movements. Next day he complained merely of weakness in the legs and was got to walk without having convulsive tremors. During the next few days he began to walk with a cane, later without support, and there were no more contractions except transiently in the left leg if the patient walked a little too long. He left the hospital cured.

Shell-shock deafmutism: Psychic treatment.

Case 562. (Bellin and Vernet, January, 1917.)

A soldier in a colonial regiment was sent, August 14, 1916, to an evacuation post with a diagnosis “deafness following shell-shock, unfit for service.” The patient asked that he be spoken to very loud because he could not hear, and he himself spoke in whispers. He kept watching his interlocutors’ lips and moved his own as if to pronounce the words.

A shell had burst nearby fourteen months before in June, 1915. After being in several hospitals, he was sent to an oto-rhino-laryngological service where he had his hearing reËducated and was taught lip reading. It was soon perceived that he could hear without lip reading and he was assured that he could be cured at once, but naturally he was not convinced. He produced a carefully filed paper stating “atrophic ozenous rhinitis, deafness from labyrinthine shock following shell explosion, hearing diminished 60 per cent right, 30 per cent left.”

However, energetic psychotherapy was started and in the absence of electricity, subcutaneous injections of ether were given. Such patients had always been cured, and a drug injected under the skin, not dangerous but extremely painful would cure him! This treatment was carried out in a dugout near enough to the lines to be daily “potted.” The patient was left for a space to reflect, and he finally accepted the chance of cure. He was exhorted to stand courageously the pain and to breathe deeply and to repeat a word more and more loudly. Finally he was made to speak normally and eventually to cry out loudly. He now felt much astonished, and in his astonishment forgot his deafness. He said that he had never spoken or heard since the accident, that he had been a deafmute from the first month of his illness, and that for the last three months he had been able to speak only in a whispered voice.

He should have been watched a few days to confirm the cure. This was impossible in the crowded dugout and no risk could be run of his escaping. Kept over night he was found next day unable to hear and talking in the same voice as before.

He was now found to be either an exaggerator or a simulator. He was given a half hour to exercise his voice in and told that he must succeed unless he was a simulator. At the end of half an hour it was found that he had skipped. He was sent back by the division surgeon with orders to send him to the otological service for inquiry. The otological service found an atrophic ozenous rhinitis, a normal larynx, perfect audition. He was given a psychic X-raying and a few electric sparks were also drawn from his neck. He then began to talk in a loud voice and to hear normally. August 30, he was sent out completely cured and rejoined his regiment.

Re treatment of deafmutism by other means than pseudo operations and anesthesia, see remarks under Case 556 concerning Colin Russel’s opinion that anesthesia does not get at the true genesis of cases. Re the teaching of lip reading to Shell-shock deafmutes, see discussion under Case 580.

Brachial monoplegia. Cure by electrical suggestion (physician bored-looking, brief, and authoritative).

Case 563. (Adrian and Yealland, June, 1917.)

Adrian and Yealland had occasion to treat an officer with a persistent functional paralysis of the arm, which had successfully withstood hypnotism, psychoanalysis, rest, massage, anesthesia with ether, and painful electrical treatment.

This patient knew something of the functions of the brain and was prepared to discuss his condition exhaustively. He was told, however, that he had come to be cured and that the nature of his cure would be explained to him afterwards. Without further discussion, the motor areas of the cortex were mapped out rapidly. The measurements were repeated aloud to impress and mystify the patient. He was assured that as soon as the shoulder area of the cortex was stimulated faradically, he would be able to raise his shoulder, and that then the rest of his arm would recover. An exceedingly mild faradic current was then applied to the scalp for a few moments and he was then ordered to move his shoulder. He did so at once. In a few minutes, all of the paralysis had vanished and the patient could raise 30 pounds. Adrian and Yealland believe that the success here was largely due to the fact that the patient was not allowed to discuss the case or criticize the treatment beforehand.

It is essential that the patient should be convinced that the physicians understand the case and can cure him. No physical sign should be examined as if it were interesting or obscure. An attitude of “mild boredom bred of perfect familiarity with the patient’s disorder” is cultivated. If the case is exhibited it should be exhibited “as a perfect example” of the type of case that is cured in five minutes by appropriate treatment. “Rapidity and an authoritative manner are the chief factors in the reËducative process.”

Re psychoelectric treatment, see Yealland’s book, published while this compilation was going to press, Hysterical Disorders of Warfare, 1918.

Brachial monoplegia following use of sling after bruise or wound. Technique of electrical suggestion and rapid reËducation.

Case 564. (Adrian and Yealland, June, 1917.)

Adrian and Yealland give the following typical case of paralysis of the arm as a very frequent and very curable form of war neurosis, occurring as a rule after a slight wound or bruise necessitating the use of a sling. The patient, having received a slight wound of the forearm, for months had a useless arm, which he could move but slightly at the shoulder on exerting a superhuman effort. Occasionally he could flex the fingers through a small angle. There was complete anesthesia of the hand and arm of long-glove type. This anesthesia was not complained of, and might not be noticed until suggested to the patient by the physician. It is well to elicit the anesthesia, however, in view of the treatment to be applied. There was no wasting of muscles; the sensory loss was typical of hysterical anesthesia; nor could the whole arm have been involved by an injury that did not affect the upper arm and shoulder.

The patient was told that he was very lucky to have come off with such a slight injury; his arm was to be set right in five minutes by the application of a special form of electricity. He was then made to sit on a large pad electrode connected with an induction coil; the other terminal is connected with a wire brush. The first effect, he was told, would be the return of feeling in the forearm; power would return with the feeling. The wire brush with a fairly strong current was drawn downwards over the forearm from elbow to wrist. He was told that he could now feel as far as the wrist, and a pin was used to convince him that he could thus feel. If he had not felt the pinprick, the current would have been increased in strength until he could feel. The hand was now treated in the same way.

He was now told that, as feeling had returned to the arm, the power of movement would be restored shortly. Adrian and Yealland remark that laymen seem to consider that loss of power and loss of feeling are inseparably connected. The electrode was now used to produce contraction in the muscles. Under these circumstances, the arm will be used hesitatingly, with an appearance of great effort; but the patient is nevertheless convinced that power is returning.

“Rapid reËducation follows at once. He is given no time to think, but urged to move the arm more and more strongly, to grip the physician’s hand, to flex and extend the elbow, etc., and the pressure is not relaxed until the whole arm has returned to its normal vigor. If recovery is stationary, faradization is repeated with stronger and stronger currents. If it seems as though he might relapse on leaving the hospital, he is told that this is very unlikely, but that if it should occur, he should report sick at once and come back for treatment with a current far stronger than that already used.”

Adrian and Yealland claim that they have applied their combination of suggestion and reËducation in more than 250 cases (including 82 cases of mutism, 34 of deafness, 18 of aphonia, 37 brachial or crural monoplegia, 46 paraplegia, 16 hemiplegia, and 18 of non-organic gait disturbance), and that although a majority of the cases have been of several months’ standing, treatment has been almost immediately successful in at least 95 per cent of the cases.

Exposure in the retreat from Mons: Persistent hysterical sciatica. Treatment by faradism and verbal suggestion.

Case 565. (Harris, 1915.)

A soldier developed pains about the hips and down the right thigh after getting wet through in the retreat from Mons, August, 1914. He was treated for a period of nine months in various convalescent homes and military hospitals, incidentally receiving forty baths at Droitwich. He hobbled on a stick, leaning upon the left leg and dragging the right stiffly. The thigh was tender and hyperesthetic.

The proper treatment of cases of hysteria, according to Harris, is strong faradism, applied by a small electrode or wire brush to the moistened skin. The stimulus is made powerful enough to force the patient to admit that he feels. The theory is that the powerful stimulation “breaks down the psychical auto-inhibition which produces the hysterical anesthesia.”

Faradism is only the first phase of the treatment. Verbal suggestion follows. Building on the basis of the feeling produced by the faradism or on the basis of the ocular evidence of motion in the hitherto paralyzed muscles, the patient is informed that the electricity will now be more and more strongly felt and that he will be cured in a few minutes.

The two elements in the therapy, then, are: encouraging verbal suggestion and the suggestion afforded by the paraphernalia of a complex looking, noisy machine. The knowledge on the part of the patient that a powerful and mysterious stimulus, namely, electricity, is being employed is a third element of suggestion.

Persistent hysterical sciatica, such as that of the present case, may require prolonged treatment. In this instance, the man was completely cured in five minutes, so that he was made able to run across the room. He said he would now be able to go back to the front, and wondered why he could not have been cured before.

Prognosis of intensive reËducation in reflex (physiopathic) disorder—complete recovery (except for the hysterical fraction of the disease) not expected.

Case 566. (Vincent, 1916.)

A young soldier was superficially wounded in the left knee, in August, 1914. A year later, he showed amyotrophy of the left calf, which measured 2.5 cm. less than the right, a weak slow Achilles reflex on the left side, cyanosis and hypothermia of the left foot, weakness and limitation of movements in the left foot, with slight contracture in flexion of leg upon thigh.

Thenceforward and for eight months, this soldier was submitted at the Tours Centre to intensive reËducation. For two hours every day upon prescription he walked, ran, and hopped upon the left leg. In September, 1916, after twelve month’s training, there was a certain improvement in his disorder. The leg was now completely extended upon the thigh, and the amplitude in the movement of the foot was almost normal; but the amyotrophy, vasomotor disorder and certain electrical disturbances remained quite unchanged. The man himself recognized that his status was greatly improved, but he could not walk more than four or five kilometers without great fatigue.

In view of the inferior results of reËducation in some of these cases, should any attempt at all be made to reËducate? Vincent thinks that that should be; but that it should be borne in mind that sometimes no results may be obtained. If the reflex disorder (in the Babinski sense) is minimal and the chief difficulty is hysterical, then sometimes the man may go back to service after reËducation; but in intense examples of reflex (physiopathic) disorder, invaliding has often proved necessary.

Re values of intensive reËducation, Vincent’s technique and results have logical resemblances to those of Yealland and of Kaufmann. Vincent established in the 9th district neurological center a method of intensive reËducation which is particularly suited to old hysterical cases. He divides the treatment into three stages: First, the stage called by the poilu by the picturesque name of torpillage; secondly, the stage of fixation; thirdly, the stage of training. According to Roussy and Lhermitte, there are few cases at the front suitable for the treatment of Clovis Vincent, which is especially devised for the old cases. See under Case 574 for further details of Vincent’s treatment.

Re prognosis of the physiopathic disorder, there has been some controversy in France. See discussion under Case 530. Re suitable treatment for physiopathic disorders, Babinski and Froment suggested the application of heat. The warm bath test is also of value in diagnosis. Babinski and Froment claim progressive improvements with hot baths, hot air douches, and light baths—but counsel great prudence. The improvement is never rapid.

Wound of calf; operations: hysterical contracture with “physiopathic” features. “Brutally conquered” by reËducation.

Case 567. (Ferrand, March, 1917.)

A French infantryman, class of 1912, was wounded, May 12, 1915, in the upper third of the right calf. His posterior tibial artery had to be ligated. In a few weeks the wound was healed, but he began to walk badly, presenting a contracture of the calf with retraction of the tendo Achillis.

Toward the last of 1915 a surgeon under the impression that the disease was organic cut the tendo Achillis but the soldier could not walk any better. As he could not take the position of equinism, he semiflexed his knee and walked upon a crutch.

Another surgeon was now found to perform a tenotomy on the flexors of the leg and put the patient in a plaster cast to correct the flexion and immobilize in extension. This second operation was in July, 1916. The patient now walked without a crutch.

He was then sent to a neurological center, Dec. 8, 1916, walking on two canes, right leg in forced extension on thigh, in permanent and absolute contracture. All movements except leg flexion could be executed, though slowly and weakly; but positive movements were impossible, except flexion of the knees. There was no sensory disorder. Reflexes were normal save that the leg reflexes were a little stronger on the affected side, and the patellar reflex on that side was nullified by the contracture. Electrical reactions proved normal. There were marked trophic disturbances of the right foot and of the lower third of the lower leg. There was a certain amount of edema, cyanosis, coldness and thickening of skin; marked muscular over-excitability of the distal extremity of the leg. In short, Ferrand was here dealing with a case of Babinski’s group of the so-called physiopathic cases. The man was somewhat feeble-minded, and anxious and a trembling suppliant for cure.

He was put, December 15, in a reËducation room and by means of fatigue, induced by violent physical exercises, was (Ferrand states) “brutally conquered.” The contracture after a half hour of physical movement of flexion and extension of the leg ceased. The patient was shown how he could himself both flex and extend the limb himself; he was then caused to do this spontaneously. These active movements were aided and at times provoked by somewhat painful galvanic discharges. The patient then walked slowly, and flexed both knees to the maximum. He was cured after a treatment of 2½ hours. There were, of course, some (surgical) intra-articular adhesions in the knee and it was necessary for the patient to break these adhesions. An X-ray had shown the bone to be intact. A slight hydrarthrosis developed the next day, but a few days later he was able to walk as well as anyone. For five weeks he followed a training platoon in the reËducation work and was evacuated, January 23, 1917, to his station, though he had entered the neurological center with the idea that he was to be invalided with a pension.

He had a few relics of physiomotor disorder when he left, including the abnormal delicacy of skin and muscular over-excitability above mentioned. On the basis of this and similar cases Ferrand believes that, although the physiopathic group of Babinski exists, it does not signify a separate clinical syndrome and the occurrence of physiopathic symptoms does not contraindicate psychotherapy.

Re this controversy, see remarks under Case 530.

Shell-shock: Paraparesis. Cure by electricity.

Case 568. (Turrell, January, 1915.)

Turrell, in a paper on electrotherapy at a base hospital, narrates a case of spinal concussion which rapidly yielded to the persuasive influence of BergoniÉ’s machine for electrically provoked exercises. Turrell grants that such a rapid cure would probably be attributed to suggestion, but thinks that the term demonstration might be preferred on account of the vigor and amplitude of the muscular contractions excited.

This soldier was driving an ammunition wagon at the front, when a shell exploded under the wagon, killing one horse and severely wounding the other. The patient himself was blown into the air, fell, dragged himself to a trench where he lay all night, and found himself in the morning unable to walk or stand. He recalls that pins were stuck into his legs by the examining medical officer and that they produced no sensation. When he was finally brought to the Third Southern Medical Hospital, he was unable to draw up or move his legs, or to stand up (yet neurologically normal).

After a few days’ rest in bed, he found himself able to walk a few steps with assistance, and was then transferred to the Radcliffe Infirmary for electrical treatment. This treatment consisted in electrically provoked exercises to the back (positive) and seat and thighs (negative). He was able to walk back to his ward, leaning on a wheelchair. Next day he walked to the electrical department with sticks, and after the exercises were repeated, he was found able to walk without assistance. On the third day, the Morton wave current was applied to the back, to clear up any persistent stiffness. The patient was then discharged on sick furlough.

Re the Morton wave and similar applications of electricity, Zeehandelaar speaks of a high frequency hall fitted up at Berlin. Touching the walls of the hall with the finger elicited a powerful spark. The scheme appeared to be on a commercial basis, and it was proposed to start similar institutions for poor metabolism and neuroses in other cities.

A year’s field service, gunshot; typhoid fever: Astasia-abasia: Lourdes-like cure: Residual amnesia.

Case 569. (Voss, November, 1916.)

A soldier in service from the outbreak of war, shot in September, 1915, afterward suffering from fainting spells, was treated in several hospitals. He developed a typhoid fever at Lindau, which was at first taken for hysterical fever. Eventually he came to the observation of Voss, unable to stand and falling hysteria-wise if compelled to walk.

Thorough examination was made. It was emphatically explained to him that there could be no reason why he should not stand or walk.

A miracle occurred. From the second day of his hospital stay he not only walked about but began to polish doors and windows with inexhaustible strength.

But when he was about to be told that he must now be looked upon as well, the miracle was not so manifest. It now transpired that he had serious gaps of memory and disorders in recognition, a sphincter disorder and ever since his typhoid incontinence with fluid feces.

In short, waking suggestion had caused a very prominent symptom to disappear, but the total personality remained sick. According to Voss, the procedures of Kaufmann are dubious just because they cannot stand the test of time. Yet so far as the cure of this man’s astasia-abasia was concerned, it was not at all unlike the cures wrought at Lourdes.

Re miracles of this sort, see cases of Colin Russel (503 and 504) as well as those of Veale (511 and 512). Voss’ arguments run parallel with the contentions of various persons that the miracle cures (such as those by anesthesia, electric suggestion, and hypnosis), do not get sufficiently to the bottom of the affections in question. Buzzard, in the preface to Yealland’s book on the Hysterical Disorders of Warfare, remarks that the question of the ultimate prognosis in cases thus suddenly cured must be left unanswered.

Dysbasia after a fall: “Kaufmann” cure in six weeks.

Case 570. (Schultze, August, 1916.)

Severe dysbasia, due to monoplegia of the right leg of sudden origin (a fall), was variously treated 64 weeks without effect.

July 15, 1916, the patient walked in on a stick, and fell down on trying to walk without. August 1, 1916, at 9 o’clock, he was rapidly examined: Anesthesia to pain and temperature; inability to lift right foot; the right knee could be lifted about a hand-breadth above the body if the foot was supported.

At 9:10, a small electrode was applied: sensibility became normal at once. Second application: leg raised much better. The man was told that he was better and that his hand could be put under the heel. Third application: Leg raised 8 cm. The patient showed pleasure at the advance. Fourth application (slightly increased strength): Patient able to stand and to lift knee with flexion at 135° while standing. Walking exercises under direction. At 9:30, five minutes recess was given for fatigue, whereupon the exercises were taken up again and transition made from stationary running to walking without aid as well as a variety of other associated acts (grasping handkerchief instead of physician’s hand, and the like). The patient became exhausted after 8 or 9 minutes running about, and another pause was given.

The large brush electrode with stronger current was now given to the back and to the back of the right leg. Practice in slow walking, lifting knee, and holding hip joint firm. The patient became tired, but remained very willing. Exercises in pulling on stockings, in climbing stairs—the whole concluded at 10 o’clock, whereupon it was found that the patient could walk alone for a distance of 50 meters. The patient was a very suggestible one. It was striking that the patient in the time between 9:35 and 9:40 minutes could walk better on the right (that is, the previously affected leg) than upon the left. Rest in bed and phenacetine were ordered, with the suggestion that in the morning he would walk much better. He became irritated after the treatment but grew quieter in the afternoon.

On August 3, he was found able to walk well, better when not observed than when observed. August 5, he complained that his leg was worse and used a cane, without permission. He was roundly scolded by the physician and threatened with being sent to bed if he did not practice earnestly. August 7, he was better, and confessed that he could not walk as well on command as he could alone; the exercises were nothing but a fraud and he could go out and beat everything up (alles zerschlagen) if he did not have to carry out such exercises.

August 15, he was much better, quiet, and satisfied. The lameness was practically gone. August 30, there was no sign of lameness, even when he was observed. According to Schultze, the Kaufmann method is not merely an Erb tradition, and rather special measures need to be taken in executing it.

Re Kaufmann’s cure, Imboden sums up this “highly logical and brutal method” as a method in which powerful electric shocks and loud military orders to perform certain exercises secure results. Imboden suggests that relapses may follow, sometimes on the slightest provocation. Mann states that Kaufmann’s method of suggestion and electric shock forms very good treatment; yet Mann states there have been two deaths under this treatment: in both instances there was an enlarged thymus at autopsy. A better technique, especially the use of the faradic current alone, might have avoided these deaths. Mann himself prefers to Kaufmann’s Ueberrumpelung milder methods, such as rest. Kaufmann keeps up the sitting until the man is cured, even if it takes two hours of electricity and staccato commands. For similar persistance, see the treatment by induced fatigue of Reeve (Cases 489-493).

Wound of shoulder: Heterosuggestion of BRACHIAL paresis. Electrical suggestion of muscular power. Recovery in five days.

Case 571. (Hewat, March, 1917.)

A reËnlisted soldier arrived at the Royal Victoria Hospital, as a case of ulnar paralysis. He had been wounded in France six months before by a bullet which passed through the fleshy part of the shoulder, above the middle third of the clavicle. Power in the right arm gradually diminished; yet two months after the wound he seemed fit enough to be sent to Egypt. The paresis developed, and in a month’s time he was invalided home. He had been unable to use a rifle for months.

The healed bullet wounds were found about the region of the brachial plexus. The patient was sure the bullet had damaged the nerves in that region. The right arm and hand were limp and over-inclined to blueness, and the muscles were flabby. Active movements of all sorts could be carried out with the arm but not against resistance. There was a definite anesthesia and analgesia throughout, and responses to touch and pain stimuli were irregular.

By way of treatment, the patient had the muscles of the paretic arm stimulated electrically, and at the same time he was told that no nerve of the neck had been injured. He was greatly surprised to see his palsied arm move vigorously.

A milk isolation treatment in bed behind screens was adopted, whereat the patient was angry, looking upon the Weir-Mitchell treatment as punishment.

On the next day, another electrical application secured complete power in the arm and abolished sensory disturbance. Three days later the man went back to full duty. According to Fergus Hewat, someone doubtless had suggested to this patient that he had received a nerve injury. He had become obsessed thereby and developed a typical functional paralysis. This was a “cortical misinterpretation,” which disappeared upon forcible demonstration of the error.

Exposure; intestinal disorder in weakminded neuropath: Camptocormia and hysterical paraplegia: Cure by psycho-electric treatment.

Case 572. (Roussy and Lhermitte, 1917.)

A French territorial, 45, was observed at the Centre Neurologique, August 28, 1916. He was a victim of hysterical paraplegia with tripod gait. There was a stiffness of the lumbar vertebral column which had lasted six months. This paraplegia had begun spontaneously after cold and an attack of diarrhoea followed by constipation. The camptocormia and disorder of gait had come on gradually in the ambulance. He came on a stretcher. He was found to be able to walk with great difficulty by leaning both hands on a cane. The two legs were tremulous in a pseudospastic gait. The next day, after a single psycho-electric treatment, cure was complete. This patient was mentally somewhat weak and a constitutional neuropath. He was discharged, cured, October 20, 1916.

Brachial monoplegia, hysterical (or feigned?). Found able to descend ladder with arms only.

Case 573. (Claude, July, 1916.)

Claude had a case of a soldier with right-sided brachial monoplegia, which had lasted for 18 months and defied efforts to cure. There was a question of simulation, and Claude handed the case over to Vincent.

The case came on service, June 20, and was seen June 21. He was then treated and found able to descend a ladder applied to a wall with the help of his arms only. On June 24, he was found able to lift a weight of 10 kilos, and could now write with the right hand, although he had been writing only with his left. This man had looked like a simulator to many physicians. He may have been a simulator or an hysteric. In any case, he was cured.

Vicissitudes of treatment of hysterical brachial monoparesis (shell burial).

Case 574. (Vincent, July, 1917.)

A French private was buried in a trench upon the explosion of a large shell, November, 1914. He said he had had a “fracture of the occiput” and had fainted away without regaining consciousness for several hours.

He was evacuated to Dunkirk, then Saint Nasire, and then to Sables-d’Olonne. He showed no paralysis or paresis of limbs. During the first month, he had violent pains in the head, spells and vomiting. There was a slight aphasic disorder. He was treated by cupping upon the head and by applications of ice.

After the visit of the inspector general, he was sent to Nantes to be trephined. Dr. Mathieu regarded an operation as useless. He was treated with bromides and the faradic current by MiraillÉ, applied to the right arm, which had become paretic.

June, 1915, he started on a three-months convalescent leave in Paris.

From October to December, he had electric treatment at the Grand-Palais.

December, 1915, he went to the SalpÊtriÈre under P. Marie, where he was given electric treatment.

January 1916, he went to Maison-Blanche under Laignel-Lavastine, where he was given electricity 4½ months.

April 4 he went back to his dÉpÔt.

Presented to the invaliding board, May 11, at Decize, he was sent to the neurological center at Bourges. He was there given massage and movements. Upon entrance he had a functional inactivity of the right arm. He should have been cured a long time before by the therapeutics employed. He was then sent to Vincent at the neurological center at Tours for special motor reËducation. Vincent found almost complete functional incapacity of the right arm, without atrophy, with normal reactions, no R. D., and normal arterial pressure. June 26, 1916, the patient was able to write, although slowly. He could sign a letter, and could lift a weight of 10 kilos.

The details of Vincent’s method mentioned under Case 566 are pursued, to use his own words, with methodical ruthlessness. This form of reËducation consists in manoeuvres that make the patients yield despite themselves. The galvanic current is used to force a man to react voluntarily or automatically. See, for example, Claude’s case of a hysterical brachial monoplegic (Case 574) found able to descend a ladder with the use of his arms only. After the physician’s victory is secured, then a sort of consolidation must be obtained by means of the execution of certain movements on the part of the patient for an hour or two. As another factor in the situation set up by Clovis Vincent, is the enthusiasm generated in the moral atmosphere in which the cure takes place. Mott has also insisted upon this atmosphere of cure, which Mott believes is in part responsible for the good results of Adrian and Yealland. Roussy and Boisseau, at Salins, started out with a process similar to that of Vincent, with a preliminary period of isolation. Roussy also uses the faradic current instead of the galvanic (see remarks of Mann concerning deaths with the Kaufmann method in Germany, under Case 570). Vincent’s three stages are given in Chart 19, page 897.

Struck by shell fragment; run over by shell; paresis and regionary sense disorder. Treatment by reËducation.

Case 575. (Binswanger, July, 1915.)

A German subaltern officer, 27, was wounded September 25, 1914, in a battle in France. He gave the following account:

“We had been firing without interruption four days, and then were sent back. While going back from cover we were under shell fire. Three or four horses fell. I got a glancing blow from a shell fragment in the back of the head, and fell down. I was not quite unconscious. I tried several times to get up, but I could not, for I had very bad pains in the head and a confused feeling in it, too. I remember also that a wheel ran over my foot, and that I got a sharp blow in the chest. Then I was unconscious for about an hour. When I awoke, there were two comrades busy over me and they pulled me back of the firing-line. Then I got to a field hospital.”

The man arrived at the nerve hospital (Jena), October 8, 1914, with insomnia, respiratory disturbance, sudden perspiration, feelings of cold in the right foot, and poor appetite. He had had nausea for a few days. Lungs and heart proved normal. X-ray of the right foot showed normal relations. The man was a small, powerfully-built man, well nourished, with lively reflexes, especially the knee reflexes, of which the right was greater than the left; slight patellar clonus, right; left plantar reflex greater than right; segmental disorder of touch and pain sense in the right foot and lower leg, a zone of analgesia lying above the zone of total anesthesia. Gait was lame on account of inability to move the right ankle joint. In walking, the right foot was trailed.

Treatment was suggestive and supported by active gymnastic exercises, breathing exercises, exercises in moving the right leg, massage, faradism and local hydrotherapy. The gait gradually improved, the cold feeling disappeared from the right leg, disturbances of pain and touch sense disappeared. The patient was released on the 2d of February, 1915, capable of garrison duty.

With respect to this man, who was married, he was from a healthy family and had healthy children. He is said, however, to have suffered from convulsions for a long time in early life, but thereafter had never been sick in any way. He was a good student and had been a post-office official since 1908. After two years’ military service, he became, in 1910, Unteroffizier-Aspirant. Later he was advanced to his subaltern position in the reserve.

This case seems to be a characteristic example of segmental disorder of sensations of both touch and pain, combined with a paresis in the same region. Mechanical and mental factors seem to have been present, and the case belongs in what Binswanger calls the “hysterosomatic” group.

Re Binswanger’s so-called hysterosomatic group, he defines the cases as having emotional, mechanical, and toxic (gas) factors. On the whole, they are best classified as a kind of psychoneurosis. Binswanger finds all physical and drug treatment without result except as supportives. He has used hydrotherapy and electrotherapy with the perfectly clear conception that the procedures were of suggestive value only. In fact, Binswanger had before defined such procedures as Realsuggestionen or material suggestions. Common verbal suggestion, says Binswanger, will work sometimes only when aided by these material suggestions. See also under Case 576.

Post-traumatic (ANTEBELLUM) seizures with unconsciousness: Further seizures, astasia-abasia, anesthesias, following no special period of stress in field service. Recovery by reËducation.

Case 576. (Binswanger, July, 1915.)

O. F., 26, healthy, of a healthy family, in military service, 1908-1910, a miner in October, 1912, had fallen into a shaft from a considerable height, and is said to have been unconscious for three days and two nights and to have had some sort of attack a short time after waking. Later he had another attack, beginning with violent headaches, running from the back to the fore part of the head, then dizziness, then a fall with unconsciousness. The whole attack lasted about four minutes and was followed by feelings of extreme fatigue.

It seems that in the spring of 1913 these attacks had begun to repeat themselves two or three times a week. In the spring of 1914 there had again been two attacks at an interval of two weeks. They had occurred on the way to work and had been introduced by the same symptoms as before. They lasted about half an hour.

He was in the war in France from August 6, 1914. While he was cooking, one day, in the middle of September, he had an attack and this without special occasion. The next attack occurred a little while afterwards, at the time of an assault. He said that he fell down and lost his senses. When he came to his senses again, he found he could not move his legs.

He was taken to a reserve hospital in Germany, and while there had several attacks with unconsciousness and spasmodic convulsions—the last on December 7, 1914. He was transferred to the Jena Hospital on the 11th.

The Jena examination had the benefit of an inquiry concerning the case. It seems that he had left the field hospital in the enemy’s country, in a half-conscious condition, and rode away therefrom aimlessly. It was only in Germany that he, on his own story, found his bearings again. However, upon admission the disturbance in walking was very noticeable, since the patient came hobbling through the garden of the clinic with the upper part of his body bent forward, and with the support of two canes. The legs were moved with difficulty; he seemed to take short, tripping steps, with the toes dragging on the ground. His inability to walk he explained through the violent pains which he would feel in the joints of the legs and an extraordinary weakness in his legs.

Physically, the man was a tall, strongly built and well-nourished subject. Neurologically, the knee-jerks were somewhat decreased and weaker on the right side than on the left; the Achilles reflexes were lively. The plantar reflex was not obtainable on the left side; decreased on the right. The abdominal reflexes were absent on both sides.

Most remarkable was the general diminution in sensitiveness of the skin to touch and pain, involving the whole body, up to the neck, where the sensory impairment abruptly ceased in a sharp line. The anesthesia was not everywhere complete. In a few places pencil strokes were successfully localized and recognized. Deep pin-pricks were everywhere recognized as itching. When the trunk was everywhere examined on both sides symmetrically, a strong pressure with a pin-head was felt as a strong pressure on the right side, but was felt not at all on the left side. Anesthesia and analgesia were total in the legs. Deep folds of skin could be punctured by needles without reaction.

The legs could be moved freely upon urgent request with the patient in dorsal decubitus. Still these movements were slow and difficult, as explained by the patient, on account of violent pains in the joints. If put on his feet, he would begin to sway greatly and permit himself to slide down to the ground, stating that he was quite incapable of standing or walking without aid. With two canes, however, he could move freely about in the ward and in the garden, and even with considerable speed, in a peculiar, dragging, shuffling way; in the execution he gave no sign of pain, contentedly smoking a cigar or a pipe.

While his status was being taken on admission, he became suddenly dull and irresponsive, with a staring look. He could not state his age or his birthplace. However, he became clear shortly, upon urging, and explained the spell by saying that the blood had risen to his head. A few days later, he was transferred to the psychiatric division. He was given strict rest in bed, smoking was forbidden, prolonged baths were used, and the legs were massaged. He felt very comfortable in the prolonged baths and could then move his legs without pain.

A few days later he was taken out of bed several times a day, the canes being removed immediately, and he was led about the day-room with the light support of two nurses. Being promised a cigar as a reward, he proved able to walk through the day-room supported by but one nurse. A week later the pains in walking exercises had disappeared. He had become able to walk alone, supporting himself lightly along the wall with one hand. Walking was still uncertain and slow.

December 20, the patient could stand free without support, swaying slightly; improvement became rapid. He could shortly stand and walk without support though his walk was still awkward and on a wide base with knees pressed in and body bent forward, soles were kept applied to the ground. December 22, the patient could walk in the garden without aid.

December 23, there was a spell of great weariness and complaint of being sick. The patient lay down on the bed, cried aloud, and had rhythmic twitchings and sudden movements with arms and legs. He scratched the right half of his face with his right hand. This spell lasted about a minute. It was repeated in the same way twice within the half hour.

He had complete amnesia for these attacks. The pupillary reactions were entirely normal in the attacks. He had been in bad spirits that day because a Christmas furlough had been refused. The attacks provoked no bad consequences and his gait improved. He was on furlough from the 30th to January 3; on the 4th he was transferred to the nerve department, but on the 12th of January he was reprimanded for a breach of discipline, whereupon at 9:15 he had an hysterical attack with the same coÖrdinate rhythmic motions as before. This attack lasted about 20 minutes. Two hours before the attack he had complained of weariness and a boiling-hot feeling in the body. Long walks were taken. On February 15 he began to feel very happy. He was informed that the charge against him for leaving his troop had been dropped. He complained of sudden weariness and headache and was markedly depressed, but he had no hysterical attack.

After February 23 he took part regularly in gymnastics, executing the movements with joy and without special weariness. He wanted to be discharged. He was discharged as fit for garrison duty and he has since gone back to field service.

Re gymnastics, Binswanger holds that they have a special value in overcoming inner psychic resistances and weak-willed persons. The Realsuggestionen (see under preceding case, 575), such as hydrotherapy and electrotherapy, serve to concentrate the person’s attention on certain regions. These regional suggestions then smooth the way for the curative suggestion, namely, the constant and monotonously repeated assurance that recovery is advancing. At the next stage, according to Binswanger, gymnastic exercises may be brought in to overcome hopelessness, indifference, or exaggeration of morbid feelings. Binswanger sets methodical tasks for the attention and the will (a so-called Uebungstherapie). If these gymnastics lead to manifest improvement, then a proper educational therapy is prescribed, which is no longer a merely exercise therapy, but consists of actions of actual value in hospital routine. The convalescents are gradually led to carry on housework, food service, gardening (the latter under supervision). Hospital clerical work is a suitable occupation. Re supervision over gardening, mentioned by Binswanger, Canadian experience indicates that the idea of supervision may be greatly extended. Particularly is this true in vocational reËducation. Kidner describes the functions of a vocational counsellor, who has to have an expert knowledge of industry and methods of industrial training, as well as an acquaintance with the varying demands for workers, a knowledge of the seasonal variations in employment, and a knowledge of occupational diseases. Re occupational therapy, Todd estimates that from 0.5 to 1 per cent of wounded men in France will require vocational reËducation. Occupational therapy is the proper vestibule to vocational training. He lists the following forms of treatment used in institutions for vocational reËducation:

• Active mechanotherapy.
• Passive mechanotherapy.
• Galvanic, static, and faradic electricity.
• Vibration.
• Hot air baths and blasts.
• Water baths.
• Colored light.
• Massage.
• Gymnastics.

Central specialized institutions such as those developed in France are necessary, and such centres should be large rather than small, according to Todd, and should contain not less than 200 beds. Todd insists that work is, after all, the most important measure of reËducation; and Turner, speaking of the home for neurasthenics at Golders Green, says that during a period of three months (the number of the patients is limited to 100, and three months is the limit of stay), the vast majority, even of the most obstinate cases, get well through the effects of sympathy and insistance upon work. Near Golders Green is the Maida Vale Hospital for nervous cases, so that in case of need the physicians there may treat the patients. Salmon gives a list of the occupations which are suitable for these cases.

Blown up by shell; wounds, right side, distention and bloody urine: Paresis of right foot and spasticity of hip; later rectal and bladder incontinence.

Case 577. (Binswanger, July, 1915.)

A Russian from the Ukraine was received at the nerve hospital, Jena, December 12, 1914. Through an interpreter it was established that he was a peasant, had been under shell fire in a skirmish at the beginning of November, and had been hurled (so he said) 1¼ meters into the air without loss of consciousness. There was a wound of the right shoulder and also, he thought, of the legs, from the air pressure. Becoming a German prisoner, he had been treated in various hospitals.

He was a strong man of medium height, with a healthy complexion. There were two healed wounds of the right shoulder, and near the twelfth spinous process a third similar scar. There were a number of ulcers and furuncles over the os sacrum.

Neurologically, the knee-jerks and Achilles jerks could not be obtained, and the plantar reflex, extinct on the left, was weak on the right. Sensitiveness to pain on both sides was lost from the knee downwards but there was hyperalgesia in the thigh. Inaccurate statements in response to tactile tests were made, apparently on account of lack of understanding. In lying down, there was a slight restriction in the movements of the legs, and active movements of the joints of the foot on the right side were impossible. Gait was ataxic-paretic, more markedly so right than left. He could walk only with two canes, and during walking the musculature of the thigh fell into a spastic tension. The tongue deviated to the left. There were severe rheumatic pains in the thighs.

It appears that some weeks before, this Russian soldier had suffered from severe rheumatic pains in both sides and was at that time absolutely unable to walk or stand. At that time, however, there was no question of a crural paraplegia of organic origin, since the man could move his legs well enough when in dorsal decubitus. There were no signs of paralysis of the rectum or bladder at that time.

Treatment at Jena consisted in regular walking exercises with support at the shoulders. The lower legs and feet remained weak and paretic. The decubital ulcers disappeared.

About the middle of December rectal incontinence began, the stool being discharged without the patient’s noticing it while being led to the bath. Later there was incontinence of feces in bed. Pains in the legs were constantly complained of. Nevertheless improvement in walking was maintained. The toes were dragged at every step and the knee-joints were thrown outward in walking. The musculature of the lower legs was weak. Knee-jerks could not be elicited more than before. He constantly complained of pains in the knees and right hip. The rectal disorder did not again occur during January.

Toward the close of January, the patient’s right lower leg and left foot would occasionally feel asleep; both legs felt cold and itched. In a general way, however, the pains had become less marked than they were at first. It seemed that he had no sensations at stool, and consequently had to resort to the closet at a definite time. Moreover, urine was discharged irregularly and involuntarily when he coughed. It appears that a few days after receiving his wounds in battle, there had been pains on micturition as well as blood in the urine, and it appears that he had been catheterized. It is probable that he had suffered from distention, as he described his abdomen, thighs and sex organs as swollen.

In February he began to be able to move alone with two canes through the ward, but he moved his legs from the knee downward very little, and dragged them after the rest of the body. Upon galvanic examination, the peroneal and tibial nerve trunks were found normally excitable. At this time the sensibility situation had changed somewhat, since complete analgesia was present only in the foot, and hypalgesia had developed upon the anterior surfaces of the lower legs. Pin-pricks were described as touches. The posterior surface of the left lower leg was normally sensitive. There was an oblong stripe about 3 cm. long, beginning in the popliteal space and stretching downward on the left side. The right lower leg was entirely insensitive. The posterior surfaces of both thighs as far as the gluteal folds were completely insensible to pain. The Wassermann reaction of the blood was negative. In this condition the patient was transferred to a prison camp hospital.

Re bloody urine, see Section B, Case 202. Re rectal incontinence, it might be inquired whether this was possibly functional. Roussy and Lhermitte devote a chapter to visceral disorders. They do not list rectal incontinence amongst the disorders noted in this war, nor have any cases of hysterical anorexia or disorders of sensation in the intestinal tract been seen during the war despite the occurrence of these latter disorders in the civilian group. The main digestive disorder that the war cases show is vomiting (see Cases 495 and 500).

Emotionality: Shell explosion; mutism. Recovery by reËducation.

Case 578. (Briand and Philippe, September, 1916.)

A plumber, 27, went into the infantry. He was very emotional and was but a short time in the trenches when the explosion of shells threw him into a state of mutism. Deafness, rather curiously, did not manifest itself for several days. He had to go back on horseback, and, as he was a poor horseman, slipped off the horse, giving himself a bad fright. When he got up, he had lost his hearing.

He was sent to several hospitals and finally to Val-de-GrÂce, in July, 1915. He recovered hearing in fifteen days, but the mutism persisted several months. According to Briand and Philippe, this is a typical case, except for the duration of the mutism. The first treatment was given this patient August 6. His respiration was examined and tracing was taken. August 15, on the morning visit, he was found able to whistle very distinctly the first bars of “Au Clair de la Lune,” and then began to sing the first verses, articulating distinctly, but stammering a little. He was now left to his own resources, without special exercises, from August 15 to September 26, and completely lost the benefit of his previous exercises. A week of special treatment allowed him to recover speech again, enough to take up every day life. The patient went out well.

The general lines of the examination in this case took up attitude in abdominal respiration and the question of respiratory pauses, especially pauses in abdominal respiration, which, in the above case, were exaggerated. Expiration was deficient and disordered. The normal adaptations that had been established during his childhood learning of speech had failed, and the patient would not have been able by himself to regain proper balance of respiration for speech.

The examination was continued to learn the difficulties of innervation of the muscles of phonation whose proper delicacy had been lost. Such a patient is a kind of bad gymnast, executing an exercise known to be hard by contracting all the muscles of the region, both the antagonist and the agonist muscles. ReËducation must, therefore, endeavor to sweep away the contractions that block sound. Then the patient must be made to perform the contractions necessary in phonation and articulation unconsciously. The methods used for teaching children might here be employed, but more elaborate and designed methods can be used with the adult, e.g.,

SÉguin and Rouma, on the other hand, counsel beginning exercises with consonants in stammerers and dyslalics.

Re tests for functional deafness, Ranjard states that on account of the complexity of Shell-shock deafness, exact diagnosis needs to be made. Examination of the hearing by speech alone, or by the watch-tick, yielded poor results; and an accurate mathematical acoumeter (SirÈne À voyelles, Marage) is recommended. See especially chapter on the functional examination of audition in Bourgeois and Sourdille’s War Otitis and War Deafness, a work translated and highly recommended by the English otologist, Dundas Grant.

Three days’ skirmish on East front: Unconsciousness, later delirium, still later (six weeks) stammering, hysterical stigmata: Recovery by isolation and reËducation.

Case 579. (Binswanger, July, 1915.)

A traveling salesman in civil life, 36, as a non-commissioned officer took part in severe fighting in the East shortly after the outbreak of the war. He was under violent shell fire at one time for five hours at a stretch. In the middle of November, after a skirmish in the woods which had lasted for three days, he was found unconscious. According to his own story, he was awakened from this unconsciousness about a week later in a hospital. He described himself as quite unable to say anything about what had gone on during that week.

The medical report on the case stated that he arrived at the hospital, November 18, in a dormant state of mind. He had appeared markedly excited and kept incessantly talking about military matters, such as the placing of machine guns, the occupation of the edge of the woods by his company, addressing the nurse as “Captain,” and the sister as “Mrs. Captain,” making as it were an official report to them. He showed shyness, and always an extreme excitement. His hands and legs were in constant motion; he complained of headaches and itching finger-tips. Sleep could be achieved only by drugs. This mental state lasted till November 26, when he became oriented. Sleep improved, but he complained of pains in the back of the head.

Upon transfer to a convalescent home, December 5, he was still occasionally excited and sometimes sleepless. On December 30, the patient began to stammer; his speech had before this been somewhat difficult, but the stammering began suddenly; speech was indistinct and slow; syllables failed to follow one another at like intervals. The headache at this time radiated from the middle of the top of the head to the side of the neck. There was a complaint of vibrating pains on the two sides of the vertebral column, and a feeling of weakness and unsteadiness in walking. The patient would sway with eyes closed and turn sidewise. The heart action was tumultuous, the pulse irregular and uneven.

The patient was transferred back to the reserve hospital on January 2, 1915, whereupon the stammering became worse, sleep restless, and arms and legs subject to spasmodic pains and twitching. On January 25, he was removed to the Jena Hospital. He remarked that at the convalescent home he became very much excited at the Christmas celebration and had to cry, whereupon his speech became more and more difficult; he could not find the beginnings of words and had to stammer. Upon admission he also complained of sharp pains in the soles of the feet and in the finger-tips.

Neurologically, there was marked dermatographia, the deep reflexes were increased, abdominal reflexes were absent; there were points of pain on pressure in both supra-orbital regions, and there was a general hypalgesia with the exception of the head, the lower legs, the feet, the scrotum, the penis and the anal region. Pin-pricks were recognized on the right side only, when the patient was tested bilaterally. They could be recognized on both sides when the patient was examined on one side at a time. There was a static tremor on both sides (?). He could move his arms, but in dorsal decubitus he could move his legs only jerkily and uncertainly. His gait was waddling with dragging of toes.

There was a marked photophobia. The palatal and swallowing reflexes were in excess; speech was hesitant and stammering. The first letters of words, especially initial consonants, could be pronounced with difficulty, explosively with cheeks blown up, after several attempts. The consonant would be repeated several times before the vowel could be added. The patient’s name was Singer, and he would pronounce it: S … S … S … Si … n … n … ger; the last syllable (ger) being brought out with a strong accentuation. The whole process took five seconds. The word Flanelllatten took 14 seconds. It seems that the patient had already suffered (in 1907) from nasal catarrh and disturbance of hearing from stoppage of the Eustachian tubes. Another attack in 1908 had been accompanied by an irritating cough, and there seems to have been catarrh on the right in 1913, as well as cerumen on the left side.

Treatment: The patient was isolated; in the next few days there was improvement in the headache. The patient complained of muscular twitchings, which would occur suddenly in different parts of the body. On February 1 there was a subjective feeling of happiness since all pains had disappeared.

The patient was given regular exercises in speaking and there was gradual improvement in speech. Body-weight increased, regular walks were taken, and the patient occupied himself with garden work.

By June, 1915, he had still further remarkably improved, working now all day long, partly in the garden, partly in the hospital office. Disturbance of speech was not noticed except for hesitation before the last syllables of long words during comparatively long conversations. All trace of difficulty in walking had disappeared. In this patient no hereditary taint could be proved. He appears to have been of normal development, serving in the army from 1901 to 1903. In his life as a traveling salesman, there was frequently catarrh of the throat, and in 1912 there was a marked swelling of the vocal cords with extreme hoarseness and inability to speak, which condition was cured after local treatment.

Re hysterical speech and voice disorders, Binswanger has found them amongst the most obstinate conditions, often persisting when all other hysterical phenomena have dropped away. He states that apparently the cure of some of these cases must be postponed until the end of the war.

Re general results of the therapeutic treatment of the war hysterias, Binswanger states that he has been able to send some cases back to the front that have successfully stayed there. He has had failures, however, even amongst men who have had no mauvaise volontÉ and have themselves desired to be sent back to the front.

Gordon Wilson observed 250 cases of Shell-shock at the Ypres salient and on the Somme. Fifty of these cases complained of deafness, and 17 of the 50 were found to have actual nerve deafness. Wilson treated “fixed idea” cases by hypnotism, and sometimes by cold water run into the ear. He, in general, divides the cases in to (a) cases of nerve deafness, (b) fixed idea cases, and (c) malingerers.

Marage states that frequent exposure to the noise of shells for long periods may produce a permanent deafness, as has long been known in naval gun-makers and boiler-makers in peace times. He advocates obturators, a good form being plasticine wrapped in gauze moulded to the shape of the internal meatus. Celluloid plugs, sometimes used, have been known to be set afire by the flash of a shell. Cerumen sometimes protects against deafness, but Mott speaks of the driving of the wax into the tympanum as a dangerous effect in certain shock cases.

BURIAL by shell explosion: DEAFMUTISM. Treatment: phonetic reËducation.

Case 580. (LiÉbault, 1916.)

A machine gunner, 26, was buried at Rheims, January 5, 1915, by the explosion of a large shell bursting over the dugout. He was unconscious three days and deafmute on coming to, without amnesia but with a feeling of constriction in the throat.

After fifteen days in the ambulance he was sent for four months to the Maritime Hospital at Brest, and treated by hypnotism. Seven or eight sittings had no other result than to fatigue him. There were then three months of convalescence. Returned to Vannes, September 20, 1915, he was put into the auxiliaries. As he could not work much he was sent, December, 1915, to the HÔtel-Dieu at Nantes. Here electric vibratory massage was given, which secured a few hoarse sounds.

Phonetic reËducation was then undertaken at PrÉs-À-goutriÈre, May 10, and his respiratory capacity increased from 170 the first week to 250 and 300 the following weeks. His blowing strength was raised from 15 to 20 to 25 at the same time. In a few weeks he was much improved and June 27 passed on to his auditory reËducation. The respiratory capacity in this man was insufficient. He could not speak, but his respiratory movements were good and he learned again to speak in a voice as good as ever.

According to LiÉbault, it is a general principle that, if the respiratory capacity is increased, the voice will clear or become better; but, if the respiratory capacity remains stationary, the voice will not improve. It is the same with normal persons. A subject with a very subnormal respiratory capacity cannot speak loudly, but, if his respiratory capacity approaches normal, he can speak normally. According to LiÉbault, all cases of this sort have had some respiratory anomaly and each case must be systematically examined with the aid of anthropometric tables, including weight, height and chest capacity. The vocal disorder is proportionate to the degree of functioning of the phonating apparatus taken as a whole. It is not merely that the larynx should be examined, but the motor side of the apparatus, the respiratory muscles, the resonating apparatus, the lips, the mouth, the nasal fossÆ and the pharynx.

Re curability of different types of war deafmute, Roussy and Boisseau maintain that the type (a) that comes gesticulating, pointing to the ears, and desirous of writing, is the type that responds most rapidly to psychotherapy. There are two other types less responsive: (b) is an apathetic type, with impassive and stupid facies, lies immobile in bed, or sits in a chair in mental confusion; type (c) shows a facies of terror, looks haggard and anxious, confused, disoriented, and possibly delirious.

Re general treatment of deaf cases, Zange suggests that emotion should not be aroused by intense auditory impressions, that he should not be reminded of his shock, and should be kept as cheerful as possible. Zange states that he found the static electric current of service, and got good results in hysterical deafness of sudden development by applying a strong faradic current.

A year’s service; leave: Hysterical aphonia developed at home. Respiratory gymnastics.

Case 581. (Garel, April, 1916.)

A soldier, 35, went on leave August, 1915. Arriving at his farm, he had a violent feeling of moral perturbation and suddenly lost his voice. When he returned from leave he seemed stupid, spoke very few words and seemed to look about in a vague and undecided way. He was several months in this state and sent January, 1916, to Saint-Luc.

The vocal cords were there found of a normal color and without paralysis. “It was, therefore,” remarks Garel, “a nervous aphonia susceptible of instantaneous cure.” The patient was made to make a sound in the lowest tone possible. While he was making this attempt, sharp pressure was exerted upon the lower part of the sternum, to provoke expiratory reinforcement. The sound emitted was loud, to the great astonishment of the patient, who, thus aided by suggestion, shortly began to talk aloud.

In this particular patient a temporary return of voice was readily obtained, but not maintained. Special exercises had to be instituted, whereupon the patient immediately fell back into a complete aphonia. He was then made to scan words, syllable by syllable, executing with his arms classical movements of respiratory gymnastics, or sometimes with the utterance of every syllable the epigastrium was manually compressed or the shoulders suddenly lowered. The patient could now read a book in a jerky manner, and after a few lines he could read without his shoulders being pressed.

Another plan was to have the man read or talk while walking. As soon as he was stopped and accosted, however, he lost his voice again. Up to the time of report it was impossible to secure a definite return of voice, as the patient was not willing to associate words with peculiar movements. It might make him ridiculous. Accordingly, the nurses were requested not to fulfil requests unless they were made aloud. Recovery was to be hoped for from this measure.

Wounded: Recurrent stammering: ReËducation.

Case 582. (MacMahon, August, 1917.)

A young English officer, previously cured of stammering while a boy, fell to stammering again after being twice wounded. The impediment was of the laryngeal type. When spoken to he was often quite speechless. In Shell-shock stammering, the chief difficulty according to MacMahon is in the production of voice consonants and vowel sounds. In mild cases the trouble is best left alone.

This officer was anxious to pass into the regular army from the reserve to which he was attached. The stammering prevented this. He was treated nine months and improved rapidly. He passed through the trying ordeal of the medical board successfully and went to his regiment.

In severe cases the patient is taught how to fill his lungs properly. He is taught to acquire an inferior lateral costal expansion in inspiration. During expiration the abdominal muscles are trained to contract slowly and strongly, pressing the diaphragm upwards and drawing the lower ribs downwards and inwards. This steady breathing produces a sensation of repose in the stammerer. He is not to raise the upper chest and not to tense the throat, tongue or jaws.

The main vowel sounds are now taught. The main vowel sounds are oo, oh, au, ah, a and ee. They combine in six ways, oh and oo in the word wound, ah and ee make the long i, au and ee in boy, oh and oo in road, a and ee in rain and fair, ee and oo in new and you. There are also words in which no main vowel or compound sounds appear, which may be placed either on the open ah position or the closed ee position. Such words as long, abbot, among, which are on the position of ah and such words as it, sister, minister which are in the position of ee. The voice consonants are b, d, g, j, l, m, n, r, v, w, y, z, w being oo sound and y the ee sound. The breathed consonants are c, f, h, k, p, q, s, t.

The treatment of stammering intensified by Shell-shock is more difficult than that of Shell-shock stammering de novo.

Wound of face: Speech disorder. Recovery by reËducation in two months.

Case 583. (MacMahon, August, 1917.)

An officer was wounded under his left eye, October 7, 1916. His speech was affected only five days later in a casualty clearing station. Observed by MacMahon, November 5, he was found to speak with great difficulty and became exhausted after a few words. He was tensing all the muscles in attempting to speak. Breathing advice was given and counsel how to relax in the abnormal efforts.

November 12, the officer, who was at Number One London General Hospital, began to speak with more freedom. “I am getting a bit better. I feel I must keep quiet, and it comes after a bit. I think far quicker than I speak.” He said that the breathing exercises had helped him most.

November 15, he still spoke in a rather staccato way; but the words did not check as they had. In a week further there had been so much improvement that he was discharged with a prognosis of complete recovery.

January, 1917, he had recovered.

Shell wound and burial: Camptocormia (psychoelectric treatment successful in one sÉance) and lameness (long reËducative treatment successful).

Case 584. (Roussy and Lhermitte, 1917.)

At a Neuropsychiatric Center, September 2, 1916, arrived a chasseur, 29, showing lameness of a pseudocoxalgic type on the left side, combined with an anterior camptocormia. The whole situation had lasted a year. The chasseur had been wounded by shell explosion on the left side and was buried on July 29, 1915. He lost consciousness and had respiratory trouble and mutism. His arched walk and lameness began August 20, 1915.

He had a number of terms in hospital and six months at the dÉpÔt. He was sent back to the front, June 20, 1916, being proposed for auxiliary work. There was some mental weakness. After one sÉance of electric treatment, the improper attitude of the trunk was corrected. The lameness, however, persisted and required long daily reËducation.

The patient was discharged cured, October 20, 1916, without lameness or camptocormia. There were a few persistent lumbar pains.

Re treatment of war psychoneuroses, Roussy and Lhermitte recommend rational and persuasive psychotherapy after the manner of Dejerine, Dubois, Babinski, and others. Hypnosis, they say, should definitely be rejected. Mental contagion must be staved off, and Roussy and Lhermitte believe that almost all cases are curable and should be sent back as competents.

They maintain that the medical officer himself plays the leading part. Many patients are “cured” when they find “good masters”; this mastery of the combined confessor and educator is greatly aided by prestige. He must speak with authority, with “iron in the velvet glove”; but with patience and persistence. If a long sitting fails, postpone work on the pretext of resting the patient. The patient must not be early threatened with discipline. Even exaggerators and malingerers must be talked to as if neuropathic.

A careful medical examination, besides correcting false diagnoses and demonstrating hystero-organic associations, will give the patient confidence in his physician.

A new patient is more easily cured than an old one. In general, patients should be treated as soon as possible after the shock. Contractures are habitually more persistent than paralysis; tremors and tic are more pertinacious than deafmutism; ante-bellum psychoneuroses are less easy to treat than cases developed by the war alone.

The neurological centers near the front, with their discipline, inaccessibility to friends, and nearness to the front, present a situation which yields easier and quicker cures than the interior; but after the two-years’ experience which proved this fact, according to Roussy and Lhermitte, many cases still get sent back into the interior for many months,—cases that ought to be cured near the front. Cases having convulsive attacks get confinement in separate rooms; chronic neuropaths are kept in bed on a milk diet.

The general features of the treatment of psychoneuroses commended by Roussy and Lhermitte are summed up in what they call the psychoelectric and reËducative method, divided into four stages: A stage (a) of persuasive conversation; (b) isolation; (c) faradization; and (d) physical and psychical reËducation. Roussy and Lhermitte got during six months in one of the army neurological centers, 98 to 99 per cent of recoveries. Clovis Vincent, in a special interior hospital (see for Clovis Vincent’s treatment, a summary under Case 575). Re the first stage of persuasive conversations, Roussy and Lhermitte discuss on the day of admission the general nature of the patient’s condition, and place him in the atmosphere of cure, in contact with recovered patients. The conversation takes place in the physician’s consulting room. The patient is gotten to promise on oath that he will submit to any methods of treatment. Although one may pass from the first stage to the third or electrical stage, forthwith, Roussy and Lhermitte recommend several days of isolation. The patient is placed in a separate room, and kept in bed on a milk diet. This isolation treatment of Weir Mitchell allows reinforcement of the suggestion by talks on the medical rounds, allows the patient, perhaps, to beg for the electrical treatment, which he may have refused at first, and lengthens the period of observation. According to Roussy and Lhermitte, spontaneous recovery not infrequently takes place during this phase of isolation. Lameness of long standing, tremors, and deafmutism disappear.

The third stage is that of faradization, executed by the physician with only such attendants as may be necessary to support the patient. At first, the man lies nude upon the bed, but later may be treated while sitting, standing, walking, or running. Feeble currents are used at first; later stronger ones. The poles are applied to the affected parts, and sometimes to especially sensitive parts of the skin, such as the ears, neck, lips, soles, perineum, and scrotum. Energetic treatment by the rapid method is indicated in the vast majority of cases, especially at the front. If a case is seen early, the rapid energetic treatment almost always cures at once. The success of the method depends upon the production of a crisis, which ought to be produced at the first sitting. Sometimes this sitting has to be continued for hours. Some patients require two or three sittings; some, still more. Instead of faradism, a cold jet of water, or even painful subcutaneous injections of ether, may be used.

The fourth stage is that of physical and psychical reËducation, important in long-standing cases. The various forms of physiotherapy are carried out by special assistants or head nurses, accompanied by psychotherapy, and if necessary by electricity. According to Roussy and Lhermitte, these reËducative methods used alone, without previous faradic treatment, are not successful. Relapse follows premature transference from the front to hospitals in the interior, and too early sick leave.

Shell-shock deafmutism. Speech recovered by suggestion and reËducation; hearing by reËducation.

Case 585. (LiÉbault, October, 1916.)

A corporal, 20, was exposed to the shock of an aerial torpedo, January 18, 1916, at Souchez. The torpedo fell a meter away. There was no loss of consciousness, but the patient was agitated for several hours, not knowing what he was doing. Evacuated to hospital, he remained several days in a stupid state. He was completely deaf and remembered poorly what had happened. He made every effort to speak, but could not. His head felt on fire. He could not open his mouth well and his lower jaw was almost in a state of contracture. He felt that his tongue could not move easily. In this status he remained until February, always trying to talk, but not succeeding.

He then arrived at HÔtel-Dieu. The mouth was now opening better and he was in a better general status, though always feeling fatigued. Vibratory massage was given to the laryngeal region. He was gradually got to emit a few sounds in a low voice. He was sent, April 26, to PrÉs-À-goutriÈre. He was now somewhat vocal, but at times would become completely aphonic once more. The voice during the first few weeks of treatment became better, and the respiratory capacity was increased from 450 the first week to 460 and 500 in the next two weeks.

May 12, he suddenly lost his voice again and wanted to commit suicide. However, in three more days he was able to speak normally again and has had no relapse. He was then put under auditory reËducation and at the time of report his hearing had slightly improved.

LiÉbault remarks that during the time when the patient could not speak his jaw muscles were contracted and his tongue could not mobilize well. He could think words but could not articulate them. It was accordingly important to cultivate the normal functioning of these muscles.

Gassing; tracheitis; crash from airplane; unconsciousness: mutism; stammering. ReËducation; hypnosis.

Case 586. (MacCurdy, July, 1917.)

A lieutenant in the Royal Flying Corps, 23, described as “unusually normal,” a successful business man, athletic, socially popular, had been for a year in the Infantry. He was caught suddenly in a gas attack, and, though he recovered after a few days in bed, had a severe tracheitis and laryngitis. The lieutenant had been very proud of his voice and its carrying power. He went to a laryngologist in London, who said that he would never be able to sing again—a matter of some worry.

He soon became an expert airman. In the spring of 1917 he was shot at by antiaircraft guns in a trip over the enemy’s lines. One of the wings was hit and so weakened that in landing the lieutenant crashed to the ground. He was unconscious for three hours and on coming to tried to shout to his servant in the distance, who, on arrival, found the lieutenant quite unable to speak.

According to MacCurdy, there was here a conversion hysteria with regression to the tracheitis that followed the gassing. The mutism MacCurdy regards as a pathological degree of an effort of protection for his voice. In hospital three weeks later he learned to whisper a few words, though with great mental effort. He regained the voiced sounds by coughing and then saying “ah.” Stammering now developed. Not more than one or two words could be said at a breath. Training to say two, three, four and then five letters in one expiration yielded improvement in the stammering. Under mild hypnosis, to the degree merely of distraction, normal speech was re-attained. There was no relapse. Singing was then practiced and in a period of six weeks the singing voice was virtually as good as it ever had been.

Shell-shock: Loss of consciousness, possibly hemorrhage from head: Spontaneous gradual recovery from anesthesias in three months: Recovery from paralysis by reËducation in a few more weeks.

Case 587. (Binswanger, July, 1915.)

A German youth of 19 volunteered at the outset of the war as a motor cycle rider. About the end of October, he was hurled from his wheel by a shell which struck close beside him and exploded, knocking his back against a pile of beams. He lost consciousness. There may have been hemorrhage.

He came to, two hours later, in the dressing station, hardly able to move his limbs. Such movements as he could make were painful. There was an evident contusion of the back. He had a fainting fit after his bath in the field hospital and then could get to bed only with support. Severe pains in the legs, especially in the knee.

In the reserve hospital, there was a second similar fainting spell, followed by buzzing in the head, feelings of pressure in the chest and an irregular pulse; all of which phenomena disappeared the morning after the fit.

A careful examination about the middle of November showed the persistence of a severe paresis of the left arm, and a less marked motor weakness of the right arm. Both legs were paretic, and there were no spontaneous movements of the leg. This paresis of the legs was combined with complete anesthesia and analgesia. Sensory impairment was found only in the right arm and trunk, and there was no evidence of sensory impairment in the left arm. Both motor and sensory disturbances of the arm disappeared rapidly.

However, at the beginning of December, 1914, the complete insensibility of the lower extremities up to the groin still persisted. The anesthesia then began to retreat, so that four days later, the upper limit of anesthesia was somewhat below the groin. There could be found a circumscribed area of anesthetic skin over the os sacrum up as far as the second vertebra of the os sacrum; but the skin around this area, as well as over each tuber ischii, gave normal sensation.

The anesthesia continued to retreat: to the middle of the thigh at the middle of December; to a level 3 cm. above the knee-cap at the end of December; to the upper end of the knee-cap on the right side and the middle of the left knee-cap, January 1. January 11, the anesthesia had retreated to a level 10 cm. below both right and left patella. February 8, sensibility in the legs had entirely returned.

While the anesthesia was pursuing this favorable course, the motor symptoms failed to improve to any marked extent, although active motion of the legs with the patient in dorsal decubitus had gradually returned to a limited degree.

The diagnosis upon arrival at the Jena Nerve Hospital was “rheumatism of the left side of the body and dislocation of the spine.”

The treatment consisted at first of rest in bed and moist dressings of the legs, but the treatment had to depend greatly upon the diagnosis. The patient complained of difficult micturition; yet there were no other positive signs of organic disease, of spine or cord.

Hysteria was the diagnosis preferred to rheumatism, despite the fact that examination at the Jena Hospital failed to show any disorder in pain or tactile sense.

The patient was a rather tall man of slender build, with a slightly accentuated second pulmonic sound, decidedly increased tendon reflexes, weak plantar reflexes, and many points painful on pressure in various parts of the head, over the spine, and in the sciatic regions. The vertebral sensibility to pressure was most acute in the region of the third, fourth, and fifth thoracic vertebrae. There was a marked dermatographia. There was no other sensory disorder and no motor disorder of the arms, though the left hand-grasp was weak. All passive movements could be successfully carried out with the legs. Upon bending at the hip, there were subjective feelings of tension in the posterior parts of the thighs. In active motion there was a marked limitation in leg movements, which appeared to be executed with great difficulty with but small excursion and with considerable trembling. The knee-joint could be flexed only when the sole of the foot had support. The lower leg could not be extended. The excursion in the joints of the feet and toes was slight. Muscular strength was in general decreased. There were no feelings of pain in muscular action but merely feelings of great effort. Gait was slow, shuffling, unsteady, hesitating and only possible with support. Fatigue set in after a few steps. In walking, the legs could hardly be bent at the knee. The soles of the feet dragged on the ground. The patient was unable to stand upright, and when placed upon his feet, anxiously and stiffly clung to some support. Without support, he fell over backwards. When supported he could move his legs at the hip and lift the feet from their base by bending the knee-joints. The patient could not sit in a chair or in bed except with support; otherwise he would fall to the right side. In dorsal decubitus he complained of pain in the loins.

With this hysterical picture, treatment of a psychotherapeutic nature was carried out. The patient was given methodical exercises in walking and standing, during which affirmative suggestions about his new capacity to walk and stand were given with monotonous repetition.

For the first fortnight he walked with the support of two nurses for a half hour every day. He was very industrious and willing to execute this treatment; and later began to exercise with a cane. Two days later, he omitted the cane and found himself able to walk about without support. He was shortly able to stand without swaying, although for some time the walk was upon a rather wide base and somewhat slow and suggestive of spastic paresis.

The general condition of this patient remained good. His appetite and sleep were good. After the middle of March, 1915, there were no more peculiarities in walking, and the patient was able to take somewhat long walks in the city and vicinity. He applied for work in the airship division, for which he already possessed some experience.

The youth appears to have been of a normal mental and bodily development, though his mother is said to have been nervous and a sister died of convulsions in childhood.

Shell-shock with loss of consciousness: Deafmutism, rhythmic head movements, anesthesia, asymmetrical areflexia. Recovery by suggestion with faradism, massage and reËducation.

Case 588. (Arinstein, September, 1916.)

A Russian private, 30, literate, lost consciousness upon the explosion of a large shell, November 10, 1915. He was brought to hospital, November 14, completely deaf and dumb, and with his head rhythmically swaying sidewise 60 to 70 times per minute. The swaying ceased during sleep. The head was carried inclined to the right; there was complaint of headache. The left leg, the trunk and the hairy part of the head were anesthetic. The knee-jerks were obtained with difficulty, the Achilles jerks were lively; the throat and conjunctival reflexes were absent; the abdominal and cremasteric reflexes were lively. The right plantar reflex was absent; the left normal. The vision of the right eye was impaired, and there was a monocular diplopia of this eye. The drum membranes were pulled in, and the disorder of hearing was explained on the basis of labyrinthine shock.

After a sÉance of written suggestion with faradism to neck and small palate and vibratory massage to throat, speech returned. November 26, the patient read in a loud voice a written phrase. He did not speak again independently until early in December, when he read aloud written matter. The return of spontaneous speech was gradual. Hearing returned December 5, when he was able to hear in the right ear by means of a tube. In the sitting posture there was less swaying of the head. If the patient lay down, rhythmic movements of the head became stronger and more rapid (120).

Shell explosion; unconsciousness: Amnesia; paralyses. ReËducation.

Case 589. (Batten, January, 1916.)

A corporal in the Belgian army was mobilized when the war broke out, and was in action continuously in the retreat from LiÈge, in the siege of Antwerp, and finally on the Yser until October 27, 1914, when the explosion of large shells rendered him unconscious. He recovered consciousness only in hospital at Calais. Though he was able to see and hear well, he was dazed and remembered nothing of what had happened. In fact, he did not understand what was said to him.

In a week’s time, his memory and intelligence returned, save for periodic attacks in which he was dazed. From the very beginning he had been quite unable to move his legs, and at first the arms were weak. He had a series of attacks of violent struggling in November and December, 1914, which the corporal himself called fainting attacks, claiming that he did not move his legs in the attacks but only his arms. In fact, he claimed that he could move neither head, body, nor legs, but only the arms. He said, “Sometimes I try hard and set my teeth, but I do not know how to move my head and my legs; I try but they do not move.” Sphincter control was maintained. Although he could see, when he attempted to read, everything went black.

He was finally admitted to the National Hospital for the Paralyzed and Epileptic on July 8, 1915, on the service of Major Walshe. He was thin and wasted. He was firmly convinced, according to the notes of Major Walshe, that he was seriously paralyzed. He said he could not lift his head; when his body was lifted, his head fell back, or rather perhaps was definitely thrown back, lolling about alarmingly. However as he lay in bed he frequently lifted his head unconsciously and placed his hands under it. When asked to lift his head, the sternomastoids were strongly contracted, but at the same time the neck extensors also, so that the head was stiffly and strongly held in an extended position. Despite the patient’s statement that he could not move the trunk muscles, he could turn over readily in bed, and when trying to move the head the trunk was fixed in a strong opisthotonos, and the abdominal walls were rigid. When requested to move his legs, he made no movement whatever, though during head movements the legs were strongly fixed in extension. On passive movements, there was no active muscular resistance. There was an indefinite blunting of all kinds of sensations. Reflexes were normal.

Major Walshe worked hard with the patient, inducing him first to lift his head from the pillow, and finally to move the legs. In three weeks’ time, the corporal could just sit up, and at the end of another month, he was able to stand in the walking machine. At the end of a third month, he was walking upon crutches, and at the end of another, he could walk upon two sticks with his feet wide apart, moving as if glued to the floor. To quote Batten, “The corporal will eventually get well but not, I think, before the end of the war.”