Part 2

Differences in muscle tonicity, in mechanical irritability of the muscles, and the presence or absence of fibrotendinous contractions are indications of a separation between the reflex and purely functional cases, as apparently demonstrated in some of the case records. True trophic disorders of the skin, hair, and bones observed in the reflex cases are also said to have no place in the illustrations of pithiatism.

The delver into the case histories of this volume will find numerous instructive combinations of hystero-reflex and organo-hysterical associations which are not to be enumerated in an introduction. The great importance of what all recognize as pathognomonic signs of organic disease--Babinski extensor toe response, persistent foot clonus, reactions of degeneration, marked atrophy, lost tendon jerks, etc.--is, of course, continuously in evidence. Extraordinary associations of hysterical, organic, and reflex disorders with other affections due to direct involvement of bone, muscle, and vessels and with the secondary effects of cicatrization and immobilization are brought out on many pages. In quitting this branch of our subject it might be remarked that considerable changes must be made in our textbook descriptions of nervous diseases in the light of the contributions to the neurology of the present war.

One is reminded in the details of some of the cases of the discussions some decades since on the subject of spinal traumatisms; of the work of Erichsen which resulted in giving his name and that of “railway spine” to many of the cases now commonly spoken of as traumatic hysteria and traumatic neurasthenia; of the rejoinders of Page and his views regarding spinal traumatisms; and of Oppenheim’s development of the symptom complex of what he prefers to term the traumatic neurosis. One who has taken part in much court work cannot but read these case records with interest, for the neurology of the war as presented in this volume and in numerous monographs which are now appearing, throws much light upon many often mooted medicolegal problems. I recall how many able and honest neurological observers have changed their points of view since the early days of Erichsen’s “railway spine,” a pathological suggestion which is said to have cost the corporations of England an almost fabulous sum during a score of years. I recall also that a certain Court of Appeals in one of our states even felt itself called upon to promulgate an opinion intended to exorcise entirely the plea for damages for alleged injuries if it could be shown that these were due to fright. The data of this book do not put weapons entirely into the hands of the attorney and the expert for either the plaintiff or the defendant.

Some of the French writers on the neurology of the war, as illustrated in the records collected by Dr. Southard, have brought to our attention distinctions which they draw between _états commotionnels_ and _états émotionnels_--happy terms, and yet not sufficient in their invention or in the explanations which accompany them, fully to satisfy the requirements of the facts presented. These writers seem to think of the commotional states as denoting some real disease or condition of the brain, and yet one which is really curable and reversible. They explicitly tell us, however, that these commotions fall short of being _lésionnel_. After all, is this not somewhat obscure? Is it not something of a return to the period of “railway spine” when one of the comparisons sometimes made was that the injury suffered by the nervous tissues produced in them a state comparable to that of a magnet which had been subjected to a severe blow? At any rate, in commotion thus discussed the nervous structures are supposed to sustain some real injury of a physiochemical character, whereas in the emotional states the neurones are, as Southard puts it, affected somewhat after the manner of normal emotional functioning, except perhaps that they are called upon to deliver an excessive stream of impulses. The latter would be classed among the psychopathic, the former among the physiopathic affections, and yet the distinction between the two is not always quite clear.

In not a few instances of Shell-shock--although these are not numerous, so far as records have been obtained--actual structural lesions have been recorded even in cases in which no direct external injury of a material kind was experienced as a result of the explosion of shells. In others the evidences of external injury were relatively unimportant. Various lesions, in some cases recognizable even by the naked eye, were present. Mott, for example, found not only minute hemorrhages, but in one instance a bulbar extravasation of moderate massiveness, the patient not showing external signs of injury. Cases are also recorded of hematomyelia; others with edematous or necrotic areas in the cord; and still others with lesions of the ependyma or even with splitting of the spinal canal, reminding one of the classical experiments of Duret on cerebral and cerebrospinal traumatisms.

It has been argued that too much stress should not be laid on a few cases of this sort--but are they as few as they seem to be? The fact is that necropsical opportunities are not often afforded. May not such scattered lesions often be present without resulting in death or even in long continued disturbance? There is no essential reason why minute hemorrhages into the brain and spinal cord, and especially into their membranes, may not undergo rapid absorption or even remain unchanged for some time without dire results.

One of the reported cases in which lung splitting occurred from severe concussion without external injury is not without interest in this connection, reminding one, as the commentator says, of those cases of severe concussion in which the interior of a building is injured while the exterior escapes. In the same connection also the cited experiments of Mairet and Durante on rabbits are not without instructiveness. As a result of explosives set off close to these animals, pulmonary apoplexy, spinal cord and root hemorrhages, and extravasations, perivascular and ependymal, and into the cortical and bulbar gray were found. Russca obtained direct and _contrecoup_ brain lesions, etc., in a similar way.

Here and there throughout the book will be found references to symptoms and syndromes which will have a particular interest for the reader--soldier’s heart, trench foot, congealed hand, tics, tremors, convulsions, sensory areas variously mapped, and forms of local tetanus, the last being distinctly to be differentiated from pithiatic contractures and those due to organic lesions of the nervous system. Cases of an affection described by Souques as camptocormia, from Greek words meaning to bend the trunk, were shown to the Neurological Society of Paris in 1914 and later, the main features of this affection being pronounced incurvation forward of the trunk from the dorsolumbar region, with extreme abduction and outward rotation of the lower limbs, pain in the back, and difficult and tremulous walking. In some of these cases, organic lesions of the trunkal tissues were present, but in addition psychic elements played a not unimportant part, and the cases were restored to health by a combination of physical measures with psychotherapy, enforced by electrical applications.

The part of this book given over to the discussion of treatment will doubtless to some prove the most interesting section. The presentation of the subject of therapeutics is in some degree a discussion also of diagnosis and prognosis; and so it happens in various parts of the volume that the particular subject under consideration is more or less a reaffirmation or anticipation of remarks under other headings.

Similar results are brought about by various therapeutic procedures. Nonne, Myers, and a few others bring hypnosis into the foreground, although non-hypnotic suggestion plays a larger rôle by far.

Miracle cures are wrought through many pages. Mutism, deafness and blindness, palsies, contractures, and tics disappear at times as if by magic under various forms of suggestion. Ether or chloroform narcosis drives out the malady at the moment when it reveals its true nature. Verbal suggestion has many adjuvants and collaborators--electricity, sometimes severely administered, lumbar puncture, injections of stovaine into the cerebrospinal fluid, injections of saline solution, colored lights, vibrations, active mechanotherapy, hydrotherapy, hot air baths and blasts, massage, etc. Painful and punitive measures have their place--one is inclined to think a less valuable place than is given them by some of the recorders. In some instances the element of suggestion, while doubtless present, is overshadowed by the material methods employed. Persuasion and actual physical improvement are in these cases highly important. Reëducation is not infrequently in evidence. The patient in one way or another is taught how to do things which he had lost the way of doing.

It is interesting to American neurologists to note how frequently in the reports, especially of French observers, the “Weir Mitchell treatment” was the method employed, including isolation, the faradic current, massage, and Swedish movements, hydrotherapy, dietetic measures, reëducative processes, and powerful suggestion variously exhibited, especially through the mastery of the physician over the patient. It is rather striking that few records of Freudian psychoanalytic therapy are presented.

When all is said, however, counter-suggestion and persuasion, in whatever guise made use of, were not always sufficient and this not only in the clearly organic cases, but in those which are ranked under the head of reflex nervous disorders. In these the long-continued use of physical agencies was found necessary to supplement the purely psychic procedures, these facts sometimes giving rise in the Paris Society of Neurology and elsewhere to animated discussion as to the real nature of the cases. The pithiatic features of the case at times disappear, but leave behind much to be explained and more to be accomplished. The cures wrought are not always permanent and in some cases post-bellum experiences may be required to prove the real value of the measures advocated. The reader must study well the detailed records in order to arrive at just conclusions; nevertheless, the tremendous efficacy of suggestion and persuasion stands out in many of the recitals.

Perhaps the author may permit the introducer a little liberty of comment. His non-English interpellations, especially Latin and French, may be regarded by some as overdone or perhaps pedantic, but are rather piquant, giving zest to the text. _Diagnosis per exclusionem in ordine_ is sonorous and has a scholarly flavor, but does not prevent the reader who lives beyond the faubourgs of Boston from understanding that the author is speaking of an ancient and well-tried method of differential diagnosis. _Passim_ may be more impressive or thought-fixing than its English translation, but this to the reader will simply prove a matter of individual opinion. _Psychopathia martialis_ is not only mouth-filling like _Senegambia_ or _Mesopotamia_, but really has a claim to appreciation through its evident applicability. It is agreeable to note that the book seems nowhere to indicate that _psychopathia sexualis_ and _psychopathia martialis_ are convertible terms.

The bibliography of the volume challenges admiration because of its magnitude and thoroughness and is largely to be credited, as the author indicates, to the energy and efficiency of Sergeant Norman Fenton, who did the work in connection with the Neuropsychiatric Training School at Boston, resorting first-hand to the Boston Medical Library and the Library of the New York Academy of Medicine. After Sergeant Fenton joined the American Expeditionary Force, Dr. Southard greatly increased the value of the bibliography by his personal efforts.

This bibliography covers not only the 589 case histories of the book, but it goes beyond this, especially in the presentation of references for 1917, 1918, and even 1919. Owing to the time when our country entered the war, American references are, in the main, of later date than the case histories. They will be found none the less of value to the student of neuropsychiatric problems.

The references in the bibliography number in all more than two thousand, distributed so far as nationalities are concerned about as given below, although some mistakes may have crept into this enumeration for various reasons, like the publication of the same articles in the journals of different countries. The list of references includes French, 895; British (English and Colonial), 396; Italian, 77; Russian, 100; American, 253; Spanish, 5; Dutch, 5; Scandinavian, 5; and Austrian and German, 476. It will be seen, therefore, that the bibliography covers in number nearly four times the collected case studies, most of these records being from reports made during the first three years of the war. The author has wisely made an effort to bring the bibliographic work up to and partially including 1919.

The manner in which the French neurologists and alienists continued their work during the strenuous days of the terrible conflict is worthy of all praise. The labors of the Society of Neurology of Paris never flagged, its contributions in current medical journals having become familiar to neurologists who have followed closely the trend of medical events during the war. Cases and subjects were also frequently presented and discussed at the neurological centers connected with the French and allied armies in France.

It may be almost invidious to specify names, the work done by many was of so much interest and value. Dejerine in the early days of the war, before his untimely sickness and death, contributed his part. Marie from the beginning to the end of the conflict continued to make the neurological world his debtor. The name of Babinski stands out in striking relief. Other names frequently appearing among the French contributors are those of Froment, Clovis Vincent, Roussy and Lhermitte, Léri, Guillain, Souques, Laignel-Lavastine, Courbon, Grasset, Claude, Barre, Benisty, Foix, Chavigny, Charpentier, Meige, Thomas, and Sollier.

For a work of this character not only as complete a bibliography as possible, but a thorough index is absolutely necessary, and this has been supplied. The author has not made the index too full, but with enough cross-references to enable those in all lines of medical work interested to cull out the cases and comments which most concern them.

My prologue finished, I step aside for the play and the player, with the recommendation to the reader that he give close heed to the performance--to the recital of the cases, the comments thereon, and the general discussion of subjects--knowing that such attention will be fully rewarded, for in this wonderful collection of Dr. Southard is to be seen an epitome of war neurology not elsewhere to be found.

CHARLES K. MILLS.

_Philadelphia_, May, 1919.

TABLE OF CONTENTS

SECTION A. PSYCHOSES INCIDENTAL IN THE WAR

I. THE SYPHILITIC GROUP (_Syphilopsychoses_)

CASE PAGE

1. Desertion of an officer _Briand_, 1915 8

2. Visions of a naval officer _Carlill_, _Fildes_, _Baker_, 1917 9

3. Aggravation of neurosyphilis by war _Weygandt_, 1915 10

4. Same _Hurst_, 1917 10

5. Same _Beaton_, 1915 10

6. Same _Boucherot_, 1915 11

7. Same _Todd_, 1917 12

8. Same _Farrar_, 1917 13

9. Same _Marie_, _Chatelin_, _Patrikios_, 1917 14

10. Root-sciatica _Long_, 1916 15

11. Disciplinary _Kastan_, 1916 17

12. Same _Kastan_, 1916 18

13. Same? _Kastan_, 1916 19

14. Hysterical chorea _versus_ neurosyphilis _de Massary_, _du Sonich_, 1917 20

15. Traumatic general paresis _Hurst_, 1917 22

16. Head trauma; shell-shock; mania; W. R. positive _Babonneix_, _David_, 1917 23

17. Head trauma in a syphilitic _Babonneix_, _David_, 1917 24

18. Shell wound: general paresis _Boucherot_, 1915 25

19. “Shell-shock” ocular palsy: syphilitic _Schuster_, 1915 26

20. Shell-shock: general paresis _Donath_, 1915 27

21. Shell-shock: tabes _Logre_, 1917 28

22. Same _Duco_, _Blum_, 1917 28

23. Pseudotabes (Shell-shock) _Pitres_, _Marchand_, 1916 29

24. Shell-shock neurosyphilis _Hurst_, 1917 30

25. Shell-shock neurosyphilis _Hurst_, 1917 31

26. Pseudoparesis (Shell-shock) _Pitres_, _Marchand_, 1916 32

27. War strain and Shell-shock in a syphilitic _Karplus_, 1915 34

28. Shell-shock recurrence of syphilitic hemiplegia _Mairet_, _Piéron_, 1915 36

29. Shell-shock (functional!) amaurosis in a neurosyphilitic _Laignel-Lavastine_, _Courbon_, 1916 37

30. Shell-shock (functional) phenomena in a neurosyphilitic _Babonneix_, _David_, 1917 39

31. Vestibular symptoms in a neurosyphilitic _Guillain_, _Barré_, 1916 40

32. Syphilophobic suicidal attempts _Colin_, _Lautier_, 1917 41

33. Simulated chancre _Pick_, 1916 42

34. Exaggeration _Buscaino_, _Coppola_, 1916 43

II. THE FEEBLE-MINDED GROUP (_Hypophrenoses_)

35. A feeble-minded person fit for service _Pruvost_, 1915 44

36. An imbecile superbrave _Pruvost_, 1915 45

37. An imbecile fit for barracks work _Pruvost_, 1915 45

38. A feeble-minded inventor _Laignel-Lavastine_, _Ballet_, 1917 47

39. A feeble-minded simulator _Pruvost_, 1915 49

40. Enlistment for amelioration of character _Briand_, 1915 49

41. An imbecile fit for service at the front _Pruvost_, 1915 50

42. An imbecile with sudden initiative _Lautier_, 1915 51

43. Emotional fugue in subnormal subject _Briand_, 1915 52

44. Regimental surgeon _versus_ alienist _re_ feeble-mindedness _Kastan_, 1916 53

45. An imbecile rifleman _Kastan_, 1916 55

46. An imbecile hypomaniacal _Haury_, 1915 57

47. Feeble-minded desire to remain at the front _Kastan_, 1916 58

48. An imbecile sent back by Germans _Lautier_, 1915 60

49. Unfit for service: feeble-mindedness? _Kastan_, 1916 61

50. Oniric delirium in a feeble-minded subject _Soukhanoff_, 1915 62

51. Shell-shock and burial: situation not rationalized _Duprat_, 1917 63

52. Shell-shock in weak-minded subject; fear, fugues _Pactet_, _Bonhomme_, 1917 64

III. THE EPILEPTIC GROUP (_Epileptoses_)

53. Epilepsy: neurosyphilis _Hewat_, 1917 65

54. Epilepsy brought out by syphilis _Bonhoeffer_, 1915 66

55. Syphilis in a psychopathic subject _Bonhoeffer_, 1915 67

56. Epileptic imbecile court-martialed _Lautier_, 1916 68

57. Psychogenic seizures in feeble-minded subject _Bonhoeffer_, 1915 69

58. Drunken epileptic: responsibility? _Juquelier_, 1917 71

59. Epilepsy: disciplinary case _Pellacani_, 1917 74

60. Same _Pellacani_, 1917 76

61. Desertion: epileptic fugue _Verger_, 1916 78

62. Specialist in escapes _Logre_, 1917 80

63. Epilepsy and other factors: disciplinary case _Consiglio_, 1917 82

64. Strange conduct and amnesia in epileptic _Hurst_, 1917 83

65. Epilepsy after antityphoid inoculation _Bonhoeffer_, 1915 84

66. Shell-shock: Jacksonian seizures--decompression _Leriche_, 1915 86

67. Blow on head: hysterical convulsions--cure by neglect _Clarke_, 1916 87

68. Epilepsy with superposed hysteria _Bonhoeffer_, 1915 88

69. Musculocutaneous neuritis: Brown-Séquard’s epilepsy _Mairet_, _Piéron_, 1916 89

70. Bullet wound: reactive epilepsy? _Bonhoeffer_, 1915 92

71. _Epilepsia tarda_ _Bonhoeffer_, 1915 93

72. Convulsions by auto-suggestion _Hurst_, 1916 95

73. Epilepsy, emotional _Westphal_, _Hübner_, 1915 97

74. Hysterical convulsions _Laignel-Lavastine_, _Fay_, 1917 98

75. Desertion: fugue, probably not epileptic _Barat_, 1914 100

76. Epileptic episode _Bonhoeffer_, 1915 102

77. Narcoleptic seizures _Friedmann_, 1915 103

78. Sham fits _Hurst_, 1917 106

79. Epileptoid attacks controllable by will _Russel_, 1917 106

80. Epileptic taint brought out at last by shell-shock _Hurst_, 1917 107

81. Shell-shock _epilepsia larvata_ _Juquelier_, _Quellien_, 1917 108

82. To illustrate a theory of Shell-shock as epileptic _Ballard_, 1915 110

83. Same _Ballard_, 1917 110

84. Same _Ballard_, 1917 111

85. Epileptic equivalents _Mott_, 1916 112

IV. THE ALCOHOL-DRUG-POISON GROUP (_Pharmacopsychoses_)

86. Pathological intoxication _Boucherot_, 1915 113

87. Same _Loewy_, 1915 116

88. Desertion in alcoholism: fugue _Logre_, 1916 117

89. Alcoholic amnesia experimentally reproduced _Kastan_, 1915 118

90. Desertion and drunkenness _Kastan_, 1915 119

91. Desertion by alcoholic dement _Kastan_, 1915 121

92. Desertion by alcoholic with other factors _Kastan_, 1915 124

93. Alcoholism: disciplinary case _Kastan_, 1915 126

94. Atrocity, alcoholism _Kastan_, 1915 127

95. Atrocity, alcoholic _Kastan_, 1915 128

96. Alcoholism and amnesia: disciplinary case _Kastan_, 1915 129

97. Post-traumatic intolerance of alcohol _Kastan_, 1915 130

98. Adventure with Parisian stranger _Briand_, _Haury_, 1915 131

99. Morphinism: tetanus _Briand_, 1914 131

100. Morphinism: medicolegal question _Briand_, 1914 132

101.} Two morphinists _Briand_, 1914 132 102.}

V. THE FOCAL BRAIN LESION GROUP (_Encephalopsychoses_)