COLUMBIA LIBRARIES OFFSITE 
 
 HEALTH SCIENCES STANDARD 
 
 HX00020141 
 
 NEUROPSYCHIATRY 
 AND THE WAR 
 
 •I 
 
 \ 
 
 A BlBLIOGRAPin \MTH ABSTRACTS 
 
 SUPPLEMENT I 
 October 1918 
 
 PREPARED BY 
 
 JVIiVBEL WEBSTER BROWN 
 
 AN, THE NATIONAL COMMITTEE FOR MEN1 \ 
 
 i-;l)Itei) by 
 FRANKWOOD E. WIIXIAMg, ^r I) 
 
 ASSOCIATE MEDICAL DIRECTOR 
 
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 w Alt vvuiuv LuAJjvunicj': 
 
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NEUROPSYCHIATRY 
 AND THE WAR 
 
 A Bibliography with Abstracts 
 
 SUPPLEMENT I 
 
 October 1918 
 
 PREPARED BY 
 
 MABEL WEBSTER BROWN 
 
 LIBRARIAN. THE NATIONAL COMMITTEE FOR MENTAL HYGIENE 
 
 EDITED BY 
 
 FRANKWOOD E. WILLIAMS, M. D. 
 
 A3S0CLA.TE MEDICAL DIRECTOR 
 THE NATIONAL COMMITTEE FOR MENTAL HYGIENE 
 
 WAR WORK COMMITTEE 
 
 THE NATIONAL COMMITTEE FOR MENTAL HYGIENE, INC. 
 
 50 UNION SQUARE, NEW YORK CITY 
 
 1918 
 
PREFACE 
 
 The literature of military neuropsychiatry has become so volimiinous since the 
 outbreak of the war that it was found impossible to include, without serious delay 
 in publication, abstracts of all important books and articles on this subject in 
 the original volume, "Neuropsychiatry and the War." For this reason the 
 War Work Committee of the National Committee for Mental Hygiene has issued 
 Supplement I, which contains as much of this omitted material, together with part 
 of the more recent literature on the subject published since the original volume 
 was issued, as there was time to prepare in the three months after the publication 
 of "Neuropsychiatry and the War." Owing to irregularity of receipt of foreign 
 periodicals, difficulties in securing translators, and other obstacles, the amount 
 of literature of many of the European countries abstracted in Supplement I is 
 very scant. It is the hope of the War W^ork Committee that it may be possible 
 to make accessible to date this omitted material, together with the current 
 literature on the subject, by publishing quarterly bibliographies as additional 
 supplements to "Neuropsychiatry and the War." Any future lists will be as 
 inclusive as possible, but only material of special interest will be abstracted. 
 In order to indicate, however, the scope of each book or article listed, a 
 descriptive annotation will accompany every entry. These supplements, if 
 issued, will be distributed free to psychiatrists and neurologists of the Medical 
 Corps, and to libraries and institutions where the publication can be used to 
 advantage. 
 
CONTENTS 
 
 PAGE 
 
 British Literature 7-15 
 
 French Literature 17—26 
 
 German Literature 27—51 
 
 Italian Literature 53-57 
 
 Literature of the Netherlands 59-62 
 
 Russian Literature 63-65 
 
 Scandinavian Literature 67-69 
 
 Literature of the United States 71-111 
 
BRITISH LITERATURE 
 
 Periodicals Abstracted 
 British Medical Journal, London 
 Lancet, London 
 Practitioner, London 
 Recalled to Life, London 
 
BRITISH LITERATURE 
 
 Maitland, E. P., and Campbell, Kenneth. Case of Temporary Blind- 
 ness. Brit. med. j., Sept. 15, 1917, p. 360 
 
 A sergeant, aged 49, was admitted to hospital with a temperature of 101.2°, and 
 bUnd. He complained of some headache. Both fundi were healthy, the media 
 were clear, and no thickening of the retinal arteries could be seen. The tem- 
 perature slowly fell to normal in eight days, when pari passu with the reduction 
 of temperature his vision began to improve, and fourteen days after admission 
 he could see well enough to read a newspaper. He later returned to duty. 
 
 The usual causes of blindness unconnected with visible eye changes are hysteria, 
 uremia, and acute retrobulbar neuritis. The case bore some relation to the last, 
 but the pupils were undilated and normal in action, there was no pain on move- 
 ment of the eyes, nor pain on pressure applied over the globes. 
 
 The case was considered to be due to some toxic condition of the blood, which 
 caused either anesthesia of the rods and cones of the retina, or of the neurons of 
 the visual cortical centres. — A. Ninian Bruce, Rev. of neurology and psychiatry 
 15:332,Aug.-Sept. 1917. 
 
 Green, Edith M. N. Blood Pressure and Surface Temperature in no 
 Cases of Shell Shock. Lancet, Lond., Sept. 22, 1917, p. 45^57 
 
 Green presents her observations on blood pressure and its relation to the 
 physical condition of patients in the British Army. 
 
 It was found that 55 men showed on admission a pressure below 120 mm.Hg., 
 and of these 25 were between 88 and 110. These were the severe cases of shell 
 shock. Of the other 55, 28 were between 130 and 150 mm. Hg., and 27 between 
 120 and 130. Of those above 130 only 4 were severe cases. With the exception 
 of 8 men, all showed subnormal surface temperature varying from 18° to 31.5°C. 
 The temperature was taken in the hand with a surface temperature thermometer, 
 the temperature of the air and a healthy control being noted at the same time. 
 
 All of the cases with a very low blood pressure were suffering from dreams which 
 woke them in a state of terror, sweating, and trembling. Their hands were 
 dusky and clammy, and most of them had a tremor. They showed a marked 
 fatiguability and irritability; most of them were depressed and showed a great 
 lack of self-confidence and initiative; all suffered from headache. On admission 
 nearly all had dilated pupils. 
 
 An improvement in the general condition was coupled with a gradual rise of 
 pressure. At the same time the dreams became less terrifying and there were 
 fewer signs of fear. In some cases which had shown a return of symptoms — 
 such as nightmares, tremors, headaches, or had some cause for considerable 
 worry — it was found that there was a drop in blood pressure at the same time. 
 In most cases there was a rise of surface temperature as the general condition 
 improved, though any subsequent fall in surface temperature or blood pressure 
 did not always coincide. a*. ISSifin.tj* k>*j 
 
 No case showed any organic lesion, and the urine was normal. 
 
 As a gradual rise in blood pressure was found to coincide with general improve- 
 ment in condition, pituitary and thyroid extracts were given in order to see 
 whether a general improvement could be obtained more quickly. 
 
 An interesting point was the almost constant relationship between the low 
 blood pressure and terrifying dreams. It seems as though the vaso-motor dis- 
 turbance which was produced at the time of the shock was rendered more or less 
 
 9 
 
10 
 
 permanent by the constant repetition in dreams of the former terrifying experi- 
 ences. At the same time the low blood pressure caused a cerebral anaemia and 
 lessened mental and physical activity, wliich prevented the man from throwing 
 off the effects of his imagination — thus a vicious circle being produced. A 
 gradual or rapid rise of blood pressure in nearly every case was accompanied 
 by a change in the character of the dreams, the terror element being less marked. 
 —J. B. H., Bost. med. and surg. j. 173: vii, x, Feb. 9, 1918. 
 
 Collie, Sir John. Management of Neurasthenia and Allied Disorders 
 Contracted in the Army; Lecture Delivered at the Royal Institute 
 of Public Health, June 1917. Recalled to life, Lond., no. 2, 
 p. 234-53, Sept. 1917. Also in Mental hygiene 2 : 1-18, Jan. 1918 
 
 That the war in Europe has been responsible for a large number of cases of 
 functional nervous disease can scarcely be a matter for surprise to members of 
 the medical profession. For some considerable time the tendency to neurotic 
 manifestations has been on the increase among the male population of all highly 
 civilized and industrial countries, and when an individual of this type has been 
 subjected to the added stress and strain of modern warfare it is not surprising that 
 sooner or later he should break down under the excessive pressure. 
 
 Col. Sir John ColUe delivered in London some time ago an address on this 
 subject. He pointed out that approximately there were 34,000 men in Great 
 Britain who were drawing pensions because of their inability to serve on account 
 of some functional nervous disease. Such men were by no means necessarily 
 cowards, indeed many of the 34,000 had distinguished themselves by signal acts 
 of bravery and when seemingly recovered many had expressed a wish to return to 
 the front — were impelled thereto by a sense of duty. Of course they could not 
 go because they were temperamentally and neuropotentially unfit for the work. 
 The time for preventing these nervous breakdowns is, if possible, before the ac- 
 ceptance of the man in the army. There are a large number of men apparently 
 physically fit who exhibit no symptoms which would justify the medical examiner 
 in rejecting them, and who yet will "crack" under the nerve-racking and emo- 
 tion-straining experience of war as it is waged to-day. It has been announced 
 recently that the Medical Department of the U. S. Army has decided to extend 
 its psychological examination to all enlisted men and to all newly appointed 
 officers of the army. The extension of this form of examination is due to the 
 success which has attended the experiment of psychological examination made 
 at Camps Lee and Devens. The purposes of the tests as outlined by Major 
 Robert M. Yerkes in charge of the section of psychology of the surgeon general's 
 office, are as follows: (1) To aid in segregating and eliminating the mentally in- 
 competent. (2) To classify men according to their mental capacity. (3) To 
 assist in selecting competent men for responsible positions. This decision of the 
 War Department is a step in the right direction, and may aid in solving the 
 problem of the neurasthenic drafted man, although there is little or no relation 
 between mental deficiency and neurasthenia. The existence of an obvious 
 tendency to functional nervous disease should be easily detected by a careful 
 examiner, but it is extremely difficult, in fact impossible in the majority of in- 
 stances, to diagnose a simple predisposition to neurasthenia. Therefore a large 
 number of cases of shock will continue to be returned from the front and the 
 object must be to treat these as efficiently as possible. 
 
 Sir John Collie, in the lecture above mentioned, says that medical treatment is 
 of no real value unless the medical men have confidence in themselves and can com- 
 mandeer the confidence of the patient. Infinite patience, common sense at every 
 turn, and real, but thoroughly disguised sympathy are essential in those who 
 undertake the care of such cases. Massage, electricity, persuasion, occupation, 
 light, graduated work, fresh air, good wholesome food, and above all a healthy 
 
11 
 
 environment are essential adjuncts. The psychotherapeutic method of treat- 
 ment has been found by experience to be wonderfully effective provided only 
 that it is in the right hands. Nothing retards recovery so much as the flying 
 visits of unthinking but kindly intentioned philanthropic lady visitors. Per- 
 suasive conversation should be systematically arranged for, in which the patient 
 and doctor can have quiet talks, so that the man is led by tact and guarded sym- 
 pathy to lay bare, what is, as it were, at the back of his mind. Nothing in the 
 nature of psychoanalysis, however, is recommended. Collie's experience is that 
 it is better that aU patients should be isolated dm-ing the early part of their treat- 
 ment. The calm restfulness of soUtude has a peculiar effect in allaying irritabil- 
 ity, and strange as it may appear, prevents morbid introspection. Isolation is 
 not solitary confinement; a nurse is in frequent attendance. The short initial 
 stage of isolation enhances the value of the suggestion of rapid recovery practised 
 by the physician and nurses. Electrical treatment for these cases is of value, 
 but the stoutest advocates of this method will not deny that the effect is inti- 
 mately associated with the mysteriousness of the electric current. There is one 
 proviso to make with regard to all treatment and that is, unless the patient de- 
 sires to get well no treatment can cure him. — Med. rec. 93: 460-61, March 16, 
 1918. 
 
 Turner, William Aldren. Hospital Treatment of Shell Shock. Re- 
 called to life, Lond., no. 2, p. 251-53, Sept. 1917 
 
 In Recalled to Life, No. 2, is an address by Lieut.-Col. Aldren Turner, C.B.M.D., 
 in which he discusses the principles of the management of the shell-shocked 
 and neurasthenic soldiers in the special military hospitals. These principles, 
 four in number, were laid down early in the war, but they were subject to modifi- 
 cation as our knowledge of these patients and of their disabilities became better 
 known and understood. The first principle was segregation. For the most part 
 the neurasthenic soldiers had been treated in institutions specially set apart for 
 the purpose under the care of medical officers specially qualified to treat them. 
 The adverse criticisms which were brought forward in opposition to segregation 
 in the early months of the war had not been justified. On the contrary, its 
 usefulness had been strengthened and extended by experience. These patients 
 did not imitate each other, or in other ways react harmfully upon each other. 
 On the other hand, it has been found that when placed in the general wards of a 
 hospital, the sufferer from shell shock not infrequently was the butt of the other 
 patients, who were unsympathetic and disposed to regard as trivial the tremors, 
 stuttering speech, unnatural gait, and other symptoms which characterized so 
 many cases of shell shock. The admixture of these patients, as had been sug- 
 gested, with cheery companions suffering from non-nervous disabilities, might 
 even be undesirable. 
 
 The second principle was to give the medical officers liberty to treat their 
 neurasthenic patients along sucli lines as they considered desirable and wliich 
 experience had shown to be of therapeutic value. There was no disorder to 
 which the axiom "treat the patient and not the disease" applied with greater 
 directness than to neurasthenia. This liberty of action was very necessary 
 when they considered the different types of neuroses and psychoses which were 
 admitted to the military hospitals under the gjiise of shell shock. Cases of 
 exhaustion recjuired rest in bed; paralytic cases required exercises and reeduca- 
 tion of the movements of the paralyze<l limbs. The simpler forms of anxiety 
 needed reassuring and explanation of the origin of their fears. The terrifying 
 dreams which disturlx-d the sleep of so many men suffering from shell shock 
 required to be analyzed and explained. The dreads and fears, delusions and 
 hallucinations, and other morbid ideas reciuired to be searched, investigated 
 and understood. After this the readjustment of the patient's mental outlook 
 towards his symptoms required to be taken in hand. It had been found that a 
 
12 
 
 too constant and too frequent use of massage, of electrical applications, of baths, 
 and of other physical methods of treatment assiduously practised at the spas, 
 tended to accentuate rather than relieve the condition for which they were used. 
 
 The third principle was occupation. Quite a number of cases of war neuras- 
 thenia and genuine shell shock in the early stages derived great benefit from a 
 "rest cure," but it had become increasingly obvious, with more experience 
 and knowledge of these cases and their causes, that rest and isolation had only a 
 limited application. The best results were obtained by a judicious combination 
 of a suitable psychotherapy and occupation, mainly of an outdoor kind. It was 
 useless to attempt to cure by work alone, a man whose mind was depressed by 
 anxiety and forebodings attributable to circumstances which he did not under- 
 stand; but if by judiciously selected work and carefully regulated outdoor occu- 
 pation, liis sleeplessness was mitigated and his circulation and general nutrition 
 improved, the value of the mental therapeutics was enhanced and supplemented. 
 
 The fourth principle was compensation. It was recognized early in the war 
 that a large number of soldiers who suffered from shell shock and nevirasthenia 
 would be unfit to return to military duty, although their ability to carry on 
 their civilian work after discharge would not be more than temporarily im- 
 paired. As it had been recognized for a long time that some forms of nervous 
 disability were prone to exaggeration, or might even be made chronic by undue 
 consideration, it was determined that nothing should be done by the payment 
 of pensions which would retard or prevent the recovery of soldiers who had been 
 disabled from nervous breakdown. It was thought, therefore, to be desirable 
 to recommend the granting of a money bonus, in place of a pension to selected 
 cases of neurasthenia and functional nervous disorder occurring amongst sol- 
 diers when treatment in hospital was no longer necessary and the patient was 
 unlikely to be fit for further military service. — Med. rec. 93: 726, April 27, 1918. 
 
 Viets, Henry. Shell-Shock; a Digest of the English Literature. J. of 
 Amer. med. assoc. 69: 1779-86, Nov. 24, 1917. 
 
 The author reviews the English medical literature of shell-shock, making 
 frequent quotations from the authorities to whom he refers. The first report 
 of cases appeared in 1915 under the term of "shell-shock." The symptoms 
 are varied, covering nearly all the functional and hysterical phenomena de- 
 scribed by authors. The importance of the problem cannot be overemphasized 
 and, if it is possible, those subject to the disease should be eliminated from among 
 the recruits before they are exposed to the perils of trench warfare. The neuro- 
 pathology of the condition has been best studied by Mott. In the fatal cases, 
 the symptoms of shell-shock resemble those of the gas poisoning, wliich most 
 neurologists hold cannot alone produce shell-shock. The treatment is largely 
 moral as well as physical and seems to have been well worked up in the British 
 hospita,Is. The writer asks in conclusion: "What can the Medical Corps of the 
 United States Army do toward the prevention of shell-shock? Obviously it 
 must be checked at the recruiting station or in the cantonment camps before the 
 men leave for France. There ought to be no question in the minds of the medical 
 officers as to the advisability of checking this condition at the source, for no one 
 who has seen the results of modern warfare on the unstable mind can do otherwise 
 than urge such measures with utmost vigor. It becomes the duty of each medical 
 examiner to weed out from the recruits such men as are liable to shell-shock. By 
 so doing an enormously important advance will be made in our army, as judged 
 by the experiences of the other armies of the Allies. We have been strongly 
 advised by Osier to check the enlistment of the neurasthenic. It is obviously 
 difficult to pick him from the crowd, as he may come up in good form, and be 
 eager to go overseas. But it is not so difficult' with the mentally deficient, the 
 'queer stick,' the 'boob,' and the butt of the practical jokers. He is soon ob- 
 served by both officers and men, and if one singles him out and talks with him for 
 
13 
 
 five or ten minutes, one ought to have no difficulty in deciding his fitness for 
 active trench warfare. One ought also to look ^-ith especial care into the past 
 history of the depressed, the man who worries unnecessarily, the self-conscious, 
 the shy, the high-strung, excitable man, the violent-tempered, the nervous, the 
 timorous, the easily frightened, or the neurotic individual. Any or all of them 
 may make poor first-line-trench soldiers. The task is difficult, but that in itself 
 should not prevent us from trjdng. What an advantage it would be to our army 
 officers, and what a saving of Ufe it would mean to our men, if the shell-shock 
 patients could be eUminated from our forces that will fight overseas! Such a 
 Utopia is probably impossible, but I feel confident that careful weeding out of the 
 mentally unfit will certainly greatly reduce the numbers of shell-shock cases that 
 are boimd to appear in our casualty lists." — J. nerv. and ment. dis. 47: 146-47, 
 Feb. 1918. 
 
 Jones, A. Bassett, and Llewellyn, Llewellyn J. Malingering, or the 
 Simulation of Disease.* Phil., Blakiston, 1917. 708 p. 
 
 The present war has brought to the front a subject which is greatly neglected 
 in peace times. To be sure, prison physicians, psychiatrists, and insurance 
 examiners are all more or less famiUar with malingerers, but now that the world 
 has been combed for soldiers, and these exposed to terrific strain, we find whole- 
 sale malingering. Artificially induced abscesses, sugar added to the urine, soap- 
 chewing, convulsive efforts, these are commonplaces in the big armies, and have 
 been described in many papers. Jones and Llewellyn, however, have undertaken 
 a monograph on the subject and produced an admirable work. After an exhaus- 
 tive study of the subject as a whole, with its psychology and medico-legal aspects, 
 the authors go into great detail in describing malingering in its relation to various 
 systems of the body; this part of the book is systematic and thorough, no vague 
 generalizations are indulged in, but the writers are specific and practical. In 
 short, they exemplify their owti doctrine that a diagnosis of malingering must not 
 be founded on incomplete examination, imperfect observation, or hasty in- 
 ference. This work might well be added to any practitioner's library; to the 
 military surgeon it is invaluable. — Med. rec. 93: 474, March 16, 1918. 
 
 Mott, Frederick W. War Psychoneurosis. Lancet, Lond., i : 127, 
 Jan. 26, 1918 
 
 While admitting that from commotion or prolonged stress of war, a stable 
 nervous organization may develop an acquired emotivity, Mott says that it 
 seems that the psychogenic or autosuggestive factor, acting on a prewar emotive 
 brain, is the chief determining cause of war psychoneurosis, and the neurotic 
 patient's protest of anxiety lest he be boarded out of the service, or not allowed 
 to go to the front, is really in many cases an indication of an exhausting conflict 
 which has been going on continually in his mind between the self-conservative 
 instinct and the moral obligation of duty and patriotism, which has its roots in 
 the social herd instinct.— J. A. M. A. 70: 1263, April 27, 1918. 
 
 Forster, Frederick C. Management of Neurasthenia, Psychasthenia, 
 Shell-Shock and Allied Conditions. Practitioner, Lond., 100: 
 85-90, Jan. 1918 
 
 In the Practitioner for January, 1918, is published a paper on the management 
 of neurasthenia, psychasthenia, shell shock, and allied conditions, by Dr. Fred- 
 erick C. Forster, in which the author points out that while neurasthenia may be 
 of different tj-pes the sufferers nearly always have in common certain symptoms, 
 the most prominent being depression, lassitude, often combined with a curious 
 restlessness, insomnia, loss of power of concentration, failure of memory, abnor- 
 
 * Published originally in London by William Hcinemann, 1917. 
 
14 
 
 mal sensations in different organs, tremblings, dragging pains, palpitation, loss 
 of appetite, and loss of vitality. This is a true word-picture of the symptoms of 
 a neurasthenic, not that they are all combined in one sufferer, but they are the 
 conspicuous symptoms that are apt to occur. Worrying over his complaints and 
 imaginary' complaints is a characteristic feature of the sufferer from neurasthenia. 
 He attaches undue importance to all his disagreeable sensations, and is espe- 
 cially anxious T\ath regard to the tachycardia, which is a frequent accompaniment 
 of the condition, imagining it to be a sure indication of a serious heart lesion. 
 
 The cure of a neurasthenic involves infinite patience and tact on the part of 
 the medical attendant. First of all, in treating a case it is incumbent on the 
 medical man to make a correct diagnosis, and definite disease of any organ must 
 be eliminated before it can be said to be a true neurasthenia. Assurance must 
 be had that the condition is not owing to toxemia, influenzal or gastrointestinal, 
 for the depression accompanying or following a toxemia of tliis description cannot 
 be labeled or treated as a neurasthenia. Forster holds that the keynote of the 
 management, a term he uses purposely in preference to treatment, is to induce 
 "self-forgetfulness," to do away with the inertia, to improve the morale by en- 
 com-aging a feehng of independence, and to adjust the patient's life so that 
 petty troubles and annoyances take their subordinate position, whether this is 
 achieved by some wholesome occupation, by drugs, or by some of the many 
 other methods which may be employed. The Weir-Mitchell rest cure is recom- 
 mended, and it is pointed out that, apart from the dieting, the chief essential is 
 to procure sleep for the patient. As for drugs, chloralamide is to be preferred 
 to either paraldehyde or the bromides, and for the general excitation mono- 
 bromated camphor with conium is useful. It is not advisable, however, to 
 prolong the Weir-Mitchell treatment after the acute stage has passed off. 
 
 It really is an interest in life that such people need. The author is not an 
 advocate of drug treatment. Regarding change of air, scene, and climate, 
 wliich really means change of environment, the suggestion is put forth that it is 
 not always possible to change the physical environment, yet much, verj' much, 
 can be acliieved by altering the mental or psychical environment, and the power 
 of creating a special mental environment is helpful in turning what is repulsive 
 into what attracts. In short, in neurasthenia it is the person, rather than the 
 disease, that demands treatment. Finally, a return to work or occupation is 
 likely to be of greater benefit by far than rest cures, that is to say, in a large 
 proportion of cases. — Med. rec. 93:464-65, March 16, 1918. 
 
 Savage, Sir George H. Mental War Cripples. Practitioner, Lond., 
 100 : 1-7, Jan. 1918 
 George H. Savage is of the opinion that a very large number of soldiers and 
 sailors will, after the war, be found more or less crippled, that is, unfit to per- 
 form their normal and accustomed duties, and that they will need special treat- 
 ment and in some cases will have to learn fresh work. For such patients, phy- 
 sical or mental cripples, he believes that colonies in the country will be found to 
 be the most beneficial. It will have to be considered whether such colonies 
 should be special or general. His own opinion is that for epileptics the colony 
 should be special, but that for other nerve disorders a union with sufferers might 
 be found useful, as drawing the patient away from his subjective state to one of 
 more active objective sympathy. — N. Y. med. j. 107:472, March 9, 1918. 
 
 Wolfsohn, Julian M. The Predisposing Factors of War Psycho- 
 neuroses.* Lancet, Lond., Feb. 2, 1918, p. 177-80 
 
 Julian M. Wolfsohn finds that throughout the massive literature which has 
 sprung up within the past three years one reads passing references mostly to the 
 
 * Practically the same article was published m Journal of the American Medical Asso- 
 ciation 70: 303-08, Feb. 2, 1918. 
 
15 
 
 relation of the symptoms of war psychoneuroses to a previous neuro-potentially 
 unsound soldier; most authors have eHcited an inherited or acquired neuropathy 
 in the majority of patients afflicted with shell shock, neurasthenia, or any of the 
 neuroses resulting from the strain of the war. But enough actual specific data 
 on the inherited and acquired neurotic factors in these cases have not been pub- 
 lished. Before drawing generalizations on this subject, one should try to answer 
 some of the following pertinent questions: (1) Of what kind of forbears is the 
 patient a representative.^ (2) What is the personal temperament of the patient.' 
 (3) What was his former calling, and how has he shouldered his responsibilities 
 during active war service.^ (4) Do acquired war psychoneuroses occur, and 
 what are the causes thereof? (5) What is the relation of the last "shock" to the 
 production of the war neurosis.^ (6) Why do not all soldiers suffer from war 
 neuroses? Before answering any of these questions one must examine all avail- 
 able data, up to the time of active service, and also the actual causes and cir- 
 cumstances exciting the outbreak of the neurosis, realizing that every individual's 
 nervous system will react according to his inherited tendencies superimposed on 
 the effects produced by environment. Therefore the object of this special work 
 is to make an intensive study of the causal factors of war neurosis as presented 
 by the family and the personal histories (up to the time of, and including the 
 cause of, disablement) of 100 cases of war psychoneuroses — viz., shell shock, 
 neurasthenia, hysteria, and exhaustion. Insane cases are not included in this 
 paper. As a control 100 cases of somatic injuries produced in the firing-line — 
 viz., enucleation of an ej'e, fracture of the skull, jaw, femur, amputations, and 
 wounds, with or without sepsis, have been similarly studied. The exhaustive 
 history in most of the cases was given by the patient himself. In some cases 
 the help of the wife or mother was necessitated to get as much first-hand avail- 
 able data as possible. From this study of 100 cases of war psychoneuroses and 
 100 cases of somatic injuries produced in the firing line Wolfsohn finds he can 
 draw the following conclusions: Cases of war neurosis are very rarely associated 
 with external or somatic wounds. The vast majority of the psychoneurotic 
 cases studied were among soldiers who had a neuropathic or psychopathic soil. 
 In 14 per cent of these cases a family history of neurotic or psychotic stigmata, 
 including insanity, epilepsy, alcoholism and nervousness, was obtained, whilst a 
 previous neuropathic constitution in the patient liimsclf was present in 72 per 
 cent. A gradual psychic shock from long-continued fear, together with the 
 sudden change from quiet peaceful environment to the extraordinary stress and 
 strain of trench fighting is the chief predisposing cause of war psychoneurosis in 
 soldiers with neuropathic predisposition. In fact, these factors may be the 
 cause of the neurosis per se. The history of the individual previous to enlistment 
 has an influence on the character and gravity of the symptoms of the neurosis. 
 Acquired neuroses with their less severe symptoms appeared only after excessive 
 fatigue, with the concussion from the high-explosive detonation acting as the 
 exciting factor. On the other hand, in the same abnormal environment, and 
 with the same powerful factors obtaining, wounded soldiers do not suffer from 
 war neuroses except in rare instances. In the wounded soldiers stu<lied no 
 neuropathic or psychopathic stigmata occurred in the family history. Previous 
 neuropathic tendencies were found in 10 per cent of these patients (controls), all 
 of which number presented mild neurasthenic symptoms. Hysteric manifesta- 
 tions, such as monoplegia in a wounded limb, are occasionally encountered in 
 injured soldiers.— Med. rec. 93: 382-83, March 2, 1918. 
 
FRENCH LITERATURE 
 
 Periodicals Abstracted 
 Annales de Medicine, Paris 
 Archives Medicales Beiges, Paris 
 Bulletin de 1' Academic de Medicine, Paris 
 Bulletin de la Societe des Hopitaux, Paris 
 Paris Medical 
 Progres Medical, Paris 
 Revue Neurologique, Paris 
 
FRENCH LITERATURE 
 
 Pitres, A., and Marchand, L. Observations on Concussion Syndromes 
 Simulating Organic Affections of tlie Central Nervous System 
 (Quelques observations de syndromes commotionnelles simu- 
 lantes des affections organiques du systeme nerveux central) 
 Rev. neurol., Paris, 23: 298-311, Nov.-Dec. 1916 
 
 In the first patient a meningitic syndrome developed soon after shell concus- 
 sion; severe headache, retraction of the head, Kernig's sign and unilateral ptosis. 
 The spinal fluid had a yellow color. He afterward developed a mental condition 
 resembling catatonic dementia prsecox. Fourteen months after the injury he 
 was reexamined and all symptoms were absent except slight weakness of the 
 legs. In the second case there was a period of unconsciousness following the 
 concussion, mental confusion, memory disturbance. The knee and Achilles 
 jerks were lost. Speech was tremulous and hesitant. Except for the per- 
 sistence of some ideas of persecution, the patient recovered in sixteen months. 
 The third patient presented a cerebellar syndrome with the addition of some 
 mental disturbance. The case simulating multiple sclerosis had lost knee and 
 Achilles jerks. The case simulating tabes had no lightning pains, but in other 
 respects was typical (the Wassermann reaction was positive). The author 
 draws two conclusions: The diagnosis in these cases is difficult. These cases 
 have as a basis an organic lesion. They are not hysterical or simulation. 
 
 Alterations in speech are divided into three classes: mutism, a stammering 
 speech, and a high-pitched voice in which the patient speaks rapidly and ir- 
 regularly. 
 
 Mental childishness, in a patient twenty-one years old, developed as a condi- 
 tion following shell shock. He talked and acted like a child, occupied his time 
 sailing boats, etc., and frequently cried in a diildish way. There were no dis- 
 orientation, no hallucinations and the neurologic examination was negative. 
 
 The fundamental question in the determination of the pension allowance in 
 nervous or mental cases is whether or not the condition present is due to service 
 in the war. The fatigue and emotions of war may act as a determining cause 
 and the value attaching to the predisposing cause, whether hereditary or ac- 
 quired, is the same as in civil life. — J. nerv. and ment. dis. 47: 63-64, Jan. 1918. 
 
 Ferrand, Jean. Hystero-traumatism witli So-called "Physiopathic" 
 Syndrome Cured by Re-education (Hystero-traumatisme avec 
 syndrome dit "physiopathique" gueri par la reeducation) Progres 
 med., Paris, 33: 81-83, Marcli 10, 1917 
 
 Attempts have been made to classify the numerous forms of paralysis resulting 
 from wounds in battle. Some are due to direct lesions of peripheral nerves and 
 their roots; others are hystcrotraumatic in nature. Between these two extreme 
 varieties there is a particular clinical type which must be isolated from others — 
 paralysis of reflex origin. 
 
 Certain neurologists describe a form of paralysis characterised by special 
 trophic, vaso-motor, electric, and reflex troubles in the paralysed limb, such 
 phemomena being sufficient in their eyes to prove the organic origin of the paraly- 
 sis, which explains their therapeutic failures. They infer from this the useless- 
 ness of even heroic psycho-therapeutic measures. This inference would seem 
 to be somewhat premature, as observations on a case in point go to prove the 
 contrary. It was that of an infantry soldier who, in May, 1915, was woimdcd in 
 
 19 
 
20 
 
 the right calf. Heahng followed a normal course, and was completed in a few 
 ' weeks. During convalescence he began to walk badly owing to alleged pain in 
 the limb, which assumed the position of equinus with contracted Achilles tendon. 
 A surgeon, believing that the lesion was really organic, severed the tendon, restor- 
 ing mobility to the foot, which could now be easily placed flat on the ground. 
 He could, however, walk no better after the operation, and, although the equine 
 phenomenon could no longer be produced, owing to section of the tendon, the 
 leg assumed another vicious position, being semi-flexed on the thigh with im- 
 mobilisation of the knee-joint. He could only barely put his foot to the ground, 
 and was extremely lame, walking with the help of a crutch. Again a surgeon, 
 never suspecting a neuropathic affection in the case of a wounded man, did a 
 tenotomy of the flexor tendons of the leg, putting it up in a plaster apparatus to 
 maintain extension of the limb. The result was satisfactory only to a slight 
 -extent, but he walked without a crutch when he was sent to a neurologic centre 
 in December, 1916. 
 
 He walked with two sticks, the right leg in a position of forced extension on the 
 thigh, and flexion was impossible. The first care was to seek for evidence of a 
 lesion of the terminal branches of the sciatic, and especially of the internal popliteal 
 branch. There was no true motor paralysis, but relative weakness of all active 
 movements. All passive ones were possible except flexion of the knee. There 
 was no sensory trouble; and all the reflexes were normal, a little stronger perhaps 
 on the affected side. Trophic troubles were very marked. All the distal part 
 of the leg was oedematous, cyanosed, almost a violet tint, very cold as com- 
 pared with the sound limb. The skin was thin, attenuated, and the toes crossed 
 each other to some extent. In the whole foot and lower third of the leg there was 
 well-marked muscular hyperexcitabUity. The slightest tap on the muscles 
 brought on violent contractions, and even dissociation of movements which are 
 not usually independent in action, such as adduction of the great toe, or abduction 
 of the little one. In a word, the case presented all the troubles attributed to 
 reflex contractures or to the phenomena called "physiopathic". 
 
 The mental state was pecuUar. A working miner, he weeps at the least exam- 
 ination, manifests absolute terror, at the slightest touch of his affected leg, and 
 trembUngly implores one to cure him. 
 
 To sum up : here was a wounded patient with a paralysed limb and contraction 
 of the knee, who presented all the signs of the paralyses called "reflex", who has 
 been subjected to a series of tentative therapeutic measures which have failed; 
 a characteristic type. 
 
 As to treatment the patient was brought into our re-education ward, and, after 
 having for a considerable time been subjected to fatigue by more or less violent 
 physical exercises, the contracture was, as it were, brutally overcome. After half 
 an hour of passive movements of flexion and extension of the leg, and after show- 
 ing him how he could bend and straighten his limb, he was induced to do this vol- 
 untarily. These active movements were aided and sometimes provoked by gal- 
 vanic stimulation of painful intensity. In the end he was able to walk slowly, 
 while he bent both knees fully, and, after a treatment lasting about two and a 
 half hours, he was cured. 
 
 The case was a particiJarly bad one, for surgical immobilisation had caused 
 intra-articular adhesions in the knee which it was necessary to rupture. A slight 
 amount of hydrarthrosis followed next morning, but a few days later he walked 
 like any normal person. 
 
 This, though a remarkable case, is not a solitary instance of the kind, and Dr. 
 Ferrand has published the general result of his researches on the subject. The 
 clinical type which has been sought to be created does not seem sufficiently 
 differentiated. We need only cite in proof the successive denominations which 
 have been given it. The term "reflex contracture" assumes a condition which 
 very often does not exist, for there is flaccidity in many of these paralyses. 
 
21 
 
 Moreover, the term "reflex" implies a pathogenic idea, which is already aban- 
 doned by the creators of the clinical type. It has been designated a "physio- 
 pathic disorder", a term which is not very precise, and has hardly more signi- 
 ficance than the old term "functional". In the minds of the authors this term 
 "physiopathic" would imply the idea of an organic lesion, or at least one not 
 functional in character. And the syndrome thus created is, in their descriptions, 
 opposed not to an organic, but to an hysterical syndrome. In this view Dr. 
 Ferrand cannot share. 
 
 He concludes his article with the following summary : 
 
 (1) Physiopathic symptoms exist, but they do not constitute an independent 
 clinical syndrome. Many patients presenting these special symptoms, separate 
 or combined, are cases of organic affections with lesions of peripheral nerves; 
 moreover, direct and not reflex. 
 
 (2) There is but Uttle relation between the reflex lesions described by Charcot 
 as occurring in chronic arthritic cases and post-traumatic lesions. These latter 
 are, moreover, described by him also amongst the hystero-traumatisms. 
 
 (3) The symptoms are not completely new. 
 
 (4) They are to be found to-day in many wormded who do not present any 
 organic lesion, but merely ordinary hystero-traumatisms. 
 
 (5) They do not constitute any contra-indication to psychotherapeutic treat- 
 ment, even of an heroic kind, and these patients are cured as well as the others. 
 In any case, from the fact of a failure of cure it is not to be inferred that they are 
 not the subjects of hystero-traumatism; for some succeed where others have 
 failed, of which the patient whose case has been recorded is an example. 
 
 (6) From a medical and military point of view, such patients (when they have 
 not been attacked with organic affections) should be considered and treated 
 as cases of hystero-traumatism. It would be dangerous to make them out to 
 be organically diseased or to treat them as such, for the contagion of example 
 would make ravages in neurological centres. 
 
 (7) To cure these patients we must employ all the most energetic means which 
 the authorities have placed at our disposal, from moral suasion to the most 
 painful electiic currents. In this way multiple successes are achieved, and the 
 army recuperated with vigorous subjects. 
 
 Such are the conclusions to which Dr. Ferrand and his colleagues have been 
 led by a practice of eighteen months in one of the most important neurological 
 centres in France. — T. Drapes, J. ment. sci., Lond., 63: 602-0-i, Oct. 1917. 
 
 Landau, Principle of Psychicallsolation in the Treatment 
 
 of Functional Nervous Disturbances (Le principe d'isolement 
 psychique dans le traitement des troubles nerveux fonctionnels) 
 Bull. Acad, med., Paris, 77: 701-04, May 29, 1917 
 
 Landau describes a new mode of treatment which he has found of great 
 value in most cases of functional nervous troubles in warfare; he has thus treated 
 about fifty cases. The patient is brought into the presence of other patients 
 who present similar symptoms, l)ut of an organic nature. A detailed clinical 
 examination of the patient is then made in the midst of his fellow-patients. If, 
 for example, his case be one of a functional causalgia, the physician reviews 
 briefly the history of the case, its mode of production, and the destructive signs 
 of these conditions. In the case of a functional palsy of a nerve, the physician 
 discusses openly before all the patients the electrical changes, and then makes 
 an electrical examination of the functional case and of an organic one. As a 
 rule, after a few of these public demonstrations and lectures, and sometimes 
 from the first one, there is benefit to the patient. By means of this kind of pro- 
 cedure Landau claims that a state of "psychical isolation" is set up. He 
 describes it also as a sort of bringing the functional patient face to face with 
 
himself. The application of the treatment must to some extent vary with the 
 particular case. Three cases are described to illustrate these points. — L. J. Kidd, 
 Rev. of neurology and psychiatry 15: 334-35, Aug.-Sept. 1917. 
 
 Hoven, Mental Diseases and the War. Archiv. med. 
 
 Beiges, Paris, May 1917 
 
 Hoven states that he does not intend to go deeply into this subject, and 
 contents himself with a brief analysis of the material which has come under his 
 observation as military alienist during the past 14 months. Out of 300 cases, 
 28 were examples of post-traumatic psychoses such as foUow^ trauma, cerebral 
 commotion or moral shock. In 11 of the 28 there had been an actual injury to 
 the cranium, while in 12 others shells had exploded close to the victims. Of 
 the 28 patients, 16 presented evidences of mental confusion, and 8 of melan- 
 cholia. There were 2 cases of dementia praecox, one of which the author de- 
 scribes, adding that in post-traumatic psychoses the possibility of dementia 
 praecox should always be borne in mind. 
 
 With the exception of 24 patients whose insanity dated from before the war, the 
 remainder of the material (256 cases) includes the ordinary psychoses of the 
 alienist, viz., dementia praecox, 61 cases, and melancholia, 52 cases, followed 
 by acute confusional insanity, with 16 cases, and progressive general paralysis, 
 with 14 cases. Other psychoses occurred only in scattering figures (manic- 
 depressive, mental disequilibration, alcoholic, etc.) However, under ordinary 
 psychoses are comprised idiocy and imbecility, with 62 cases; i.e., the mental 
 ailments were found to be associated with subnormal mental development. 
 This contingent was, of course, the result of hasty selection during mobilization. 
 The subjects presented either mental confusion, melancholia, or nervous crises. 
 Latent mental weakness was in part brought out by alcoholic abuse. Those 
 actually insane before the war were mostly volunteers suflFering from paranoia, 
 paraphrenia, epilepsy, and alcoholism. 
 
 The author states there is no specific war psychosis. The alleged "battle 
 hypnosis" is no more than acute mental confusion with dream hallucination, 
 occurring especially in post-traumatic psychoses. These patients are very 
 wakeful, with an exaltation of psychic automatism and a sensorial erethism. 
 Acute mental confusion is characterized in general by lacunar amnesia, which 
 disappears slowly, and persists after other symptoms have vanished. 
 
 Simulation of insanity is rare, but dementia praecox often passes at its onset 
 for simulation because the victims indulge in silly, absurd, affected behavior. 
 In true simulation the patient is always abnormal, a psychopath. In contrast 
 with actual simulation, exaggeration is common. Psychopathic deserters are not 
 uncommon, and much care is necessary for the proper fixation of responsibility. 
 
 By what mechanism does warfare cause insanity? No one knows now, but 
 after the war is over it may be possible to answer this question. No doubt in- 
 sanity is produced by a commingling of psychic and somatic insults. Home- 
 sickness, loss of sleep, fatigue, at once suggest themselves, and we may add appre- 
 hension of danger, shell concussion, etc. Hereditary taint and history of neu- 
 ropsychic manifestations are very common; in fact, predisposition in some form 
 is almost universal. In some material, alcoholism, whether as effect or cause of 
 predisposition, is present in a third of all cases. 
 
 The practical aspect is diagnostic and not therapeutic. But few of these men 
 are fit for duty, for they can seldom react properly to discipline. They must be 
 mustered out, and, if necessary, interned. The best modern treatment is life 
 in farm colonies, which results in more or less improvement. The inoffensives 
 are able to do useful work for the army in various capacities — basket-weaving, 
 shoemaking, woodworking, baking, etc. — Med. rec. 92:637, Oct. 13, 1917. 
 
- 23 
 
 Guillain, Georges, and Barre, J. -A. Alterations of Pupillary Reac- 
 tions in Shock due to Bursting of Large Shells, without External 
 Wound (Les troubles des reactions pupillaires dans la commotion 
 par eclatement de gros projectiles sans plaie exterieure) Bull. 
 Acad, med., Paris, 78: 158-59, Aug. 28, 1917 
 
 A study of twenty-six cases of recent shell shock; the possibility of even a 
 minimal wound of the eyeball was excluded. The pupillary changes comprised 
 mydriasis; inequality of pupils with or without unilateral or bilateral loss of 
 light-reaction, ArgyU-Robertson pupils, or the paradoxical light-reaction. The 
 pupillary changes were commonly transitory, lasting from three to twenty days 
 or longer, and ultimately disappeared. In six of the cases there was xantho- 
 chromia of the cerebrospinal fluid with a slight meningeal reaction. The ques- 
 tion is raised whether a xanthochromic or blood-stained cerebrospinal fluid, 
 rendered toxic by haemolysis, may not act on the root-fibres of the cranial nerves 
 either on the centripetal or the centrifugal limb of the reflex pupillary arc, or 
 whether small basilar clots may compress the root-fibres. The central origin of 
 these pupillary changes by small intra-peduncular haemorrhages is held to be 
 unlikely. The writers incline to the belief that most of these cases are of peri- 
 pheral origin, either a true commotion of the retina or of the nerves of the intrin- 
 sic eye-muscles, resulting in a temporary asthenia of one or both of these muscles. 
 — L. J. Kidd, Rev. of neurology and psychiatry 15: 332, Aug.-Sept. 1917. 
 
 Roussy, Gustave, Boisseau, J., and d'Oelsnitz, M. Psycho-neurotic 
 Contracture of Foot or Hand (Les acro-contractures et les acro- 
 paralysies) Annales de med., Paris, 5: 515-44, Sept.-Oct. 1917 
 
 This profusely illustrated article reviews the experiences with 141 cases of 
 contracture or paralysis after minor woimds of the region. — J. A. M. A. 70: 890, 
 March 23, 1918. 
 
 Crinon, Advanced Psychiatric Centers. Progres med., 
 
 Paris, 33:364-65, Oct. 27, 1917 
 
 Psychic changes should be recorded as scrupulously as the organic, writes 
 Crinon. It is now officially ordered that the concussion syndrome has to be 
 specified on the card. The "psychically disabled" should have their record 
 as complete from the first as is the rule for the physically maimed. This would 
 permit also suitable measures from the very first, when they are much more 
 likely to prove effectual. The influence on the brain of physiologic disturbances 
 from shell-shock or toxic infections should be arrested as early as possible. To 
 neglect this allows the psychic changes to deepen and crj'^stallize into delirium 
 or confusional states. All this requires advanced psychiatric stations. Their 
 existence is still further justified by the important task of sifting out the men to 
 be sent to the nerve centers and the psychiatry centers farther back from the 
 front. Many men only lightly affected could do well in them and be promptly 
 restored to full duty. Sent back into the interior, their psychic disturbances 
 become more and more confirmed and durable. At the best, the men are returned 
 after months of convalescence when, if they had been given specialist treatment 
 close to the front, they would have been in the ranks again in much less than a 
 month. Toxic delirium of alcoholic origin is often mistaken for a more per- 
 manent trouble. It requires only a special course of internment and treatment 
 . which is as available in a well-equipped advanced psychiatric station as elsewhere. 
 Men subject to convulsions can also be kept under observation here, and the 
 nature and number of their attacks determined. Crinon thinks it is as absurd 
 to exempt men from service on account of a single epileptic seizure — which is 
 now the regulation — as to exempt those who have not good teeth. — J. nerv. and 
 ment. dis. 47:147, Feb. 1918. 
 
24 
 
 Damaye, Henri. Psychiatry in the Army. Progres med., Paris, 33 : 
 362-64, Oct. 27, 1917 
 
 Damaye analyzes 638 cases of mental or nervous aflfections that passed 
 through his service last year. The mental disturbances were usually transient 
 when the men were kept back from the front. The proportion of the per- 
 sisting and incurable cases is surprisingly small in comparison to the more 
 or less prompt recovery of the others. The mixed cases are especially numer- 
 ous, namely, those in an intermediate stage between mental debility and de- 
 mentia prsecox, with and without delirium, or between hebephrenia and actual 
 loss of mental balance. Hysteroepilepsy and hysteroneurasthenia were par- 
 ticularly frequent. The various types of mental anomalies are listed; the largest 
 group was 71 cases of melancholia with notions of persecution; 39 cases of 
 melancholia with a neurastheniform state; 51 of acute brief attacks of delir- 
 ious excitement with hallucinations, and 37 of simple mental debility. In 
 24 cases there was desire to commit suicide; in 19 malaria was commencing, 
 and in 399 there was sUght albuminuria, with more or less perfect compensation 
 of some heart defect. The albuminuria disappeared in most of them after a 
 week of rest, but in others it persisted unmodified. The etiology of these nervous 
 and mental disturbances is complex, predisposition, emotions, intoxications and 
 fatigue all cooperating. The attacks of convulsions nearly always coincided 
 with exhausting fatigue. Syphilis is a predisposing factor in the mental dis- 
 turbances, and a combination of malaria and alcoholism, but all the mental and 
 neuropathic troubles and even the syndrome of general paralysis can be started 
 by some concussion mishap. This "presses the button" as it were. Treatment 
 in all cases was to give at once a bath at 37° C. for one half hour if the man is 
 tranquil, and for an hour at 40° C. if he is excited. A calomel purge was then 
 given and the man was put to bed. The baths are repeated daUy and no food 
 but milk is allowed for two or three days. If the lu-ine findings are negative, he 
 is then given the restricted and then the full milk-vegetable diet. By this means 
 the effects of the digestive disturbances, etc., are overcome. No wine is ever 
 allowed; milk or "glyzin" are the only beverages given. The patients are aU 
 given, besides, a solution of 40 drops of tincture of iodin in 100 gm. gum mixture, 
 fractioned, during the day. This is kept up for five to ten days. It serves to 
 sterilize the digestive tract, promote leukocytosis, and acts as a general tonic. 
 Cold baths are not advisable, but, if conditions call for it, a daily injection of 5 
 eg. of sodium cacodylate is given. When there is much mental distress, morphin 
 is the resource and the much excited patients are given, beside the baths, 4 gm. 
 of chloral in 120 gm. of gum mixture at night and possibly a very cautious in- 
 jection of hyoscin hydrobromate. The most practical arrangement for the 
 psychiatric service is to have an advanced station, moving with the front lines, 
 and, farther back where aU is quiet, a psychiatric center and a neurologic center 
 to which the men can be evacuated from the advanced station. The evacuation 
 should always be in charge of specialist attendants. — J. nerv. and ment. dis. 47: 
 150-51, Feb. 1918. 
 
 Cheyrou, Asthenia from Overexertion at the Front. Pro- 
 
 gres med., Paris, 32: 378, Nov. 10, 1917 
 
 The regimental physician often encounters pathologic conditions for which 
 fatigue is the main factor. Cheyrou has found that this was the clue to many 
 clinical pictures, and that improvement promptly followed treatment addressed 
 to the fatigue. Lumbago is the simplest and earliest form, and the horizontal 
 position for twenty -four hours banishes it as a rule. Fatigue fever is not un- 
 common, after special and prolonged exertion, with constipation, pains back of 
 the eyes and in the back and along the tibias, with acceleration of the pulse and 
 
25 
 
 rise of temperature. All of this may disappear under a few days of bed rest, 
 repeated laxatives and restriction to water, with administration of quinin. In 
 the severer cases the digestive apparatus, kidneys or heart may bear the brunt of 
 the attack. Some of the men returning from the trenches at Verdun had reached 
 such a stage of autointoxication from the prolonged constipation that enteritis 
 followed and several weeks elapsed before normal conditions were restored. The 
 nervous system shows the effect of excessive fatigue in various ways that he 
 describes. These asthenic states, scarcely knouTi before the war, are prevalent, 
 and reduce the resisting power to infections. Prophylaxis should include 
 measures to keep the diet varied and oppose constipation. Suitable provisions 
 for sleeping would aid much in proper recuperation. Overexertion might be 
 avoided by better distribution of energy and labor. The watches should be 
 relieved of tener, and supplementary rations and hot drinks supplied in the hardest 
 sectors. As fatigue reduces the alkalinity of the blood, alkalies should be sup- 
 plied artificially, and diuretics and laxatives given to keep the emunctories open. 
 Cheyrou suggests in treatment progressively large injections of strychnin to 
 reenforce the nervous system, giving drops of epinephrin to restore muscular tone. 
 He advises fiu-ther utilization of physiologic serum with epineplirin. Administra- 
 tion of extracts of the suprarenal capsules has aided materially in overcoming 
 asthenia and hastening elimination of toxins. Extract of testicles might be 
 given with it, concluding with a course of tonics and means to recalcify the or- 
 ganism.— J. A. M. A. 70: 350, Feb. 2, 1918. 
 
 Guillain, Georges, and Barre, J.-A. Transient Sphincter Disturbance 
 from Shell Shcck. Bull. Soc. med. des Hop., Paris, 41:1110, 
 Nov. 16, 1917 
 
 Guillain and Barre report twelve cases of complete retention of urine or in- 
 continence of urine after shell concussion without direct contact. Such sphincter 
 disturbances are rare as they have encountered only these twelve cases among 
 several hundred men with shell shock.— J. A.M. A. 70: 815, March 16, 1918. 
 
 Crouzon, O., and Mauger, N. Frequency of Infectious Antecedents in 
 War Tachycardias. Bull. Soc. med. des Hop., Paris, 41 : 1237, 
 Dec. 7, 1917 
 
 Crouzon and Mauger state that in ninety-six cases of tachycardia in soldiers 
 on active service they found over 50 per cent with a history of typhoid, acute 
 articular rheumatism or other infectious disease, nearly all before the war. In 
 four other cases the tachycardia developed after gassing; in four after concussion, 
 and in two after a wound of the chest. Dumas, in the discussion that followed, 
 remarked that he had sometimes found tachycardia an early symptom of pul- 
 monary tuberculosis. He added that some of the candidates for the aviation 
 course came from the front with tachycardia, but it subsided under rest and 
 restriction of tobacco and alcohol. The men were anxious to get to flying and 
 they usually threw off the tachycardia. The power of psychic influence is well 
 shown, Josue added, by the tachycardia that develops in men being examined 
 for the aviation course; it develops solely, he declares, from the candidates' fear 
 of being rejected.— J. A. M. A. 70: 1040^ April G, 1918. 
 
 Boisseau, J., and D'Oelsnitz, M. Hysteria as an Element in Con- 
 tracture of the Hands (Mains figees) Paris med. 7: 501, Dec. 
 22, 1917 
 
 Boisseau and D'Oelsnitz refer to cases of contracture or paralysis in soldiers 
 with or witliout organic lesions. They have had 108 cases of the kind in which 
 the contracture had lasted from one to eighteen months in G3 and from eighteen 
 
26 
 
 to thirty-six months in 45. The contracture was of the "accoucheur's hand" or 
 the "priest blessing" type in many, and was usually of a type that can be repro- 
 duced at will. These and other features of the cases convinced them that the 
 motor element in the affection was of hysteric or — as they prefer to call it — of 
 pithiatic origin and hence susceptible of being cured by psychotherapy. They 
 prepared the men for the treatment by keeping them in a circle of already cured 
 cases, thus impressing on them the possibility of a cure. Then the application 
 of systematic psychotherapy resulted in a sudden and complete cure of the motor 
 element in 71 cases; in 17 cases the cure was rapid and complete, while it took 
 some time for the complete cure in 14 cases. The psychotherapy failed com- 
 pletely in only 6 cases, and in all these there was no concomitant organic lesion. 
 Of course the long disuse of the muscles took longer before normal conditions 
 were restored but the abrupt overcoming of the long contracture confirmed the 
 pithiatic nature of the contracture or paralysis. — J. A. M. A. 70 : 576-77, Feb. 23, 
 1918. 
 
 Babinski, J., and Froment, J. Hysteria, Pithiatism and Functional 
 Nervous Disturbances of War (Hysteric, pithiatisme et troubles 
 nerveux d'ordre reflexe en neurologie de guerre) Paris, Masson, 
 1918. 295 p. 
 
 In a previous issue of the first edition of this work by Babinski, we have had 
 cause to say that Babinski's contributions offer little or nothing to the interest of 
 the hysterical problem by his erection of a new entity, which he terms pithiatism, 
 namely, a disease which is caused by suggestion and can be cured by persuasion. 
 The modern student of medical phenomena finds nothing dynamic in such a 
 discussion and no student of energetics who has completed the study of the 
 activities of the human body can obtain from this book any fundamental phil- 
 osophical concepts of any value. On the other hand the clinician will find any 
 number of extremely interesting descriptive points well illustrated and admirably 
 outlined. To the student of the deeper psychology, independent of the par- 
 ticular phase in which it may be presented, Babinski's conception is superficial 
 and static— N. Y. med. j. 107: 384, Feb. 23, 1918. 
 
GERMAN LITERATURE 
 
 Periodicals Abstil-^-cted 
 Deutsche medizinisehe Wochenschrift, Berlin 
 Jahreskurse fiir artzliche Fortbildung, Munich 
 Medizinisehe Klinik, Berlin 
 
 Monatsschrift fUr Psychiatric und Neurologic, Berlin 
 Miinchener Medizinisehe Wochensclu-ift 
 Neurologische Centralblatt, Leipzig 
 
 Psychologische und Neurologische Wochenschrift, Hamburg 
 Sammlung Zwangloser Abhandlunger zur Neuro- und Psycho- 
 pathologic des Kindesalters, Jena 
 Schmidts Jahrbuch, Bonn 
 
GERMAN LITERATURE 
 
 Buschau, George. War Psychosis (tJber Kriegs-Psychosen) Med. 
 Klin., Berlin, lo: 1588-91, Oct. 18, 1914 
 
 It is a well-known fact that accidents cause psychic disturbances more violent 
 both in intensity and duration than the results of physical injuries. The clinical 
 picture resulting from the fright and the shock connected with these accidents 
 is known as "fright neurosis" or traumatic neurosis. An ordinary shock is often 
 strong enough to affect seriously the nervous system. The patient becomes 
 pale, his eyes protrude, his mouth opens, speech is lost, his hair stands on end, 
 perspiration is profuse, the heart begins to palpitate, hands and legs tremble and 
 he loses control over bladder and rectum. In severe cases, the patient becomes 
 confused and excited, talks incoherently, etc. These conditions generally clear 
 up in a short time, but sometimes they develop into chronic psychic disturbances. 
 If nerve shock is complicated by permanent sequelae, we must assume a predis- 
 position of the nervous system, either congenital or acquired. In other words, 
 the individuals so affected are either psychopaths or are predisposed to a nerv- 
 ous or mental disease through the influence of alcohol, tobacco, poisonous gases, 
 syphilis or other infectious diseases, and so are not able to resist the psychic 
 strain. 
 
 War, with its terrors and emotional shocks, is a more potent factor than any 
 other in the causation of mental disease. Here the writer reports in brief ob- 
 servations made during previous wars. 
 
 The causal factors of mental disease may be either physical or psychic, as, for 
 instance, injuries about the head, excessive heat, intemperate use of alcohol, 
 contagious diseases accompanied by fever, physical exertions of every kind, 
 forced marches, lack of sleep and insufficient food, worry about family affairs, 
 great emotional tension before battle, horrifying impressions during battle, panic 
 during retreat, etc. 
 
 The observations made by Nasse in 1866 and those of Jolly are compared. A 
 synopsis of the official report of the Sanitary Commission at the end of the 
 Franco-Prussian War in 1871, which contains a detailed symptomatological study 
 of the forms of mental diseases found at that time, is then given. 
 
 The writer differentiates between cases of mental disease which originate with 
 head injuries and are caused by cerebral concussion or by organic lesion of the 
 brain, and those which are of a purely functional nature. 
 
 Dr. Otto Holbeck, the Russian psychiatrist, is quoted by the writer. Holbeck 
 believes that loss of consciousness immediately after bullet shot through the 
 head does not occur frequently, and then only in comparatively severe injuries. 
 After regaining consciousness, the patient shows several forms of psychic dis- 
 turbance such as dullness, apathy, depression, impaired memory, especially re- 
 trograde amnesia, childish manner, abnormal sensibility, increased irritability, 
 fits, rage, violence, delirium, etc., and sometimes great hilarity, mental confusion, 
 hypochondriac and melancholic states and intense emotionalism. These con- 
 ditions are caused by concussion of the brain, which is diffused mechanical 
 injury, and not by the organic change of a particular part of the biain. 
 
 The writer makes the following statements with regard to the prevalence of 
 psychic disturbances that are of a purely functional nature: 
 
 Dementia precox leads with 35%; psychopathic constitution follows with 
 ^5.5%; then come epileptic insanity, alcoholism, melancholia and depressive 
 conditions, delirium, neurasthenia, hysteria and progressive paralysis. All of 
 these disturbances are found in times of peace as well as under war conditions. 
 
 29 
 
30 
 
 The most frequent disturbance among soldiers is a peculiar clinical picture which 
 the writer wishes considered as war psychosis far excellence. It resembles cere- 
 bral neurasthenia to a great extent, but includes also hysterical symptoms and 
 conditions of mental dullness. This symptom complex is identical with "de- 
 fatigatio" known, since 1870, as exhaustion psychosis plus terror psychosis. 
 The symptoms chronologically arranged are great depression, marked nerv- 
 ous exhaustion and increased debility of the nervous system, with a favorable 
 prognosis. 
 
 The writer briefly reviews the observations of Awtokratow, then those of 
 Krauser made during the East Asiatic expedition. The clinical pictures were 
 various but coincided to a great extent with those described by Stierlin as psy- 
 chical consequences of catastrophes such as the earthquake of Valparaiso, the 
 railroad accident of Muellheim, etc. 
 
 The author believes that exhaustion and horror are to be considered the main 
 etiological factors of war psychoses. The fact that not all individuals exposed to 
 these conditions are affected shows, moreover, that predisposition must also be 
 considered as an important etiological factor. An inferior psychopathic consti- 
 tution shows itself in a lowered resistence to violent external impressions. 
 
 The extensive statistics of Awtokratow concerning the frequency of psychoses 
 during the Russo-Japanese War are of little value because the abuse of alcohol 
 in the Russian army gives a false impression. According to these statistics, 
 alcohol psychoses amounted to 34.68% among the officers and 10.86% among 
 the enlisted men. Epilepsy among oflBcers was 4.88%, among enlisted men, 
 27.9%. 
 
 Weyert, Psychiatric Observations and Experiences in the 
 
 Army (Militar-Psychiatrische Beobachtungen und Erfahrungen) 
 Samml. zwangl. Abhandl. ii: 2-150, 1914-15 
 
 The mihtary authorities are attempting to lessen the number of war neuroses 
 and psychoses, especially borderline cases, by preventing the enlistment of the 
 mentally diseased and by recognizing as early as possible all those in the army 
 unfit for military service. To further this endeavor, it should be compulsory for 
 the insane asylums, sanitoria, institutions for the feebleminded, and the like, to 
 report all such cases to the military authorities. In spite of these precaiitions 
 many inferior men are admitted to the army. It should therefore be the duty of 
 oflBcers to report immediately all cases that attract attention because of peculiar 
 behavior, stupidity or dullness. Pamphlets and lectures on popular psychiatry 
 would always help the officers to realize that men with such symptoms are not 
 always malingerers and that such cases require immediate medical treatment. 
 To further this purpose, special military psychiatric bases have been established. 
 
 At Posen, 106 cases were studied and the following diagnoses made: 
 
31 
 
 
 Total 
 number 
 
 Enlisted 
 men 
 
 Non-com- 
 missioned 
 officers 
 
 Commis- 
 sioned of- 
 ficers 
 
 Alcoholic psychoses 
 
 Dementia praecox 
 
 Progressive paralysis 
 
 Organic brain diseases 
 
 Manic-depressive psychoses . . . 
 Chronic paranoia 
 
 9 
 
 23 
 
 1 
 
 4 
 
 2 
 
 1 
 
 11 
 
 5 
 
 4 
 
 20 
 
 25 
 
 1 
 
 106 
 
 4 
 
 20 
 
 
 
 1 
 
 
 
 1 
 
 11 
 
 
 
 3 
 
 20 
 
 22 
 
 1 
 
 83 
 
 4 
 3 
 1 
 2 
 1 
 
 
 4 
 
 
 1 
 
 
 16 
 
 1 
 
 
 1 
 1 
 
 
 Epilepsv 
 
 
 
 Neurotic constitution 
 
 Neurasthenia 
 
 Mental defect 
 
 1 
 1 
 
 
 
 Psychopathic constitution .... 
 Hallucinatory psychoses 
 
 Total 
 
 2 
 
 
 7 
 
 These stations were intended to be used for purely mental cases, therefore 
 neurasthenia and hysteria are represented by low figures. It is evident that the 
 presence of mental disease has an unfavorable influence upon purely nervous 
 cases, therefore separate services are advisable. 
 
 Statistics show that a large percentage of mental cases occur among volun- 
 teers. Many of them deny their defects in order to enlist, especially when they 
 have been unsuccessful elsewhere. They frequently show a tendency to moral 
 laxness. Stier states that in France eighty per cent of the deserters were from 
 the volunteers. 
 
 The prognosis for types of dementia precox in the war is much more favor- 
 able than in times of peace. There were no very severe cases. Investigation 
 showed that in about fifty per cent of the cases hereditary factors could be dem- 
 onstrated. It was proved also that in about fifty per cent symptoms such as a 
 great desire to work followed by periods of laziness, boastfulness, irritability, 
 sensitiveness, anxiety, vanity, egotism, emotionalism, shyness, a tendency to 
 seclusion, neglect of personal appearance, megalomania, attacks of vertigo, 
 hallucinations, headaches, etc., had existed before enlistment. In such cases, 
 the existence of dementia precox before enlistment was assumed and claims for 
 indemnity were not granted. Simon believes that predisposition should be con- 
 sidered only as a secondary etiological factor and that the difficulties and hard- 
 ships of military service should be considered the chief cause. Most of the other 
 writers on this subject, including the writer of this article, are of the opposite 
 opinion. Very often, after a several months' stay in the army, patients will be 
 discharged who had shown symptoms of schizophrenia previous to their entering 
 the service, but who were apparently normal during those few months. In such 
 cases, the examining physician is not to be held responsible for overlooking the 
 symptoms. The possibility of occurrence is, therefore, an important point 
 in deciding forensic questions. Of the cases sent by the military courts to the 
 stations for examination as to their degree of responsibility in committing of- 
 fences, twelve were diagnosed as hebephrenics, eight as catatonics and one as a 
 paranoiac. 
 
 It is difficult to differentiate clearly between mental dullness as a physiological 
 phenomenon and congenital mental weakness as a psychopathological phenomc- 
 
32 
 
 non. This is especially true in individuals who have received no intellectual or 
 moral training, for then it is difficult to know whether the defect is due to the 
 lack of training or to a pathological condition. A diagnosis of congenital mental 
 debility can be pronounced only when it is clear that attempts at establishing 
 proper standards of conduct tln"ough education have proved futile. Such dem- 
 onstration is difficult on account of the lack of authoritative information to be 
 had from witnesses such as ministers, teachers, parents, etc. Hereditary factors 
 could be proven in twelve of the twenty cases diagnosed as congenital mental 
 debility, parental tuberculosis among them. Some of the symptoms in men of a 
 retiring disposition were abnormal voraciousness, lack of personal cleanhness 
 and of a sense of order, incapability to divide a given period of time properly 
 so as to perform necessary duties, inability to follow instructions, stupidity, poor 
 memory, absent-mindedness, and insubordination. In cases of the erethical 
 type, these and other symptoms were present, such as boastf ulness, excitability, 
 a tendency to joke, etc. The writer groups cases of congenital mental debihty 
 into three classes as follows: 
 
 1. Cases of a mild type, that may still be used for military service. 
 
 2. Cases of moderate severity, where military service is out of the question 
 but where the individual is responsible for his actions. 
 
 3. Severe cases, which exclude both the possibility of military service and re- 
 sponsibility for actions. 
 
 Many views have been expressed as to the nature of epilepsy. In this con- 
 nection the question is simply whether or not genuine chronic epilepsy may be 
 caused by skull injuries. Binswanger, Mendel and others admit the possibility. 
 Surgeons and neurologists with surgical knowledge recognize a traumatic gen- 
 uine epilepsy, and believe that, where the clinical diagnosis fails to recognize a 
 traumatic etiology, an operation may reveal convincing signs. X-rays may also 
 help in establishing the diagnosis of traumatic epilepsy. 
 
 The writer agrees with Redlich, that in trying to establish an epileptic dia- 
 thesis, only those cases should be considered epileptics that give proof of true 
 epileptic fits. So-called psychic equivalents should be regarded with skepticism. 
 
 Cases of general psychopathic constitution were frequent. The main etio- 
 logical factor in fifty per cent of these cases was heredity. Those that exhibited 
 congenital causes were (1) cases of hereditary degenerative constitution of the 
 general type, (2) cases of an epileptoid nature, (3) cases of unstable temper- 
 ament, (4) cases of sexual perversion, (5) degenerates with constitutional states 
 of depression. Traumatism is considered an etiological factor in acquired psy- 
 chopathic constitutions. Cases of each type are described in detail. 
 
 Chronic paranoia was of rare occurrence, comprising less than one per cent of 
 all the admissions. The age of the men varied from twenty to forty years. 
 This group consisted of chronically querulous individuals always engaged in a 
 fight for their rights, with or without cause. 
 
 Neurotic constitution and acquired neurasthenia were very rare, and only a 
 few cases of hysteria came under observation. Among the organic brain diseases 
 were cerebral lues, progressive paralysis and cerebral tumor. The writer gives 
 his experiences with cases that had previously been inmates of a reformatory, 
 which group comprised 14.4% of the cases observed. Numerous statistical 
 tables are given. 
 
 Mendel, Kurt. Psychiatric and Neurological Observations at the 
 Front (Psychiatrisches und Neurologisches aus dem Felde) 
 Neurol. Centralbl., Leipsic, 34: 2-7, Jan. 2, 1915 
 
 The writer has found that the occurrence of psychoses in the present war is 
 astonishingly rare. This is probably due to the thoroughness of the examinations 
 
33 
 
 at the time of conscription which eliminate all the psychologically doubtful 
 cases. 
 
 Special divisions for mental diseases in the field hospitals were unnecessary. 
 Isolation in a special room or in barracks in the grounds of the hospital was suf- 
 ficient until the patients could be transported to the base hospital. During the 
 process of transportation they had to be kept very quiet. This was accomplished 
 by a subcutaneous injection of morphine and hyoscin, and in one case by mechan- 
 ical restraint. The latter procedure will often be necessary on account of the 
 lack of continuous baths or trained attendants. 
 
 War psychoses as a nosological entity do not exist, but war may give to psy- 
 choses a distinctive coloring. For example, patients in the operating room under 
 narcosis talked only about war and military service, giving commands, making 
 reports, etc., during the period of excitement. Even in other conditions such 
 as hallucinations, etc., war was always in the foreground. In one case of amentia, 
 however, the patient did not know where he was and imagined himself to be in an 
 insane asylum. 
 
 The writer confirms Bonhoffer's statement with regard to dementia precox 
 that, considering the age of the majority of soldiers, he believes the war will cause 
 a great number of cases of schizoplirenia. 
 
 He has not observed any cases of manic-depressive psychoses. Hysteria was 
 usually more frequent among officers than among privates. The majority of 
 patients accused of disciplinary offenses were chronic alcoholics. 
 
 The same article also treats of the writer's experiences with cases of tetanus. 
 
 Jolly, P. Observations in the Nervous Division of a Reserve Hospital 
 (Erfahrungen auf der Nervenstation eines Reserve Lazaretts) 
 Schmidts Jahrb., Bonn, 82: 141-47, March 1915 
 
 The paper is based upon 319 cases observed by the writer in the reserve hospital 
 at Nuremberg. They were men between the ages of eighteen and forty-five 
 who had been found fit for service, trained for a brief time, and had then served 
 at the front for a shorter or longer period. There w-ere no cases of pure psychosis, 
 for these were treated in a special psychiatric ward, but cases of degeneracy and 
 psychopathic constitution were observed. Patients of the former type usuallj' 
 combined some form of malingering with minor ailments. It was difficult to 
 classify the psychopathic cases as many of them were of the border-line type. 
 If such men reach the front, they are likely to cause much trouble, both for them- 
 selves and their comrades, and arc especially susceptible to alclioholic temptation 
 and stimulation. It is interesting to note that not a single case capable of being 
 diagnosed as general physical and nervous debility was found among army re- 
 cruits. All men of this type had been weeded out during the reservist stage. 
 
 Among tlie patients eighty were diagnosed as neurasthenic. Cases of cardiac 
 neurosis were included in this group. Most of these patients liad manifested 
 symptoms of nervous trouble before the war. Those who claimed to have been 
 perfectly healthy before entering the service generally exhibited tlio clinical 
 picture of exhaustion neurasthenia. Characteristic symptoms, observed mostly 
 in officers, were a tendency to weep and great irritability. 
 
 The diagnosis of fifty cases was hysteria. Spasmodic fits appeared as the 
 predominant symptom. Some patients had shown evidence of these previous to 
 service; in others Ihey developed after enlistment. The fits varied from slight 
 twitchings during perfectly conscious states to the most violent convulsions at- 
 tended by unconsciousness. In one patient they assumed a most dramatic form. 
 The man would first be overc;ome by a violent attiwk of treniblhig, after which he 
 would rehearse silently some liattle scene, going through the motions of loading 
 his rifle, aiming, firing, etc., followed by a second trembling fit; then he would 
 become calm and sink into a period of total amnesia. Tiiese patients are gener- 
 
34 
 
 ally irritable and averse to discipline, but after cure many of them can be returned 
 
 to the front. 
 
 The chief etiological factors are physical and mental over-exertion, shell shock, 
 and heat stroke. The condition in one case had been caused by the man's 
 having to spend the night near a pile of dead horses. 
 
 A number of interesting cases of hysterical paralysis are described. In one, 
 in which the man lost the entire use of both arms after slight shell shock, it was 
 found that the patient, ten years previous, had had a stroke of radial paralysis. 
 His condition of shell shock showed improvement upon application of the f aradic 
 current. The writer believes that in cases of general asthenia the desire for war 
 indemnity plays an important part. Symptomatology of several cases is given in 
 detail. 
 
 Another group of the hysterical type is comprised of cases of psychogenic 
 tremor and similar motor disturbances. Causative factors are shell shock, 
 exhaustion and climatic conditions. Treatment through mental suggestion by 
 assuring the patient that his troubles are curable and non-organic in nature 
 seemed the most generally successful thereapeutic method. Other forms of treat- 
 ment used were bromides, opiimi, wet packs, baths, massage and faradization. 
 Sometimes the injection of scopolamin brought relief. 
 
 Two cases of shell shock with unconsciousness are described in which an un- 
 usual manifestation was observed — a peculiar, slow movement of the head result- 
 ing in a forced position resembling that seen in torticollis. An interesting case 
 history of functional motor disturbance following heat stroke is cited. This pa- 
 tient, immediately after his stroke, was seized with spasms of the arms and tremors 
 of the legs. The position and action of the arms was very curious. They were 
 bent at right angles at the elbow across the chest, and then violently extended. 
 This motion was continuous and so rapid that there were 220 flexions and ex- 
 tensions per minute, or 198,000 during the fifteen waking hours. In sleep they 
 ceased. The whole body and head were involved in the shaking motion. 
 
 Epilepsy was not often found. A case is described. 
 
 The nervous pathologj^ of shock, particularly shell shock, is discussed in de- 
 tail. Among psychic causative factors are consciousness of danger, seeing a 
 comrade suft'er a horrible death, and many other conditions and events of modern 
 warfare. Organic causes are the tremendous atmospheric pressure caused by the 
 explosion of the shell, the poisonous gases liberated from it, and the concussion of 
 the whole body and skull in cases in which the man is thrown down violently or 
 blown up or against some fixed object, such as a tree or wall. Physical and men- 
 tal exhaustion may produce a condition of susceptibility to shell shock, but it also 
 occurs in strong-nerved men. In nearly all cases, the initial shock is followed by 
 a period of unconsciousness of longer or shorter duration. Sometimes no nervous 
 consequences follow and the men continue in the service. Symptoms in those 
 nervously affected are vertigo, impaired hearing, headache, increased excita- 
 bility of the heart and of the muscles, vasomotor disturbances and hyperemotional 
 states. Other cases showed neurasthenic symptoms, such as trembling of the 
 tongue and fingers, hypochondria, depression, etc. Hysteriform symptoms were 
 exhibited by others, such as functional paralysis of both arms, trembling of the 
 whole body accompanied by spasms, head movements and facial tics. Deafness, 
 mutism and aphonia were frequent. Speech disturbances are discussed at length. 
 
 The writer concludes his article by brief comments upon nervous affections 
 caused by shots through the head, and upon peripheral paralysis. 
 
 Westphal, A., and Hiibner, A. H. Nervous and Mental Diseases in 
 the War (tjber nervose und psychische Erkrankungen im Kriege) 
 Med. Klin., Berlin, ii: 381-84 and 413-17, April 4 and 11, 1915 
 
 The writers believe that there are no real war neuroses nor psychoses — that 
 these affections are not essentially different from those observed in times of 
 
35 • 
 
 peace. There is a difJerence of opinion as to the frequency of these so-called 
 war neuroses and in order to make this question somewhat clearer they have 
 collected data from which the following clinical cases may be cited. 
 
 1. The patient had previously been healthy and free from mental or nervous 
 disorders. He was exposed to shell-fire for a long time. After the near-by 
 explosion of a shell, he was buried alive under the soil. From that time on he 
 suffered from headaches and for a period was mentally unbalanced. At this 
 time he received news of his captain's death, upon which he was seized with an 
 acute attack of excitement and delirium, during which he rolled on the floor 
 and smashed everything in his proximity. He was admitted to the hospital 
 in a condition of stupor with alternating catatonia. After a long sleep the symp- 
 toms cleared up, but retrograde amnesia covering a period of several weeks 
 persisted. He remembered nothing of his captain's death and subsequent 
 events, and kept complaining of headaches. He was abnormally sensitive to 
 noise and had visual illusions, general hyperesthesia, and complete ageusia. 
 
 2. Patient was a volunteer. Nothing was known of his heredity, but he had 
 always been healthy. His shoulder was grazed by a shrapnel piece but no 
 serious injury resulted. He lost consciousness and on the next day became 
 delirious. He would leap up suddenly at night and run shooting toward the 
 French trenches. At another time he shot towards the ceiling and cried, "The 
 Russians are coming." He remained in this condition for two days. He 
 suffered at first from paralysis of the right arm and leg, which later was re- 
 stricted to the arm only. He also complained of headaches. He confabulated, 
 raved at night of his war experiences, and at times was hysterical. There was 
 complete amnesia and hj'peresthesia of the right arm and shoulder, but no 
 other symptoms. 
 
 3. This patient, a non-commissioned officer, was very excitable but otherwise 
 healthy. His mother was very nervous. He was injured in his foot and thigh, 
 but the wounds healed quickly. While at the hospital he slept badly and 
 dreamed of horrible war scenes. When he first attempted to walk there were tics 
 of the muscles of face and neck. His head was drawn backward and sideways 
 and he made grimaces. The other symptoms were marked tremor of the upper 
 extremities, sometimes a tremor over the whole body, slight hemi-hyperesthesia, 
 very active tendon reflexes, vasomotor disturbances and an unsteady gait. He 
 was easily influenced by suggestion. 
 
 From the description of these and other cases the wTiters conclude that 
 clinical pictures of nervous disease among combatants vary greatly, and that 
 they are by no means so rare as has been sometimes believed. However most 
 cases occurred in predisposed individuals. In other instances predisposition 
 could not be proven. The explosion of shells in the immediate vicinity, even if 
 no physical injury results, is the most important of the direct etiological factors 
 of nervous diseases in the war. Shell-shock has such a powerful effect upon the 
 nervous system that it can cause severe nervous symptoms, even in non-disposed 
 individuals. These symptoms are both of a hysterical and neurasthenic nature. 
 Among the former are abasia, paralysis of the extremities, tremors, and dis- 
 turbances of speech. The various neurasthenic symptoms are headache, vertigo, 
 insomnia, vaso-motor disturbances and tachycardia. Some cases exhibit pecul- 
 iar contractures of the muscles of the neck, conditions of utter exhaustion and 
 general and sometimes a localized sensory hyperesthesia, often of a lasting 
 nature. A combination of these symptoms results in the various forms of the 
 clinical picture of traumatic neurosis. The prognosis of the traumatic war- 
 neurosis seems more favorable than that of the pension neurosis. The number 
 of cases of true psychoses, apart from cases of general nervous disturbances, and 
 the "border-line" cases, was very small. 
 
 The types of war psychoses were practically the same as tliose in times of peace. 
 In the manic and depressive cases there was a peculiar tendency to activity. 
 
36 
 
 coexistent with loss of self-confidence, and a state of acute fear combined with 
 motoric unrest and insomnia. A few of these cases resembled dementia precox 
 and sometimes symptoms were observed corresponding to those of acute delir- 
 ium. Men who had never displayed psycliic or somatic disturbances of any 
 kind at times showed the paralytic and tabetic symptoms of metasyphilis. 
 
 The writers then take up the medico-legal work of the psychiatrist in military 
 services. 
 
 These questions frequently arise : 
 
 1. Is the patient fit for military service.^ 
 
 "2. Is he entitled to claim indemnity? 
 
 S. Is he responsible for misdemeanors that he has committed.^ 
 
 The wTiters believe that the authorities should make every effoit to keep men 
 that are unfit for military service out of the army. Strict examinations should 
 always be made, both of those who themselves claim to be unfit and of those 
 who laud their health because of a desire for enlistment. Medical officers at 
 the draft examination are not always at fault when mental disturbances are 
 overlooked. The consultation of all available records of insane asylums and 
 similar institutions as well as prophylactic measures should prevent such 
 occurrences. The parents of boys suffering from diseases that make them 
 undesirable for military service should be notified. Diagnosis is comparatively 
 easy in cases of paralysis, dementia precox, amentia, paranoia, mania and 
 melancholia. The service of moderately severe cases of neurasthenia and hys- 
 teria is always doubtful. For example, several cases of hysteria, after being 
 honored for their valor, and at times decorated with the Iron Cross, subsequently 
 suffered complete mental breakdown and only a few could be returned to the 
 front. Employment behind the lines should be given in such cases. Cases 
 afflicted with spasms, especiallj^ hysterics, have been frequently looked upon as 
 malingerers, although various symptoms, such as fits and analgesia, were present. 
 The number of real malingerers is not great. 
 
 The majority of cases that claimed indemnity belonged to the accident neu- 
 roses group. Claims were not granted until very detailed histories of patients 
 were obtained. This was an important point, since cases were found that had 
 already tried to gain compensations from various companies and had failed, after 
 which they tried to obtain compensations from the military authorities. 
 
 The treatment of cases suffering from neurasthenia and hj^steria frequently 
 gave good results. The patients were sent out of the clinic as quickly as pos- 
 sible and made to resume their former occupation. This saved many from per- 
 manent incapability of work. 
 
 The writers were called upon in twenty-three cases to state their opinions in 
 the legal procedure against enlisted men. The offenses that were committed 
 had occurred mostly in the interior. The non-military offenses were seven 
 thefts, one embezzlement, one case of immorality, one case of libel, and one case 
 of wearuag the Iron Cross without being entitled to it. Among the military 
 offenses were ten cases of desertion, two of lack of respect to superiors, one of 
 insult to superiors, two of assault, three of misuse of weapon, and one of coward- 
 ice. None of these could be termed healthy in a clinical sense. Alcohol was 
 frequently a causal factor in these offenses. Psychopaths who had been de- 
 prived of alcohol for a long time became much excited after taking a few glasses 
 of wine. Total abstinence would be the most desirable thing but it is hardly 
 possible to enforce this in a large army. It is important, however, that the 
 superior officers keep an eye on those who, in a state of intoxication, are liable 
 to cause trouble. After a prolonged period of abstinence only small doses of 
 alcohol should be allowed. 
 
 Several interesting cases in which alcohol was responsible for the patients' 
 offenses are described. One is cited here. The patient's two brothers, his 
 father, his father's two brothers, and his great uncle were heavy drinkers. 
 
37 
 
 nearly all of them having shown signs of delirium. His mother had fits as a 
 child. The patient himself had gone to school only occasionally, and then was 
 troublesome to his teachers and rude and brutal to his classmates. He also 
 committed thefts. After he left school he had several positions as an appren- 
 tice, but he never learned any trade. He left these positions and was finally 
 employed as an unskilled laborer, but was again discharged because of his 
 irritability. He then enlisted in the army. Here he got eighty-five days of 
 confinement for disciplinary offenses. He was convicted sixteen times for brutal 
 acts, burglary, thefts, insults, public misdemeanors and exliibitionism. Ob- 
 servation showed that he had a continuously sullen temper, was irritable and 
 inexact in his statements, that he slept badly, stammered and showed many 
 signs of degenerac3\ He was tried for desertion and afterwards made two 
 attempts to escape. At the time of committing these offenses he was without 
 exception under the influence of alcohol. He admitted that he was very 
 sensual and felt forced to masturbate immediately after taking alcohol, which 
 caused him to commit his sensual offenses. The writers suspected this to be a 
 case of epilepsy but, as the patient's statements were very unreliable, notliing 
 further could be diagnosed. This case shows how difficult it sometimes was to 
 come to a definite conclusion. The writers state that in cases of apparent 
 desertion like the above, the court always assumed that they acted so only tem- 
 porarily, and sentenced them accordingly. 
 
 Redlich, Emil. The War and the Nervous System (Einige allgemeine 
 Bemerkungen iiber den Krieg und unser Nervensystem) Med. 
 Klin., Berlin, ii : 469-73, April 25, 1915 
 
 The writer docs not discuss organic injuries of the nervous sj^stem but limits 
 himself to the question of the degree of resistance of the human nervous system 
 during war time. He believes that our age is one of increased capability 
 and nervous resistibility and that there is no justification in speaking of a 
 progressive degeneration of the civUized nations. Two factors, however, are 
 worthy of attention. Insomnia, especially among peasants who had never 
 before known anything of sleeplessness, was very frequent. Dreams about war 
 scenes seemed to disturb their sleep. There was also variation of body tem- 
 perature and of heart action apparently without adequate cause. 
 
 The writer believes that in cases where a compensation does not come into 
 consideration, a comparatively small number of wounded soldiers develop 
 "traumatic neurosis." 
 
 Shell explosions in the immediate vicinity are one of the most frightful of war 
 conditions. Officers have reported that whole companies that had been exposed 
 to shrapnel showers were attacked with crying fits, vomiting and other nervous 
 conditions, but that the psychic balance was re-established as soon as the re- 
 serves had t^ken their places. Even in cases where the patient had been 
 wounded and had suffered concussion of the brain, the symptoms of a traumatic 
 neurosis rarely develop. Another point of importance is that traumatic 
 neurosis is a relatively benign condition. 
 
 The writer corroborates Oppenheim's statement that sj'mptoms of traumatic 
 neurosis often developed as an immediate consequence of the trauma even 
 before the wish had a chance to take effect. 
 
 The prognosis of the traumatic neurosis is much more favorable now than in 
 times of peace. This is ascribed to two facts: (1) The patients are young and 
 healthy; (2) The incentive for obtaining a disability compensation is stronger 
 in times of peace than now. Besides, if the patient is resigned to the thought 
 that h(; will be compelkvl to return to the front, whether or not the nervous 
 disorders have disappean'd, he makes astonishingly rajjid progress. This is 
 especially true of traumatic neurosis in which hysterical symi)toms predominate. 
 
38 
 
 particularly in organic lesions of the nervous system. Therapeutic methods 
 however are questionable because of their severity and painful nature. Many 
 cases of hysterical paralysis and anaesthesia, tremors, peculiar astasias and 
 abasias, which, under ordinary treatment remained uninfluenced for months, 
 have been cured in a single sitting by the application of a strong faradic current. 
 It goes without saying that this form of treatment removes the symptoms but 
 not the hysteria. Isolation and a milk diet, added to this method, have given 
 good results. Such cases are sometimes considered malingerers, but many 
 authorities maintain that genuine malingering is very rare; it is one of the 
 symptoms of traumatic neurosis.. 
 
 The writer believes that, in cases of traumatic neurosis with neurasthenic 
 symptoms, predisposition is an important factor. Explosions, hardships and 
 scenes of terror, or injuries may cause the outbreak of the latent condition. On 
 the other hand, acute exhaustion neurasthenia is very rare. 
 
 The treatment of neurasthenia is totally different from that of cases of hysteria. 
 Many have been cured by a complete change of environment. Spontaneous or 
 miraculous cures of neurasthenia are not possible. The psychological factor 
 in the treatment is of the greatest importance. The patient must be convinced 
 that his troubles have no organic basis, that his mere dislike of service at the 
 front is not a sufficient reason for declaring him unfit for such service, that his 
 stay at the hospital is only for the purpose of increasing his resistance to disease. 
 
 The writer has met several cases of depression, particularly in soldiers who 
 were worried about their families left in the regions occupied by the enemy. He 
 has also observed cases of schizophrenia, that became acute during the war, 
 confusional states, progressive paralysis and alcoholic psychoses. 
 
 The rest of the article deals with the influence of the war upon the civilian 
 population in regard to mental and nervous diseases. A few interesting cases 
 are cited. 
 
 Marburg, Otto. Neurology in War (Neurologic im Kriege) Jahr. 
 . fiir artz. Fortbild., Munich, May 1915, p. 1-14 
 
 In modern warfare, injuries of the brain and of the peripheral nerves are more 
 frequent than they have been in former wars. The recent progress in surgery, 
 however, gives scope for greater attention to such injuries and also to those of 
 the spinal column. Only the skilled surgeon can perform these operations, but 
 the neurologist is constantly needed for consultation and assistance. 
 
 Bullet shots grazing the skull and injvu-ing the skin without affecting the bony 
 structure are important only in as much as the clinical pictm-es resulting from 
 them resemble "concussion" neuroses. When the bullet strikes him, the soldier 
 falls to the ground, remains unconscious for a few moments, vomits and has a 
 short period of amnesia. This is therefore a typical pictm-e of concussion of the 
 brain. A few days later the patient is somewhat apathetic and nauseated, com- 
 plains of headache and his pulse is slow. Improvement takes place after an 
 interval of from eight to fourteen days of rest, but the headaches and the low 
 pulse rate may persist for weeks. X-rays are absolutely essential since the inner 
 table may not always escape injm-y. These shots are frequently accompanied 
 by conditions of stupor or clinical pictures resembling Korsakoff's psychosis, or 
 followed by nem-asthenia and hypochondriasis. The prognosis is generally 
 favorable and the treatment which consists in strict confinement to bed, at least 
 until the pulse is normal, rarely lasts more than four weeks. 
 
 Tangential shots always necessitate operations. Even if they only injure the 
 bone, the splinters in the inner table cause lesions of the brain. Infections, 
 abscess formations or encephalitis often follow. In the beginning, the clinical 
 pictures resemble those of the grazing shots. Here also there is concussion of 
 the brain, slow pulse and headaches, but along with these, there are, according to 
 the location of the lesion, paresis, paraplegia, aphasia and hemianopsia. The 
 
absence of irritation phenomena even where motor areas are involved, is very 
 striking. Paraplegia was for the most part flaccid with increased reflexes and 
 the presence of Babinski and Oppenheim signs. The brain abscesses resulting 
 from these shots are usually accompanied by an exceedingly subnormal tempera- 
 ture at about 35.9° C, bradycardia (pulse 52) and marked moroseness. At times 
 there was a rise in temperatm-e and leukocytosis preceding the abscess formations. 
 An X-ray examination is absolutely essential in gaining a clear picture of the 
 extent of the lesion. The prognosis in tangential shots is comparatively favor- 
 able, if unaccompanied by brain abscesses. The fatality is usually one in thir- 
 teen compared to brain abscesses where there are eight fatal cases out of every 
 eleven. Surgical treatment is almost always necessary even if it may have to be 
 postponed for a period of two or three weeks. Spontaneous cures are possible, 
 though in such cases there is likely to be a later abscess formation. 
 
 When the projectile remains in the bony substance or the brain matter the 
 injuries may be classed as either superficial or deep-seated. The symptoms re- 
 sulting from the superficial shots are identical with those of the tangential shots. 
 Brain abscesses usually form in front of the bullet. In such cases an operation 
 is advisable and the prognosis is favorable but an X-ray examination is essential 
 in diagnosis. Sometimes there are no symptoms except the initial slight con- 
 cussion, and on one such occasion a soldier refused to be sent to the hospital, 
 remaining at the front for eight days, when he showed symptoms of a brain 
 abscess. Surgical treatment is not to be used in the case of these deep-seated 
 shots for the abscess formation has usually penetrated the ventricles, leading to 
 pyocephalus, meningitis, etc. 
 
 Penetrating shots that leave the brain may do so either at a distance of not 
 more than a few centimeters from the entrance — these are known as segmental 
 shots — or they may traverse the brain in a sagittal or frontal direction, in which 
 case they are called penetrating shots proper. Lesions of the latter tj^e are 
 very frequent but the symptomatology varies. There are cases in which no clin- 
 ical symptoms exist after the initial concussion and the accompanying general 
 symptoms. Then again, regional symptoms in others are very marked. The 
 prognosis on the whole is favorable provided there is no infection. Operations 
 are absolutely contra-indicated. 
 
 In cases of the segmental shot, the symptomatology, prognosis and treatment 
 are the same as for cases of tangential or superficial shots. A few cases may be 
 cited. One shot, penetrating both mastoid processes directly behind the ear, 
 caused cerebellar affections with peculiar disturbances of speech. Another shot, 
 entering somewhat higher, caused cortical blindness. Still another, entering 
 near the left eye, and leaving beliind the right ear, caused the clinical picture of 
 bulbar paralysis of the right side. 
 
 The most important complications of brain shots are pyocephalus, meningitis, 
 cerebral hernia, ventricular fistula and cerebral prolapse. A sudden rise of tem- 
 perature to 40° C, a rigidity of the whole body musculature and a decrease of the 
 pulse rate generally indicate a rupture of the ventricle. Basal meningitis with 
 cranial nerve involvement soon follows, but often disappears as rapidly. This 
 picture generally corresponds to pyocephalus, the infection finding its way most 
 likely through the foramen of Magendie. It is striking that the side away from 
 the convex part of the bullet lesion was always the most largely involved. The 
 question as to whether spinal puncture is necessary to relieve meningeal compli- 
 cations must be left open, for in two cases a cure was affected without it. The 
 prognosis of ventricular fistula is favorable, the treatment consisting in absolute 
 rest. Cerebral prolapse, the most frequent complication of brain shots, is due 
 to a congestion and edema caused by infection. Another causative factor may 
 be the premature transportation of the patient. The prognosis is favorable but 
 the regional symptoms are mostly of a more permanent character, and disappear 
 only when the herniae recede. There are also primary prolapses caused by the 
 
40 
 
 shot itself. In these eases, surgical interference is contra-indicated since the 
 symptoms generally disappear after a few days. 
 
 Rest is the most essential feature in the treatment of such cases. A very sim- 
 ple remedy consists in the local application of tincture of iodine. Pock forma- 
 tion and the retention of even the smallest quantity of secretions must be pre- 
 vented. 
 
 The ratio between brain shots and spinal column shots is 1 to 6. Those caus- 
 ing lesions of the spinal-marrow indirectly are (1) bullet shots penetrating the 
 thorax or arrested in the thorax (2) grazing, penetrating or arrested shots in the 
 spinal column (3) shots arrested m the spinal column (4) shots penetrating the 
 spinal marrow. The clinical picture resulting is known as "commotio medullae 
 spinalis", where commotio implies a tearing of lymphatic capillaries. Tliis re- 
 sults in the formation of edematous traumatic degeneration, etc., which in turn 
 may cause symptoms that correspond to a tj'pical lesion of the spinal column. 
 The term "commotio medullae spinalis " is not very definitive. It is used mostly 
 in connection with symptoms occurring after a heavy fall. Immediately after 
 the accident, the patient shows paralytic weakness of the extremities but re- 
 covers without treatment in the course of three or four weeks. Tliis is not a 
 functional disturbance but one of an organic nature, since an increase in reflex 
 and urinary symptoms clearly indicates definite anatomical lesion of the spinal 
 marrow. Sorhe of the striking features in the clinical pictures resulting from 
 these shots may be mentioned. The symptoms appear directly after the injury. 
 At first there is usually flaccid paralysis, but after a few days it often becomes 
 spastic, sometimes, however, remaining flaccid for months even if the lesion is 
 far above the centers responsible for the paralysis. A lesion in the cervical 
 region causes flaccid paralysis of the upper and spastic paralysis of the lower ex- 
 tremities. Atrophy of the muscles of the hand, rectal and bladder disturbances 
 and decubitus occur very early. The sensory disturbances are the same that 
 we get in a transverse lesion of the cord. Above the anesthetic zones there is 
 generally a small zone of hyperalgesia, seldom involving the whole of one or two 
 segments. In lesions of the dorsal region we get a flaccid paralysis of the lower 
 extremities. Lesions in the lumbar region often produce loss of patellar and 
 Achilles reflexes with no involvement of bladder and rectum, flaccid paralysis 
 of the lower extremities and corresponding sensory disturbances. The Brown- 
 Sequard syndrome is frequently present. Tenderness upon pressure over the 
 spinal column and spontaneous root-pain is very rare. Five or six weeks suffice 
 to show clearly the possibilities for cm-e. The latter two conditions indicate 
 surgical procedures. Patients with a flaccid paralysis that has lasted tliree or 
 four months are frequently able to use their legs spontaneously a few weeks after 
 the operation. Decubitus and cystitis do not contra-indicate operations unless 
 the lesions are of a very severe nature. Pulmonary and abdominal complica- 
 tions do, however, call for surgical treatment. 
 
 Injiu-ies of the facial nerves caused by bullet shots are most frequent. There 
 were two cases of facial paralysis, however, that seemed to be of rheumatic origin. 
 
 The peripheral nerves, especially the radial and the peroneal, are involved in 
 injiu-ies of the extremities. A striking feature in these cases is the relative ab- 
 sence of pain, even when sensory nerves are injured. Sensory disturbances are 
 slight compared with motor disturbances. The atrophic processes seem to 
 occur later than is usually the case. Trophic and vasomotor disturbances are 
 common and extensive. Other symptoms are coldness of the limbs, cyanosis, 
 hj'peridrosis, hj'perkeratosis and changes in the hair and nails. Nerve lesions 
 are generally complicated by extensive suppuration and therefore the conse- 
 quent callus and connective tissue formations make surgical operations very 
 diflBcult after a healing process of several weeks. 
 
 The best time to operate is in complete absence of any degenerative reaction. 
 It might also be advisable to use surgical methods when a slight reaction has 
 
41 
 
 started but has been stationary for a long time. An early operation is best. 
 Slight improvements may sometimes remain stationary and then cause very 
 irritating contractures. A trial of two or tlu-ee months is sufficient however, to 
 show whether an operation is needed or not. Palpation of the nerve for the 
 purpose of diagnosis has been recommended in order to determine whether or 
 not it has been severed by the shot. 
 
 Hartmann, Fritz. Training Schools for "Brain-Cripples" (Ubung- 
 schulen fiir Gehirnkriippel) Miinch. med. Woch. 62 : 769-70, 
 June 8, 1915 
 
 A large percentage of cases of brain-injury in the present war, after more or 
 less extensive treatment, are discharged as "surgically" cured but only a few 
 of these are organically and functionally cured. All the rest may be classed as 
 "brain-cripples". As a result of surgical interference in many of these cases, 
 even if no organic lesions remain, there are permanent functional disturbances, 
 either of a motor, psychomoter, or sensorj-motor nature. These cases are dif- 
 ferent from those occurring in times of peace when most of the cases in hospitals 
 for mental diseases are degenerate types. The war sufferers were young, strong 
 and healthy at the time of the injury. 
 
 Therapeutic methods, too, are different in both instances. In the ordinary 
 cases of mental disease we try to arrest, to limit or to remove the underlying 
 causative factor, whereas in the case of the so-called brain-cripple v,e must deal 
 with a completely healed wound in the brain. The scar does not become worse, 
 no matter what functional disturbances result from it. Therefore, the brain, 
 structurally unchanged, is capable of being restored to a marked degree. Brain- 
 areas that are functionally related to those more or less injured adopt the func- 
 tions of the latter and in this way the defect is practically made up for. The 
 same principle also holds true for the motoric processes in the extremities, for the 
 motor speech apparatus m central lesions and for the higher senso-motoric 
 functions of the sensory systems. The restoration of the lost or incapacitated 
 functions should, therefore, be the first therapeutic aim of the medical profession. 
 This may be accomplished by means of reeducation. 
 
 This method is not new, for it is being used in the treatment of various other 
 types of cases such as abasia, speech defects, and hemiplegia. The new schools 
 for the training of orthopedic cripples also use the same method. It is com- 
 paratively new, however, as applied to the brain. It is practised by a special 
 school in the University Clinic at Graz, Austria. The aims of this school are to 
 arouse or create anew the various processes of perception, apperception, memory 
 and orientation, to reconstruct the faculty for apprehension through the senses, 
 to overcome defects, to do away with pathological associations and to form new 
 ones in their stead, and to stimulate the power of abstract conception. This 
 treatment is based more upon the pedagogical than upon the medical skill of the 
 leaders of this school, but since the results obtained are so encouraging, a trial 
 on a larger scale is planned. 
 
 Kastan, Max. Forensic Psychiatric Observations in the Array (Foren- 
 sisch-psychiatrische Beobachtungen an Angehorigen des Feld- 
 heeres) Deutsche med. Woch., Berlin, 41:734-37, June 17, 
 1915 
 
 Psychiatrists study psychic disturbances occurring in the army so as to dis- 
 cover the role tTiat predisposition, bodily exhaustion and over-exertion, strong 
 emotions, and other conditions of army life, play in the production of various 
 
42 
 
 clinical pictures. Military delinquents often exhibit these pictures, so for this 
 reason are frequently subjects of careful psychiatric study. 
 
 Extensive work along this line has been done by such men as Schultze, Meyer, 
 Monkeberg, and Craimer. The cases described by them uiclude mostly deser- 
 tion, abandonment of post of duty, disobedience and disrespect. In the Konigs- 
 berg Clinic about fifty such cases were treated up to February 1915. Three of 
 these were officers, seven were volunteers, eight regulars, six reservists, seven- 
 teen national guardsmen, a few belonged to the medical corps and the rest to 
 other divisions connected with the military organization. Out of these fifty 
 cases, four had previously been dismissed from the army, two of these on account 
 of mental defects, five had been in asylums for inebriates and the insane, and 
 fifteen had been previously convicted, one of them only by a military court, 
 nine by a civil court and one had been acquitted on the strength of a medical 
 expert's diagnosis of mental deficiency. 
 
 There were comparatively few cases of simple psychic disturbances among 
 those that came under observation. Manic-depression and general paralysis 
 were not present at all. There were eight cases of dementia praecox. One of 
 these was accused of attacking another soldier with a knife During the eight 
 weeks he was under observation he spoke only once and then just a few words. 
 He was in bed most of the time, uttering now and then a hoarse laugh, staring 
 at the wall, or twisting his moustache. Whenever he came to trial, he would 
 put his hands behind his back as he did when he was arrested and tried to 
 conceal the knife. Another case was at first very uncommunicative, irritable 
 and excited. Gradually he quieted down and began to show interest in his 
 surroundings. He accused his wife of being a spy, said that people wished to 
 make a spy of him while on post duty, and thought his name had been dishonored. 
 He had entered the army as volunteer, but deserted because he was afraid. 
 Another case of dementia praecox attracted attention by uprooting shrubs and 
 trees in the park in order to look for spies and enemy shells. He had invented a 
 process, so he believed, to ozonize the "poisoned" water of the Konigsberg water 
 supply, which it was his duty to guard. He also imagined the presence of worms 
 and bacilli in every glass of water. Because he drew plans of the aqueduct, he 
 was accused of betraj'ing mihtary secrets. Another case wrote many letters 
 to the authorities discussing the political situation in a foolish manner and was 
 accused of lese-majesty. Two other cases had deserted and committed thefts 
 at the same time. One of them had previously suffered from kleptomania. 
 
 There were nine cases of low-grade mental defectiveness, most of whom were 
 accused of desertion, and of other crimes such as theft, assault, murder, mutiny, 
 etc. One man stole a horse from a peasant, left his regiment and in his uniform 
 went to a small town where he was known. Another case was sent to the post- 
 office to deposit a considerable amount of money and at the same time to look 
 for a stolen bicycle. He stayed in the city, depositing the money after several 
 days. When he was arrested, he claimed that he had been searching for the 
 bicycle in a distant city. His liistory showed that he had frequently run away 
 from home and that he had often been convicted of fraud and embezzlement. 
 In the case of these defectives, the combined effect of two different motives was 
 the cause of their desertion. When they left their regiments they were too stupid 
 to find their way back and then were overcome by fear of punishment for having 
 stayed away so long. 
 
 The degenerates and psychopaths constituted the largest group of cases, 
 ranging from the liighly intelligent but emotionally unstable individual to the 
 low-grade criminal. Most of these had previously shown some forms of mental 
 abnormality and had been inmates of institutions for the mentally diseased, 
 prisons or reformatories. Some of them seemed to derive great pleasure from 
 decorating themselves in the most bizarre and foolish manner with crude repre- 
 sentations of military honors and insignia. Tattooing was frequent. They 
 
43 
 
 often made a practice of petty and sometimes useless thievery, stealing handker- 
 chiefs, broken tooth-brushes, and other trivial articles. One cadet who had been 
 recognized as a psychopath at a military academy and therefore dismissed, 
 reenlisted in the army at the beginning of the war. After being slightly wounded 
 in the head, he was sent to a hospital. Here he suffered from all kinds of gran- 
 diose delusions, disappeared when he was well enough to walk, but later returned 
 to duty and spent most of his time writing poetry. 
 
 One patient showed clearly Ganser's syndrome. Two other cases of hysteria, 
 who, in states of utter exhaustion closely resembled psychopaths, were also 
 accused of desertion. Three cases of epilepsy were charged with desertion, when, 
 after an absence of a few weeks, they again reported at the front, one of them 
 saying that he had been in Petrograd. Several alcoholics were accused of dis- 
 respect, disobedience, and insult to superior officers. One of them showed a 
 tjiJical picture of complete amnesia. Another had killed a woman because he 
 had been told to shoot all spies. 
 
 From these observations, the writer concludes that military conditions give a 
 certain uniformity to all criminal acts. Indi\'iduals with strong emotions and 
 great initiative are often guilty of disobedience and disrespect and, where these 
 characteristics are lacking, they are usually deserters. 
 
 WoUenberg, R. Occupation Therapy in Military Hospitals for Nervous 
 Diseases (Lazarettbeschaftigung und Militarnervenheilstatte) 
 Deutsche med. Woch., Berlin, 41: 757-60, June 24, 1915 
 
 The most important etiological factor of nervous diseases is predisposition 
 involving both heredity and personal experiences. Thus there may be individ- 
 uals by heredity endowed with a labile mental equilibrium who lose their balance 
 after a series of unusually exciting events. In the treatment of such cases, 
 quieting mental influences are the only cure, and intelligent and useful occupation 
 is the most important of these influences. 
 
 The same principle must be applied in treating patients suffering from nerv- 
 ous disturbances in war time since their cases are similar to those in times of 
 peace with regard to both etiology and symptomatology. This fact is verified 
 by the WTiter's experience in that all cases had shown signs of nervousness before 
 the war. The occupation selected for such patients should be useful and should 
 make them more contented. Moreover, no man should be forced to do some- 
 thing for which he has no inclination nor should he be made to do work calling 
 for over-exertion on his part. There should also be no unfair competition with 
 the work of the civilian population. A well-chosen occupation can make the 
 patient stronger, improve his general condition, arouse self-confidence and in 
 this way bring about mental equilibrium. All forms of work have been intro- 
 duced such as wicker-work, net-work, fret- sawing and knitting and embroidering 
 by machine, the making of fishing nets, hammocks, blankets and shoes from 
 remnants. An opportunity for heavier liodily work is also afforded in the car- 
 penters' and cabinet makers' shops and in farm-work. Business courses in 
 typewriting, stenography, accounts, etc., are also given. 
 
 Entertairunent, like work, is an important factor in psychic influence and 
 should be often available. In the hospital there are various facilities for this 
 purpose, the gymnasium with all its opportunities for games and exercises being 
 an attractive center. To induce the men to take part in these exercises various 
 rewards are offered such as better rations, personal privileges, freedom from 
 strict supervision, and sometimes small money prizes. Formal entertainments 
 in the evening such as concerts and recitals are not enjoyed so much as the light 
 forms of entertainment arranged by the patients themselves. 
 
 Strict discipline, together with a close cooperation of attendants, is indispens- 
 able for success. The results obtained so far have been fairly satisfactory since 
 
44 
 
 one-tliird of the men were discharged after a period of three months. The writer 
 beUeves that the outlook for the future will be even brighter when this system- 
 atic occupation therapy will have been in force for a longer period. 
 
 Riebeth, Neurasthenia Among Soldiers (tJber Neurac- 
 
 thenie bei Kriegsteilnehmern) Psych.-neurol. Wcch., Hamburg, 
 July 3, 1915, p. 71-76 
 
 The statement that victory in a war of to-day will go to the nation possessing 
 the strongest nerves has been made many times. One of the nervous aflfections 
 tending most to lower the power of resistance of the nervous system and the 
 physical fitness of the soldier is neurasthenia. Observations upon 2,526 soldiers 
 treated in a special hospital showed that neurasthenia, next to hysteria and psy- 
 choneuroses, is the most frequently found nervous disorder. True psychoses 
 are comparatively rare. Neurasthenic states were found in all classes of the 
 city population and in the peasantry but were not frequent among the profes- 
 sional and industrial classes of large cities. The etiological factors are the same 
 in war as in peace, although the clinical pictures were somewhat affected by war 
 conditions. These causative factors may be of a psychical or physical nature. 
 A strict differentiation of the two can rarely be made. Usually they are coexist- 
 ent. Among physical causes may be mentioned over-exertion, insufficient sleep 
 or nutrition, loss of blood after wounds, fever, pain, suppuration and infectious 
 diseases, especially tj-phoid fever. Among psychical causative factors are the 
 tremendous nervous strain of being under fire in long battles in which heavy 
 artillery now plays so important a part, the continuous effort to keep the atten- 
 tion fixed, the frightful scenes of the battlefield, mutilation of friends and com- 
 rades, and. last but not least, anxiety and worry about families left at home in 
 probable danger. 
 
 The writer divides the symptomatology of neurasthenia into cerebral, psychic, 
 spinal, gastro-intestinal, cardio-vascular and sexual manifestations. He groups 
 neurasthenic disorders as to their origin, into exogenous and endogenous t\'pes. 
 In the former the exciting cause is an injury or event affecting the nervous 
 system of mentally healthy individuals; in the latter, the chief etiological factor 
 is nervous insuflSciency in persons with a congenital predisposition. The exo- 
 genous type is often found at the front after great battles and also at hospitals 
 in the interior after long or arduous transportation experiences. 
 
 In such cases the clinical picture is unvaried — apathy, craving for rest and 
 sleep, a tendency to ill humor and a desire to be let alone. More severe cases 
 can sleep little and when they do so have terrifying dreams; they are in a con- 
 tinuous state of emotional excitement and fancy they have symptoms of all 
 kinds of ailments. Usually, after a few days of rest and suflScient food, a normal 
 state of mind is regained. Cases with onset before the war are not necessarily 
 of endogenous origin, especially in men who have done over-strenuous brain- 
 work and so are likely to be in a state of acquired chronic nervous exhaustion. 
 
 In most instances, rest, quiet and good and sufficient food will bring about a 
 complete cure. Therapeutic measures should be employed, if for no other reason 
 than for their beneficial psychic effect. These should be limited to three sittings 
 a week. Hydrotherapy in all its forms is especially important. Diet is a chief 
 factor. Treatment by electricity may be used to advantage. Cases of this kind 
 are very susceptible to psychotherapeutics, in which, needless to say, the per- 
 sonality of the physician plays a most important part. Very nervous patients 
 should always have a private room. Two months should be the limit for hos- 
 pital stay. 
 
 The writer lays great stress upon supplying discharged patients with suitable 
 occupation. Outdoor work is the best. Sometimes such cases may be sent 
 
45 
 
 back into the service and employed at the rear of the army. Provision should 
 be made also for cases unfit for any kind of work and so discharged. Their 
 condition is likely to become serious again and alcohol is often an easy solace. 
 
 Binswanger, Otto. Hystero-somatic Symptoms in War Hysteria (Hys- 
 tero-Somatische Krankheitserscheinungen bei der Kriegshys- 
 terie) Monat. fiir Psych, u. Neurol. Berlin, 38: 1-60, July and 
 Aug. 191 5 
 
 The article is based upon the experience of the writer in a hospital for nervous 
 diseases during the first seven months of the war. 
 
 War neurology has demonstrated that emotional shock, in conjunction with 
 other injuries, may cause a symptom complex identical in all its details with the 
 well known chnical picture of hysteria. It is the purpose of the writer to show 
 that these symptoms may develop also in individuals who have always been 
 perfectly healthy and in whom no neuropsychopathic constitutional anomalies 
 can be demonstrated. 
 
 In many cases it was proved that excessive physical over-exertion lasting for 
 weeks, insufficient food, loss of sleep, etc., had lowered the power of physical 
 resistance, and that emotional factors, such as the strain caused by many days 
 in the trenches under continuous shell-fire, had prepared for the breakdown. 
 Some violent, unexpected psycliic shock was all that was necessary. A factor 
 is here met with, which is not characteristic of the modern conception of hysteria. 
 In the majority of shell shock cases the patients reported having been blown up 
 often as high as ten metres, and witnesses confirmed this statement. Some said 
 they had distinctly felt, before they lost consciousness, the tremendous atmos- 
 pheric pressure caused by the explosion. 
 
 Binswanger's theory is that the mechanical injury of distinct sectors of the 
 nervous system, which takes the form of molecular changes within injured neu- 
 rons, gives the clinical picture in such cases its distinctive character. In con- 
 firmation of the same theory, hysterosomatic disturbances were found in func- 
 tional regions which, Ijefore the war, had shown pathological affections. Thus, 
 hysterical dysbasia and abasia, with or without tremor, frequently became acute 
 in soldiers, who, before the war, had been treated for debility, tendency to fatigue, 
 paresthesia, etc. Reports of a number of interesting cases are given showing 
 that, in states of war-hysteria, new hysterical symptoms may appear after very 
 slight exciting causes, but only in organs previously injured. There are, how- 
 ever, cases in which no such process of preparation nor preexisting organic in- 
 juries can be demonstrated, and in these the violent psycMc shock alone must be 
 considered the etiological factor. 
 
 As opposed to other observers, Binswanger considers hyperesthesia and anes- 
 thesia, hyperalgesia and analgesia the most important symptoms of such disorders 
 as found in peace times, and that their mere existence forms a conclusive diag- 
 nosis unfler such coaditioJis; however, in cases of war hysteria, hemianesthesia or 
 hemianalgesia are seldom found because war hysterics are rarely constitutional 
 hysterics. 
 
 The writer next discmsses in detail, with illustrations, the fact that sensory and 
 motor disturbances are always associated. 
 
 Tremor is a chief symptom of hysteria in males. Seventeen case histories are 
 reported in detail, with prognosis. From these cases the author draws the fol- 
 lowing conclusions: 
 
 1. War hysteria, from the point of view of clinical picture and hystero-somatic 
 complex, may be divided into two chief classes: (a) cases in which family and 
 personal histories prove a pre-existent hysteropatliic constitution; these cases 
 are very few in number; (b) cases in which there is no proof of predisposition. 
 
46 
 
 2. Cases of hysteria have developed even before the war under the influence of 
 psychic tension, physical exertion and minor organic diseases. In such cases 
 the chief etiological factors were emotinal, cerebral or spinal shock, and toxic 
 effects of noxious gases. Exciting causes of both groups were over-exertion, 
 irregular and insufficient nutrition, loss of sleep and high mental tension. 
 
 3. The hystero-somatic clinical pictures developed either immediately after 
 the onset of the causal factor, or after a period of incubation. 
 
 4. The clinical symptoms of groups 1 and 2 are the same. However, the 
 most varied combinations of motor sensory, angio-neurotic and secretory dis- 
 turbances of an irritative or inhibitive character are found. The most frequent 
 manifestations are tremors of aU kinds, shaking dysbasias and astasias, monople- 
 gias, monoparesis and hemiparesis with contracture, slight spastic conditions, and 
 finally affections of the pain-sensations. 
 
 5. The theory of a psychic mechanism as the origin of these motor and sensory 
 symptoms is not demonstrable. 
 
 6. Proof of the psychogenic character of hystero-somatic disturbances, on the 
 other hand, can be deducted from the success of the therapeutic methods used in 
 treatment. The case histories previously cited show that, because of erroneous 
 opinions as to the real nature of the trouble, all sorts of physical and medical 
 treatment proved valueless. When finally hydrotherapy and electrotherapy 
 were used, it was always as suggestive, not physical, agents. Psychotherapy was 
 the only treatment that promised to be generally successful. Gymnastic exer- 
 cises were used, not only to increase the physical health of the patient, but also 
 to train the attention and the will power. When the first signs of improvement 
 occurred, to the regular treatment was added some form of occupation or recrea- 
 tion compatible with the patient's taste and education. Keeping the patient 
 busy, restoring his self-confidence, and giving sympathetic encouragement 
 brought about wonderful results, although allowance had to be made for failures. 
 Hysteria, especially aphonia, is the most stubborn of the nervous affections to 
 treat. 
 
 Mann, Ludwig. Disturbances following Shell-Explosions (Uber Gra- 
 natexplosionsstorungen) Med. Klin., Berlin, ii : 963-64, Aug. 29, 
 1915 
 
 There is always a question as to the nosological conception of cases resulting 
 from shell explosions in all discussions of this subject. This is undoubtedly due 
 to the confusing nomenclature. Some writers use, the term "shell contusion", 
 and others, WoUenberg and Westphal, speak of "shell concussion". These 
 terms, however, apply only to one group of cases, since not all cases are charac- 
 terized by a contusion or a concussion. The individual temperament is an impor- 
 tant factor in all non organic conditions and this accounts for the great variety of 
 clinical pictures. Other factors such as fatigue, exhaustion and emotional states 
 are also present. For these reasons the etiological factor only should be consid- 
 ered and the diagnosis of such cases should be expressed as "disturbances follow- 
 ing shell explosions". 
 
 Among the twenty -three cases observed by the writer of mental disorders fol- 
 lowing shell-fire one is of great interest in as much as the emotional state pro- 
 duced by his occupation, namely, that of digging and filling military graves, was 
 a direct cause. These feelings resulted in a condition of mental dullness, during 
 which he did not react to any external impressions. Even while his condition 
 was improving, the mere mention of war was suflBcient to cause a total relapse 
 into his former state. The memory of the olfactory sensations received during 
 his occupation was very painful to him. 
 
 In two cases only was alcohol an important etiological factor. Conditions of 
 paralysis were very frequent, among them deafness, mutism and deaf-mutism. 
 
47 
 
 There is still a question, however, as to whether or not the actual air contusion 
 and detonation are to be regarded as direct causes of these conditions. This 
 question is influenced by the fact that, in most cases, no apparent lesions exist 
 and psychotherapy is the most efficacious treatment. 
 
 In two cases simple treatment of the laryngeal region with the faradic current 
 brought speech back. Treatment by suggestion cured another case of deafness. 
 This seems to demonstrate that these disturbances are of psychogenic origin. 
 There was also a case of paresis of both legs and one arm following immediately 
 the explosion of a shell but without any organic lesions. In two cases peculiar 
 change in the grammatical use of language was observed. The men talked like 
 children, for example, "I headache", "I not well". In another case the patient 
 was relieved of the spasms of one leg and tremors by any involuntary movement 
 on his part. 
 
 How are these conditions to be explained.? In some cases predisposition could 
 be proved but not in the majority. Most of the men were hardened soldiers who 
 had been in the firing-line more than once. They had probably been through 
 great hardships and deprivations and were in a condition of phj-sical and mental 
 exhaustion, or they were in a state of maximum mental tension. Under such 
 conditions, the explosion makes a strong and deep impression and remains inti- 
 mately connected with memory of the accompanying events. 
 
 The psychological explanation of these disturbances is only a matter of specula- 
 tion. The following two theories may be suggestive: (1) An outlet for the 
 strongest emotions at the moment is presented by the oncoming unconsciousness. 
 There is therefore no reaction to these emotions and they are repressed. (2) 
 Normally there exists an inhibitive mechanism preventing a centripetal stimulus 
 from being transferred to the centrifugal paths. This stimulus first reaches the 
 higher centers in order to cause a motor innervation. It is possible that by a 
 coincidence of particular circumstances such as exhaustion, surprise, fright, ac- 
 oustic impressions, etc., a centripetal stimulus of great strength reaches the brain 
 so suddenly that the inhibitive mechanism breaks down, thus allowing the stim- 
 vdus to reach the motor tracks and so prevent a normal innervation. 
 
 The prognosis in purely mental disturbances following explosions generally is 
 favorable but tnis depends on the predisposition of the patient. A hysteric will 
 always remain a hysteric. In a case of temporary monosymptomatic hysteria, 
 complete rest brought about a cure. A correct early diagnosis is important, how- 
 ever, in order to send the patient to a special hospital without any loss of time. 
 
 Hoffmann, Rudolph. Labyrinthine Disturbances (Detonationslaby- 
 rinthosen) Miinch. med. Woch. 62: 1269-70, Sept. 14, 1915 
 
 The writer emphasizes a certain symptom that he found among fifty cases of 
 auditory injuries caused by detonations, which was hitherto practically unknown. 
 In each case of labyrinthine shock, sensory disturbances of the external ear could 
 be proven, but pure affections of the auditory apparatus were never demonstra- 
 able. An extreme sensibility of the external meatus to heat and cold was ap- 
 parent. The disturbances of sensibility varied according to the injury done. 
 In the most severe cases there was complete analgesia. 
 
 The sensory disturbances were not dependent on the distribution of the periph- 
 eral nerves. In most cases they involved the whole external ear and a zone of a 
 finger's breadth around it. The writer believes that to classify these sensory 
 disturbances as hysteria would be incorrect since there were no other clinical 
 symptoms. Symptoms relating to the vestibular canal were of very slight 
 prominence. Vertigo was present but soon disappeared. Spontaneous nystag- 
 mus never occurred. It may be of interest to note tliat collections of cerumen in 
 the ear and chronic otitis media offered a certain protection against the effects 
 of detonation. The treatment of these cases consisted of rest in bed for the first 
 
48 
 
 few days. As internal medication twenty-five drops of tincture of valerian 
 were given. Bromides were never used. In all such cases, suitable occupations 
 and reading matter should be provided. The nurses should talk to the patients 
 in clear and loud tones so that they may not realize their defects of hearing. 
 Patients with a bilateral impairment of the cochlea nerve should be taught lip 
 reading. A few interesting cases are described. 
 
 Weygandt, W. Observations on War Psychiatry (Kriegs-psychia- 
 trische Beobachtungen) Psych, neurol. Woch., Hamburg, Dec. 
 II, 1915, p. 215-16 
 
 The writer has observed that frequently men who were absolutely healthy 
 before the war, and some who had had symptoms of epilepsy from which they 
 had apparently recovered, during the war developed hysterical disturbances 
 showing epileptiform symptoms. 
 
 The prognosis in cases following shock or exhaustion is very favorable so that 
 such cases need not be considered unfit for further service, especially as there is 
 such a great need for recruits. When the question of indemnity arises it is dif- 
 ficult to state definitely, in such cases of psychic disturbance, that shock and 
 fatigue are the only causes of the condition, but we must admit that war experi- 
 ences are direct causes of the disease in individuals with a luetic taint, in manic 
 depressives and in cases of dementia praecox. 
 
 In cases of so-called "mobilization psychosis", particularly of the catatonic or 
 paranoid form, a latent pre-existing psychosis must frequently be assumed. 
 
 Nonne, Max. The Therapeutic Use of Hypnosis for Cases of War 
 Hysteria (Zur therapeutischen Verwendung der Hypnose bei 
 Fallen von Kriegshysterie) Med. Klin., Berlin, 11:1391-96, 
 Dec. 19, 1915 
 
 The writer has come to the conclusion, through his observations, that hysteria 
 is the most frequent of all war neuroses. After a very clear and comprehensive 
 definition of hysteria according to his conception of the term, he discusses diag- 
 nosis. The first point emphasized is that the clinical picture and course of the 
 case prove absolutely the presence of a purely functional disturbance; whether in 
 the genesis of the clinical picture mechanical, psychogenic or ideogenic factors 
 were wholly or partly active or entirely absent is of no consequence in the prac- 
 tical diagnosis. To speak of cramp neurosis, akinesia, dyskinesia amnestica, 
 fright neurosis, anxiety neurosis, cardio-vascular symptom complex, etc., has 
 no point; this giving to certain clinical pictures names suggesting the possibility 
 of incurability is to be strictly avoided. 
 
 Nonne found 151 neuroses among 352 nervous cases that came under his care. 
 Yet the proportion of such cases is comparatively small when one realizes that, in 
 
 making the rounds of the reserve hospitals of the Army Corps, among 600 
 
 patients there were only ten cases of war neurosis. The writer believes that a 
 wrong impression as to this proportion has been spread abroad through incorrect 
 diagnoses. He describes in detail several cases labeDed as organic in which the 
 predominant symptoms disappeared after a few hj^^notic treatments, and ad- 
 mits that such faulty diagnoses are easily made in cases in which hysterical 
 paralysis is associated with vasomotor disturbances. It is surprising to note 
 the disappearance of the chief symptoms as soon as the functional vasomotor 
 disturbances are removed. 
 
 Hysterical disturbances were usually monosymptomatic. The majority of 
 cases had never shown any previous signs of nervous disturbance or of a neuro- 
 
49 
 
 pathic condition. An initial state of unconsciousness was usual, but some cases 
 showed no disturbance of consciousness at any time. 
 
 The writer's observations led him to the conclusion that in most cases no cure 
 is possible. Sometimes there is a temporary cessation of symptoms, but the cure 
 is rarely lasting or complete. Curative measures employed were hydrotherapy, 
 electrotherapy, massage, gymnastics, and mental suggestion. Hj'pnotism has 
 rarely been used, for there is a marked prejudice on the part of the medical pro- 
 fession against its employment as a therapeutic method. The author makes a 
 strong plea for its use, not only in helping the patient to recover from his dis- 
 abling symptoms, but also in clarifying the diagnoses of doubtful cases. In the 
 sixty-three cases treated by him, the predominating symptoms were as follows: 
 
 Abasia astasia 14 
 
 Superior monoplegia 11 
 
 Inferior paraplegia 5 
 
 Hemiplegia .' 3 
 
 Mutism 5 
 
 General tremors 12 
 
 Isolated muscle contractures 6 
 
 Isolated sensory disturbances 1 
 
 Isolated tics 4 
 
 Isolated respiratory spasms 2 
 
 Of these sixty-three cases, fifty-one were cured, or rather freed of their symp- 
 toms. One case out of each of the above groups is described in detail. One 
 quick spontaneous cure, and this only a partial one, occurred in the total num- 
 ber of cases. Five patients were cured by suggestion without inducing hyp- 
 notic sleep, and twenty-eight quick cures followed the use of hj-pnotism. In 
 twenty-three cases gradual cures were brought about through employing hj'p- 
 nosis. In closing, Nonne summarizes the etiological factors cooperating in the 
 production of the symptom complex of hysteria. Among the least important 
 are neuropathic heredity and diathesis. Hypnosis was used with equal success 
 for such cases and for patients who had no such abnormality. The various 
 classes of society and city and country dwellers showed about the same degree of 
 responsiveness to hj^pnotic treatment. 
 
 Lowy, Max. Neurological and Psychiatrical Observations on the War 
 (Neurologische und psychiatrische Mitteilungen aus dem 
 Kriege) Monat. fiir Psych, u. Neurol., Berlin, 37: 380, 1915 
 
 With the exception of a few cases of intercostal neuralgia, trigeminal neural- 
 gia, herpes zoster, tetanus following dysentery and a larger number of cases of 
 eschias, neurological and psychiatrical disturbances in the writer's regiment were 
 rare. This regiment belonged to the "Landsturm" and was composed mostly of 
 men between the ages of thirty-two and thirty-eight. Light beer was used on 
 the average of from three to four pint-glasses a day. This amount was increased, 
 however, on Sundays and holidays. Whiskey and wine were rarely used. Men 
 such as saloon-keepers, waiters, cooks, etc., with an alcoholic predisposition, de- 
 veloped cases of alcoholism. 
 
 The majority of psychoses present were depression, manic-depression, and 
 compulsive ideas on a depressive and psychasthenic basis, hypochondria, de- 
 mentia precox and epilepsy. Attempts at suicide were rare. iVll those with 
 manifest psychoses had been excluded at the time of the physical examination 
 for recruits, therefore the number of cases occuring later was smaller than had 
 been expected. 
 
 Since war is like prison in as much as it causes a total change of the conditions 
 of life, one might expect to find clinical pictures resembling prison psychoses. 
 
50 
 
 However, only two such cases occurred, one with Ganger's syndrome, and the 
 other with paranoid phantasy symptoms accompanied by hallucinations, but 
 with no loss of orientation. 
 
 It is also remarkable that among 1,000 soldiers who habitually used alcohol in 
 moderate and sometimes larger quantities there was not a single case of delirium 
 tremens after several weeks of total abstinence in spite of the presence of pre- 
 disposing factors such as gastro-intestinal disturbances, fever, pneumonia, 
 pleurisy, etc. Fresh air and vigorous exercise seemed to offset somewhat the 
 effects of predisposition. In one case the use of alcohol after long abstinence 
 caused a pathological intoxication. 
 
 The effects of heavy shell-fire are next in importance to alcohol as an etiological 
 factor in psychiatric cases. Diarrhea and an increase in dysentery during heavy 
 shell-fire was frequently observed. Paresthesia and weakness in the legs often 
 remained days after the cannonade had ceased. Some paresthetics showed 
 symptoms of symmetrical hysteriform analgesia of the hands and feet, most fre- 
 quently of the glove and stocking type. One case complained of poor eyesight, 
 and one showed a limitation in the field of vision. There was also one instance 
 of traumatic neurosis with a suggestion of verbigeration. Cases of epilepsy 
 during the march or in the fighting line were rare. 
 
 Meyer, S. War Hysteria (Kriegshysterie) Deutsche med. Woch., 
 Berlin, 42: 69-71, Jan. 20, 1916 
 
 The clinical picture of hysteria changes with periods of time and with man. 
 It reflects like a mirror phases of the mental states of man, — the races, classes, 
 sexes, and different degrees and kinds of education. Hysteria always follows in 
 the wake of great movements, therefore it is to be expected that we should find 
 it now accompanying the world war. 
 
 A traditional theory has existed that hysterical symptoms can always be traced 
 back to suggestion or auto-suggestion; that hysteria is really imaginary. The 
 war has proved conclusively that the cause of hysteric states must be more than 
 mere suggestion; that the patient must have had an actual, disturbing experi- 
 ence to develop such symptoms. The forms in which hysteria appears are 
 strongly influenced by the war. For instance, hysterical paralyses are very 
 rare among males in times of peace, but in wartime they are numerous, and were 
 invariably, in the author's experience, sequelae of shell explosions or of injuries 
 from ■ bullets, resulting in inability to use the limbs. Contractures are often 
 found and sometimes a combination of contracture and hysterical paralysis. 
 
 Prognosis in cases of hysterical paralysis following shock is usually favorable, 
 but paraplegias resulting from bullet wounds are apt to resist treatment rather 
 stubbornly. The writer condemns strongly the suggestion theory of the origin 
 of hysteria in treating patients. He advocates assuring cases that their organs 
 are intact and that they will certainly recover the use of them, but he denies that 
 they can be "talked out of" their disease any more than that they have been 
 "talked mto it." 
 
 The exciting causes of war hysteria are varied, but all have a common ele- 
 ment — the affective factor which is the sine quo non of the production of the 
 disease. On the other hand, in the hysteria of everyday life, we have to deal 
 with a continuation and intensification of symptoms due to some pathological 
 organic condition. 
 
 _ Treatment is not easy, but is invariably successful if the patient can be con- 
 vinced that he is improving. 
 
 Such cases should never be returned to the ranks, as relapses are almost 
 inevitable. 
 
51 
 
 Schultz, J. H., and Meyer, Robert. On the Clinical Analysis of the 
 Effect of Shell-shock (Ziir klinischen Analyse der Granatschock- 
 wirkung) Med. Klin., Berlin, 12: 230-33, Feb. 27, 1916 
 
 The term "shell-shock" is often applied to the diagnosis of cases where the 
 symptoms are not all recognized. It is used in about the same way that "trau- 
 matic neurosis" is used in times of peace. "Shell-shocked" patients are those 
 who have been in close proximity to an exploding shell, but who have not re- 
 ceived any visible injuries. They may complain of headache, auditory and 
 equilibratory disturbances, insomnia, changes of personality, irritative motor 
 symptoms and tremors. All these complaints must be carefully considered, and 
 close cooperation of neurologist and otologist is advised. The Barany testis 
 indispensable. The writers have had their patients examined by an otologist 
 first. He subclassified them into (a) cases with traumatic rupture of ear drum, 
 and (b) those with the otoscopical picture of a normal drum. Both groups had 
 an impairment of hearing in one or both ears. 
 
 The histories of patients were recorded as completely as possible. The Barany 
 test was finally given but, since no revolving chairs were obtainable, the observa- 
 tions were limited to the phenomena occurring spontaneously or after caloric 
 stimulation. 
 
 Several cases from the above mentioned groups are described. To illustrate 
 the method of examination, a single tj^ical case wiU sufiice. A certain soldier 
 came under observation three days after a shell had exploded directly in front of 
 him. He claimed to have been unconscious for fifteen minutes, and, from that\ 
 time on, to have suffered from vertigo, impairment of hearing and headache, 
 especially over the eyes and in the occipital region. There had been'no vomiting 
 however. Otoscopy showed both drums unaffected, with normal light reflex. 
 However the power of hearing was diminished in both ears. Family history was 
 negative. The patient had taken part in the campaign from the[ beginning and 
 had had dysentery. He now complained of "being easily startled" and of dis- 
 turbed sleep. Examination showed sluggishness of pupillary' reflexes to aU stim- 
 uli, mild tremors of hands and tongue, and slightly increased reflexes. 
 
 The writers draw the following conclusions: 
 
 Psychopathic individuals react upon a psychophysical injury with various 
 symptoms which are not to be explained by the nature of the injury but by the 
 mode of reaction of the individual case. It is for this reason that predisposed 
 individuals will invariably, in case of shell-shock, show the same type of psycho- 
 pathic symptoms that would be likely to arise under other conditions of strain, 
 A few cases are described to show that prognosis in non-predisposed individuals, 
 even in cases of severe labyrinthic disturbance, is much better than that in pre- 
 disposed persons. 
 
 As forms of treatment the authors suggest isolation, hypnosis, psychotherapy, 
 catheterization and massage in accordance with individual requirements. 
 
ITALIAN LITERATURE 
 
 Periodicals Abstracted 
 Chirurgia degli Organi di Movimento, Bologna 
 Giornale di Medicina Militare, Rome 
 Policlinico, Rome 
 Riforma Medica, Naples 
 
 Rivista di Patologia Nervose e Mentale, Florence 
 Rivista Italiana di Nem-opatologia, Psychiatria ed Elettroterapia, Catania 
 
ITALIAN LITERATURE 
 
 Mingazzini, G. Syndromes of Organic Nervous Lesions following 
 Shots through the Brain (Sindromi nervose organiche consecu- 
 tive a lesioni da poviettli del cervello) Policlinico, Rome, 23: 
 409-28, Dec. 1916 
 
 The writer, as director of the cUnic for nervous diseases at Rome has had ample 
 opportunity to study cases of bullet shot through the brain. He describes in 
 detail seven cases, which may be summarized as follows: 
 
 1. Penetrating shot through the left parietal bone, corresponding to the 
 Rolandic area, resulted in glosso-facio-brachial paresis on the right side. The 
 accompanying symptoms are hypesthesia, stereognosis and pain and heaviness in 
 the region of the skuU lesion. A secondary operation brought great relief. 
 
 2. Tangential shot through the left parietal bone, causing lesion of the superior 
 part of the Rolandic area resulted in spastic hemiplegia with atrophy of the right 
 hand and foot, muscular epileptiform spasms of the Jacksonian type on the 
 same side, and marked motor abasia and hypesthesia, especially pronounced in 
 the arm. An operation cleared up these symptoms, leaving only hemi-hypesthe- 
 sia. 
 
 3. Penetrating shot through the antero-medial part of the right parietal bone, 
 causing compression of the middle third of the paracentral lying underneath, 
 resulted in severe left hypesthesia and hemiplegia. When the bone splinters had 
 been removed, a crural monoparesis still remained, together with a more circum- 
 scribed hypesthesia. 
 
 4. Penetrating shot through the left parietal bone, injuring the underlying 
 cerebral tissues, resulted in severe dysarthria, spastic paralysis of right side, 
 Jacksonian epileptic fits and right hemi-hypesthesia. An operation did away with 
 all symptoms but did not affect the sensory disorders. 
 
 5. Penetrating shot through the left parietal bone, causing lesion of the Rolan- 
 dic area, was followed by complete motor aphasia, right hemiplegia and hypes- 
 thesia. Operation removed the aphasia and somewhat lessened the paralysis 
 but did not alter the sensory disorders. 
 
 6. Serious injury to the right parietal bone caused abscess in the Rolandic 
 area. When the abscess was healed, the following syndrome remained: spastic 
 paralysis of the extremities on the left side, with atrophy more marked in the 
 upper, Jacksonian convulsions in these same limbs, hypesthesia and petit mal 
 seizures. 
 
 7. Shot through the postero-lateral region of the left frontal bone with com- 
 pression of the centers of Broca and Rolando resulted in motor aphasia and right 
 hemiparesis. An operation did away with these symptoms but a marked as- 
 thenia in the extremities of the right side and a severe dysarthria appeared. 
 From these observations the writer draws the following conclusions: 
 
 1. Broca's region contains the speech centers and so influences directly articu- 
 lation. A lesion of this area may therefore give rise to motor aphasia and some- 
 times to dysarthria. 
 
 2. Marburg and Ranzi's statements, that bullet injuries of the brain result at 
 first in a flaccid paralysis which only rarely tends to become spastic, should be 
 modified. The writer has observed many cases with persistent spastic paralysis 
 associated with contractures. 
 
 3. Motor and sensory areas must be well separated, the latter extending in a 
 posterior direction much farther then the former. The writer believes this, since 
 in most cases operations cleared up the motor disturbances but did not affect 
 the sensory disturbances. 
 
 55 
 
56 
 
 Sandro, D. de. Functional Mutism from a Bomb Explosion and 
 Hysterical Mutism; their Cure by Etherization (II mutismo fun- 
 zionale da scoppio di granata e quello degli isterici. Loro cura 
 con I'eterizzazione) Riv. patol. nerv. e ment., Florence, 22 : 9, 
 Jan. 1917 
 
 A record of two cases, in a soldier aged 25 and a woman aged 35, in whom com- 
 plete cure of their mutism took place after three or four minutes' inhalation of 
 ether. The success of the treatment is attributed to the irritation of the res- 
 piratory tract in general and of the larynx in particular. — J. D. RoUeston, Rev. 
 of neurology and psychiatry 15: 331, Aug. Sept. 1917. 
 
 Redard, Paolo. Inability to Straighten the Spine as Effect of War 
 Traumatism. Chir. degli organi di movimento, Bologna, i: 
 257-67, May 1917. lUus. 
 
 Redard gives photographs of men who are unable to stand up straight, the 
 attitude resembling that of one trying to touch the floor with his finger tips. 
 One illustration shows twelve men with this form of contracture. The mild 
 cases, wdth signs of hysteria, recover without much being done, but the medium 
 cases require systematic treatment, and the grave cases with organic lesions in 
 the spine and emaciation are usually rebellious to treatment. Psychotherapy 
 and contrasuggestion are useful aids to the usual physical therapy. Men with 
 the mild forms do best when sent home, and in any event should be kept apart 
 from others with the same trouble. Attempts to straighten the spine should 
 be made very gently. Forcible correction in psychoneuroses may induce de- 
 plorable aggravation. As the trouble is almost invariably curable sooner or 
 later, the question of discharge from the army on account of disability should 
 not be even suggested.— J. A. M. A. 70: 350, Feb. 2, 1918. 
 
 SeppiUi, G. Mental Disturbances in Soldiers in Relation to War (I 
 disturbi mentali nei militari in rapporto alia guerra) Riv. ital. 
 neuropatol., psichiatr. ed elettroter, Catania, 10: 105-14, May 
 1917. References 
 
 Although there is no special war psychosis, war favours the development of 
 some psychopathic states rather than others, especially those in which the 
 emotional factor and physical factor constitute an important etiological element. 
 
 Among 260 soldiers admitted to the asylum at Brescia the majority presented 
 confusional syndromes. Other psychoses were less frequent. Neurasthenia 
 and hysterical syndromes were seen, especially those showing ambulatory de- 
 terminism and other atypical forms. — ^J. D. Rolleston, Rev. of neurology and 
 psychiatry 15: 337, Aug.-Sept. 1917. 
 
 Agostini, Cesare. Use of Epileptics in the War Zone (Sulla utilizza- 
 zione degli epilettici in zona di guerra) G. med. mil., Rome, 67: 
 24-33. Jan. 31, 1918 
 
 Agostini seriously discusses this subject. The likelihood of seizures at inoppor- 
 tune moments would ordinarily eliminate the epileptic from any sort of military 
 service. Nevertheless "epilepsy" is a very elastic term, comprising numerous 
 conditions in which major crises do not occur, as well as states which, while 
 attended with convulsions, belong not really under epilepsy but under psychas- 
 thenia. It is the subject who suffers only with the infrequent mild or abortive 
 crisis or symptomatic paroxysm who could be utilized for military work. It is 
 admitted that war has caused or awakened only a very small number of cases of 
 
57 
 
 true epilepsy. Many subjects of trifling epilepsy are interned in insane asylums 
 and prisons and some of them have learned trades and become skilled workmen. 
 Such men are also found in civil life, supporting themselves and but little in- 
 convenienced by their infrequent, mild seizures. Of 142 alleged epileptics 
 referred to the author's insane asylum, not over a third proved to be true epilep- 
 tics. The same overwhelming proportion of false epileptics occur in other 
 statistics. Apparently the skilled artisans among these subjects are those most 
 needed.— Med. rec. 93: 644, April 13, 1918. 
 
 Gatti, L. Paralysis from Shell Air Shock. Rif. med., Naples, 34: 102, 
 Feb. 9, 1918 
 
 Gatti reports a case of extremely acute paralysis with atrophy following 
 close on explosion of a large bomb without actual contact. The tetraplegia was 
 of the type of anterior poliomyelitis, and Gatti assumes that the anterior portion 
 of the spinal cord had been injured by the air contusion. He knows of only one 
 similar case on record. The paralysis and the atrophy gradually invaded all 
 the musculature except in the head and neck, but there were no sensory dis- 
 turbances and the sphincters behaved normally. Instances of traumatic anterior 
 poliomyelitis are on record. Some injury of the blood vessels in the bulbar 
 region is evidentlv responsible for the whole set of symptoms. — J. A. M. A. 70 : 
 1267, April 27, 19i8. 
 
LITERATURE OF THE NETHERLANDS 
 
 Periodicai^ Abstracted 
 Nederlandsch Tijdschrift voor Geneeskunde, Amsterdam 
 
LITERATURE OF THE NETHERLANDS 
 
 Van der Hoeven, H. Psychoses in Camp. Nederlandsch tijdschrift 
 voor geneeskunde, Amsterdam, i : 158, Jan. 19, 1918 
 
 Van der Hoeven relates that complete anesthesia of both halves of the body 
 was found almost constantly in the several hundred soldiers that have passed 
 through his service for nervous and mental disease. He foimd further that a 
 large percentage of the men could have the cornea struck with the handle of a 
 percussion hammer without the least trace of pain. There was lacrimation but 
 no pain. Restriction of the visual field was common, and urticaria was easily 
 induced by stroking the skin. He comments on the difficulty in the military 
 environment of examining men with psychopathies. The commander assumes 
 simulation whenever a man with normal temperature complains of symptoms, 
 and it is a fact that now all the manifestations of disease are more or less influ- 
 enced in the soldier by his distaste for military service and his longing to go 
 home. Entirely opposite to the e3q)eriences in civihan circles, the mobilized 
 Netherlands soldier more or less unconsciously strives to make the most impres- 
 sive presentation of his symptoms. With all other forms of disability, the classi- 
 fication of the men as fitted for full duty, light duty, and capable only of man- 
 ual work, has proved beneficial, but not so with the psychopathies. — J. A. M. A. 
 70: 1046, April 6, 19l8. 
 
 61 
 
RUSSIAN LITERATURE 
 
 Periodicals Abstracted 
 Russkiy Vrach, Petrograd 
 
RUSSIAN LITERATURE 
 
 Soukhanofif, S. A. War Psychoneuroses. Russkiy vrach, v. 14, 1915 
 
 Soukhanofif does not admit that the war generates special psychoses which might 
 be referred to a new definite group of mental derangement. Only the external 
 manifestations of the usual psychoses may be modified; the essential, fundamen- 
 tal symptoms and signs remain unchanged. The most common psychoneurosis, 
 the traumatic, appears in two forms : the commotional type, due to air concussion 
 of the central nervous system, and the psychogenous hysterical type, caused by 
 the emotional shock. Then there also occur combined forms in which the symp- 
 toms of both these types are found. In some cases, the psychogenous hysterical 
 phenomena complicate the clinical picture of an already existing neurosis, such 
 as psychasthenia and epilepsy. Finally, it must be admitted that air concussion 
 may cause anatomic changes in the viscera and the central nervous system, even 
 without external lesions. — J. A. M. A. 65: 1150, Sept. 25, 1915. 
 
 65 
 
SCANDINAVIAN LITERATURE 
 
 Febiodicai^ Abstracted 
 Hygiea, Stockholm 
 
SCANDINAVIAN LITERATURE 
 
 Nordlund, H. To Detect Simulation of Deafness. Hygiea, Stockholm, 
 79: 1361, Dec. 31, 1917 
 
 The long list of measures that have been proposed to detect malingering in 
 regard to the hearing shows that none of them is absolutely reliable. Nordlund 
 describes fourteen methods based on sp>eech; eleven tuning fork or similar meth- 
 ods, and seven methods for detecting bilateral deafness. Few attempt to 
 simulate absolute bilateral deafness; if it is attempted, the Gowseef method or 
 the Kindlmann method is instructive. With the former, the man's back is 
 brushed with a brush or the hand or both. Then the investigator uses only one 
 on the subject and the other on his own coat, brushing his own coat with the 
 brush or hand while the subject's coat is brushed with the other. The sound and 
 the touch combine so that the normally hearing are unable to tell whether the 
 hand or the brush is being used on their own backs. The deaf person, not hearing 
 the sound on the other i>erson, is able to tell by the sensation on his own back 
 which is being used. Unilateral deafness is tested best, perhaps, with the Lom- 
 bard-Barany method, that is, the use of an apparatus that produces a noise 
 intermittently while the subject is reading aloud in his ordinary voice. Uncon- 
 sciously he raises his voice and loses control of it when he hears the noise of 
 the automatic drum. It may be necessary to apply a number of the tests to 
 detect the simulation; if all give concordant results, they may be accepted as 
 conclusive.— J. A. M. A. 70: 968, March 30, 1918. 
 
 69 
 
LITERATURE OF THE UNITED STATES 
 
 Periodicals Abstracted 
 American Journal of Public Health, Boston 
 American Medicine, New York City 
 Boston Medical and Surgical Journal 
 Journal of the American Medical Association, Chicago 
 Medical Record, New York City 
 Mental Hygiene, New York City 
 Military Surgeon, Washington 
 New York Medical Journal 
 New York State Hospital Quarterly, Utica 
 Proceedings of the Boston Society of Psychiatry and Neurology 
 Proceedings of the New York Neurological Society 
 Proceedings of the United States National Academy of Sciences, 
 Washington 
 
LITERATURE OF THE UNITED STATES 
 
 Auer, E. Murray. Some of the Nervous and Mental Conditions Arising 
 in the Present War. Mental hygiene i : 383-88, July 19 17 
 
 Auer advocates the assigning at base hospitals of huts to the neuropsychiatric 
 service where soldiers suffering from functional nervous and mental conditions 
 may receive treatment in the way of rest, isolation, proper food, etc. 
 
 The great change for the soldier usually occurs on the firing line. The aver- 
 age man goes into training directly from indoor office work and is greatly im- 
 proved physically and morally by this training and by the outdoor life, but later 
 the fatigue of long marches, exposure, worry, the monotony of the trenches, 
 morbid fears, horrible sights, all tend to fan to a flame any neuropathic predis- 
 position — and careful inquiry into individual histories has almost invariably 
 shown that earlier neurotic manifestations can be proved in cases of nervous 
 breakdown. Physically these individuals are of the average masculine type, 
 often exhibiting stigmata of degeneration, such as low brow, facial asymmetry, 
 adherent lobules, deviated septum, high palate, etc. 
 
 Auer cites briefly a number of illustrations, taken from his observations while 
 on hospital duty with the British expeditionary force, of the numerous and 
 varied manifestations of "shell shock". 
 
 "The element of fear or anxiety was relatively uncommon, considering the 
 wealth of fear-producing stimuli, but in the markedly neuropathic individuals 
 one encountered a feeling of incompetence, a fear of doing something wrong and 
 consequently being shot, a premonition of some impending danger, a fear that 
 something might arise in which he would fail or of going to sleep lest he should 
 not awaken. . . . 
 
 "This outline is offered merely as a brief suggesstion of the comprehensive 
 possibihties and the necessity for trained neurologists and psychiatrists in the 
 present great war. Depressing as are these manifold conditions, it is with intense 
 pleasure that one sees the usually fortunate outcome of proper care in their disap- 
 pearance and the re-establishment of mental equilibium. ... At the base 
 hospital one can fairly well employ psychotherapy in the form of absolute quiet, 
 isolation, re-education and persuasion, and medicotherapy, hydrotherapy and 
 lumbar puncture when indicated. I cannot insist too strongly upon the value 
 of quiet, rest and isolation as practiced by placing screens when available be- 
 tween the cots in the early control of these cases. . . . Removed from the 
 site of trauma, the noise, and din, reassured as to safety, after a complete rest 
 of varied duration, the individual is almost invariably able again to resume his 
 place in civil life, where in time he looks back upon his illness, as he himself not 
 infrequently will say, 'as a dream,' or sometimes, more fortunately, has no 
 recollection of his experience." 
 
 Farrar, Clarence B. The Problem of Mental Disease in the Canadian 
 Army. Mental hygiene i: 389-91, July 1917 
 
 Of the total number of soldiers invalided to Canada, the proportion of nervous 
 and mental cases has been fairly constant at 10 per cent, classified as follows: 
 
 1. Neurotic reactions, 58 per cent. 
 
 2. Mentiil diseases and defect, 16 per cent. 
 
 3. Head injuries, 14 per cent. 
 
 4. Epilepsy and epileptoid, 8 per cent. 
 
 5. Organic diseases of the central nervous syst<-ni. 4 jxr <<'iit. 
 
74 
 
 These figures are compiled from the returns of medical boards which examine 
 the men to determine discharge disability. 
 
 Group 1 may be subdivided as follows: (a) Constitutional neurotic tempera- 
 ment. More or less permanent condition aggravated during service, not nec- 
 essarily at the front, (b) Somatoneuroses. Injuries and illness whether pre- 
 existent or due to service, upon which disproportionate subjective symptoms 
 have been built, and wliich often long survive the actual physical disability, (c) 
 Specific war-reactions developing in the majority of cases at the front under stress 
 of fighting. Predisposition is of course very often demonstrable in these cases as 
 well. Most typical of these reactions is the so-called "shell-shock," although, 
 to be sure, this condition in common with others of the group is made up of 
 symptoms characteristic of the neuroses in general. From the military records 
 it is not possible to differentiate numerically these various types, but the third 
 subgroup far outnumbers the others. 
 
 Group 2 comprises: (a) Psychoses of familiar types, the majority, as would be 
 expected, being dementia praecox. (b) Primary mental defect, (c) Psycho- 
 patliic inferiority. This condition, easily unrecognized in routine medical 
 boards, has been the cause of many obvious difficulties. The class includes 
 many of the inefficient and undesirable soldiers, whose history often shows that 
 they have made good neither in civil nor military life. They are usually the 
 trouble makers in the convalescent homes and furnish a considerable number of 
 the men with grievances concerning pension claims and treatment of the returned 
 soldier in general. 
 
 Group 3 is made up mostly of cases of gunshot or shell wounds of the head, 
 with loss of bone. Strictly considered, the majority of these cases might be 
 omitted from the categories of nervous and mental diseases. It is very rare for 
 a head case of this sort to present symptoms of neurosis or psychosis. Variable 
 headache and dizziness are the only fairly constant symptoms. 
 
 In group 4 the percentage of genuine epilepsy is not determinable from avail- 
 able records. Some of the cases with epileptiform convulsions turn out to be 
 initial paresis, or dementia praecox, or a neurosis. 
 
 Group 5, the smallest of all, is made up chiefly of paresis and tabes, with rare 
 diagnoses of brain tumor, multiple sclerosis, etc. 
 
 The program of differentiation and group treatment of nervous and mental 
 conditions among returned soldiers in Canada includes: 
 
 1. A reception hospital for war neuroses and similar conditions, observation 
 of doubtful states, etc. These cases are received at the Ontario Military Hos- 
 pital at Cobourg. 
 
 2. An institution for the severe and chronic types of mental disease. Hitherto 
 these cases have as a rule been sent to the provincial hospitals in their respective 
 districts. 
 
 3. The establishment of an institution or colony for epileptics is under con- 
 sideration. 
 
 4. The establishment of a center for the observation and treatment of syphili- 
 tic conditions is also contemplated. In most of the cases of paresis and tabes 
 there is a pre-enlistment history of infection, but the evidence on the records 
 points' as a rule to the development of the disabling symptoms during service. 
 The question of pensionability in many cases offers considerable difficulty. The 
 importance of attention to syphilitic history and serological and neurological 
 evidence of syphilis at examination of recruits is very obvious. 
 
 Hitherto where syphilitic treatment has been indicated in continuation of that 
 begun overseas, this has as a rule been done in active treatment hospitals, while 
 the later cases, such as paresis, have found their way to the provincial hospitals. 
 An initial segregation of all syphilitic cases among returned men at a center 
 where all the indications of observation, classification and treatment could be 
 met is believed to be desirable. 
 
75 
 
 5. Convalescent homes. These were the first institutions established in 
 Canada for the reception of disabled soldiers and accommodate all types of con- 
 valescents. While there is but one special institution of each type above referred 
 to, the convalescent homes are scattered throughout the Dominion and to them 
 cases are transferred when treatment has reached a late stage and especially if 
 it is desirable that an invalid should be in an institution in his home district. 
 
 The war reactions outnumber probably all other types of nervous disability 
 combined and demand proportionate attention in management and treatment. 
 At the special institution at Cobourg the following points are kept in mind: 
 
 (a) The maintenance of military discipline and individualized control is found 
 to be of indispensable and first-rate importance in dealing with these cases. 
 
 (b) Hydro-and electro-therapeutic treatment is of considerable service in 
 many cases. 
 
 (c) Occupation-therapy with suitable variety of work is of almost universal 
 importance. 
 
 Treatment of a higlily specialized sort has been developed under the auspices 
 of the psychological department of Toronto University, following the plan of 
 motor training applied by Dr. Franz at the Government Hospital in Washington. 
 This method is found useful in certain cases of functional paralysis, incoordina- 
 tion, affect-inhibitions, tremors, and other kinetic disorders. 
 
 In the general policy of caring for the war neuroses it has been demonstrated 
 over and over again, that patients while under treatment should be shifted as 
 little as possible from one institution to another. It is also as a rule not well to 
 have the patient in the vicinity of his home, and home visits are certainly con- 
 traindicated in the severer neuroses. The conscious will and purpose to get 
 well are often difficult to establish and all opposing factors must be kept in mind. 
 
 MacCurdy, John T. War Neuroses. Psychiatric bull. 2 : 243-354, 
 July 1917 
 
 Dr. MacCurdy defines war neuroses as "those functional nervous conditions 
 arising in soldiers which are immediately determined by modern warfare and 
 have a symptomatology whose content is directly related to war." Two t\pes 
 of war neuroses exist and may be classified as (1) conditions of anxiety, and (2) 
 conditions of simple conversion hysteria. Case liistories illustrating these two 
 types are given. The first trial the recruit usually meets is the exijcrience of 
 being shelled and he is immediately struck with fear. The sight of the mangled 
 remains of comrades also creates horror and it is with great efi"ort that the soldier 
 is able to check his feelings and grow accustomed to these sights. ISlany such 
 individuals do not fully recover from this state of mind and are therefore poorly 
 adapted to a soldier's life. They are quickly fatigued and develop disal)ling 
 symptoms. Fatigue is of great importance in the devcloj)mcnt of a neurosis as 
 it is the almost universal occasion of the dissatisfaction witli his work which leads 
 to a breaking down of the soldier's adaptability and the development of more 
 permanent symptoms. The conditions producing fatigue are l)oth physical and 
 mental. This condition is characterized by a feeling of tenseness, a restless de- 
 sire for action or distraction, irritability, difficulty in concentration and a tend- 
 ency to start at a sudden sound, such as that of expUxUng shells, without really 
 being afraid. At night there is great difficulty in falling askvp with a long perit)d 
 of hypnagogic hallucinations. When sleep (loes come, it is troubled by dreams 
 and therefore afforrls no real rest. When this condition persists for some time, 
 fear develops and then horror at the sights of carnage. Kitlier a physical ac- 
 cident or a mental shock may cause the final comi)lete breakdown. The stupor- 
 ous states that follow a concussion or some mental trauma may be characterized 
 by a loss of consciousness followed by a period during which consciousness re- 
 appears and then subsides again. While conscious, the patieiil is extremely con- 
 
76 
 
 fused, disoriented, complains of severe headache, is frequently incontinent or 
 suffers from retention and may have to be catheterized. Delirium, too, at this 
 time is a usual occurrence. In the functional type of stuporous state, the patient 
 lies with dilated pupils, in a cold sweat, with shallow breathing, incapable of any 
 voluntary movement and often trembling violently. When voluntary move- 
 ment is possible he is dazed, inactive, confused and amnesic. In this stage of 
 the neurosis, the patient's sleep is greatly troubled by violent nightmares and 
 becomes something to be dreaded. Photophobia may be a frequent occurrence 
 in the acute phases of the neuroses. ^Tremors are always present, and sometimes 
 ataxia. Symptoms suggestive of disturbances of the thyroid glands are very fre- 
 quent, but usually disappear in a short time. The eyes protrude slightly, and the 
 upper eyelid may lag behind the eyeball on looking down; the pulse is rapid, there 
 is excessive cold sweating and sometimes an enlargement of the thyroid gland. 
 Emotional coldness and inability to express affection are frequent. These symp- 
 toms tend to subside after a few weeks, but may last months. The patient 
 is still easily fatigued and stiU starts at sounds. Complications are likely to 
 appear, the most frequent of which is depression. The patient is dissatisfied 
 first with himself and then with the way in which he is treated. It is easy to 
 differentiate between malingering and anxiety neuroses, since the malingerer 
 will not speak frankly about his terror whereas the man in a true anxiety state 
 does not try to conceal it. 
 
 The treatment of the anxiety states depends upon the individual and should be 
 psychologically determined so that, whatever the cause, its effect may be re- 
 moved. For tliis reason, consistent plans of treatment should be followed and 
 patients transferred as little as possible from one hospital to another. They 
 should be placed in a quiet environment and yet not too far away from the firing 
 line so that they may not develop an idea of permanent freedom from military 
 duties. The first step in treatment should be absolute rest, usually for a short 
 time, so as to remove the fatigue symptoms. Sedatives should be used as little 
 as possible, preferably only on the first night. The patient must then be told 
 that he will soon recover but that he must help bring this about; that he will not 
 be asked to do anything disadvantageous to his health but that, since liis disease 
 is curable, he will eventually have to be sent back to the line. Everything should 
 be made as quiet and pleasant as possible for him. Occupation in some form 
 should be provided in every case, but it should be under the control of the phy- 
 sician who should watch its effects on each patient. It is essential for a cure that 
 the patient get some insight into the cause of his neurosis and that he be made to 
 understand how he had developed a tendency to tliink of liimself rather than of 
 the need of the army and the country and so became a victim of fear and horror. 
 When he sees that it was purely a selfish desire to avoid responsibility as a citi- 
 zen he will try to control his symptoms. In a short time, the man worth while 
 will be eager to help in the struggle. The physician must always sympathize 
 with the patient as an individual but must never relax medical discipline. 
 Many case histories are given to illustrate the course of the anxiety states. 
 
 Conversion hysterias are more frequent than the pure anxiety states but they 
 are much simpler in mechanism than the latter. They are defined as neuroses 
 "in which there is an alteration or dissociation of consciousness regarding some 
 physical function." Fatigue and anxiety are important factors in these cases 
 but to a less degree than in pure anxiety states. The symptomatology is ex- 
 tremely varied and consists mostly of those conditions that would provide relief 
 from active service. Mutism, aphonia and deafness are most frequent. Motor 
 disturbances including monoplegias and paraplegias or paresis are next in im- 
 portance. Tics, spasms, contractures, tremors are very common. Hyper- 
 esthesias may occur alone whereas paresthesia and anesthesia usually accompany 
 hysterical symptoms. Blindness, amblyopia and disorders of smell and taste 
 are rare. There is nearlv alwavs some weariness and a distinct aversion to 
 
77 
 
 fighting. The wish for a "bhghty one", or some form of physical injury or 
 disease, is present in practically every case. Occasionally the aversion to fight- 
 ing is the direct outcome of physical accident or disease that removes the patient 
 from the trenches, creating a desire not to return. This attitude constitutes the 
 background of hysteria. ^Vhen organic and functional disturbances are com- 
 bined diagnosis is difficult. The functional disturbances may overlap the other 
 and the physician may believe the condition to be non-organic. In such 
 cases a final diagnosis may be made only after treatment on purely functional 
 lines has been successful and has reduced the disability to its organic distribu- 
 tion. . . . 
 
 "Quite the most difficult problem, however, is to differentiate a conversion 
 hysteria from malingermg. As I have had little opportunity to see cases of 
 malingering as thej' are presented at the front, I am unable to say much on 
 this topic that is not second-hand. Some workers rely largely on the suggesti- 
 bility of the hysterical patient as a diagnostic criterion. Occasionally one meets 
 with a physician who goes so far as to state that no patient who is not hj'pno- 
 tizable has a true hysteria, and therefore must be malingering. As the individual 
 capacity to hypnotize varies greatly from man to man tliis is probably a rather 
 unsafe rule. Again, if one relies on the impression wliich the personality of the 
 patient makes on the physician, error is apt to be frequent. The true malingerer 
 is usually, if not always, a psychopath. Again it may require a rather exhaustive 
 study to determine whether the symptoms are produced on the basis of a con- 
 scious or an unconscious wish, wliich is essentiallj' the difference in etiology be- 
 tween malingering and hysteria. Probably the safer guide is the liistory of 
 onset. One should inquire, therefore, as to the mental attitude of the patient 
 before the symptoms began. In a true hysterical case an admission is apt to be 
 made as to the breaking down of adaptation to warfare and the consequent wish 
 to be rid of it all, particularly the wish for an mcapacitating wound. The malin- 
 gerer is not apt to reveal the history because the symptom represents this wish 
 to him quite consciously. The hysteric, on the other hand, because there has 
 been an unconscious motivation, does not see the connection between this pre- 
 vious desire to be incapacitated and the symptom liis malady presents. He is, 
 therefore, more apt to be frank in the matter. In another respect the history 
 may be of importance, I imagine. In all the cases, which I have had an oppor- 
 tunity of examining, whose symptoms arose wliile in the trenches, there was a 
 history either of concussion or of a definite precipitating cause, the immediate 
 result of which was some disturbance of consciousness, no matter how slight. 
 Frequently it amounted to no more than the patient's being dazed for a few 
 minutes and finding himself with the hysterical symptom, when he became quite 
 clear again. As the opinion of the physician on this matter when delivered to a 
 court martial may mean life or death for the soldier, I would prefer to leave this 
 last diagnostic criterion as a suggestion until such time as further experience may 
 show whether the phenomenon in question is universal or not." 
 
 Naturally individuals with a psychoneurotic temperament are more apt to 
 develop symptoms and, when these are removed, to develop new ones, than the 
 more normal soldiers. However, symptoms may remain for a long time, even 
 in the latter group, unless appropriate treatment is given. 
 
 Strict discipline has often been successful but there is always the danger that 
 too much coercion may be regarded by tlic patient as unjust and therefore a 
 firmer foundation for neurotic symptoms be laid. Treatment based on sug- 
 gestion, including hypnotism augmented by electricity, has been more suc- 
 cessful than disciplinary treatment but many objections may be made to this 
 combined method. It is of doubtful value because it aims at the removal of 
 symptoms rather than of causes. The patient, himself, cured in such a way, 
 regards the treatment as a miracle and fears recurrence. The best method of 
 treatment for the conversion hysterias is undoubtcfily reeducation. The patient 
 
78 
 
 should be told the nature of his symptoms and that he must help to regain the 
 lost function. At this point suggestion may be of great value. It is also of im- 
 portance that the physician establish a friendly relationship with the patient 
 and encourage him to speak openly of his fears and troubles. 
 
 Many men are invalided from the trenches with heart symptoms, who show 
 no signs of valvular trouble. This has been called "soldier's heart." The 
 symptoms are weakness, shortness of breath, palpitation and dizziness. Fre- 
 quently there is a region of hyperalgesia over or near the heart. It is suggested 
 by some physicians that this "disordered action of the heart" is a form of the 
 war anxiety neurosis. Some internists state that fifty per cent of these cases are 
 neurotics. Among cases that MacCurdy has examined he recognized two types 
 that correspond roughly to the anxiety and conversion hysteria groups. The 
 first group have a strong desire for death before the actual appearance of the 
 symptoms. In the second group there is a desire for an incapacitating wound 
 and the heart symptoms are looked upon as a disease and not worried about. 
 On the whole the number of cases of purely neurotic heart conditions that develop 
 at the front is insignificant when compared to the anxiety states and common 
 conversion hysterias. 
 
 In conclusion, MacCurdy speaks of the prophylactic measures to be taken to 
 prevent such great loss in the efficiency of the army as war neuroses have pro- 
 duced. Careful exclusion of the unfit at the time of enlistment is necessary, but 
 many difficulties arise in connection with this method. Often the man best 
 adapted to civil life is not capable of being the best soldier. On the other hand, 
 there are men who have shown histories of previous breakdowns, yet who 
 turned out to be fine soldiers. The only thing to be done is to exclude all those 
 who show marked psychopathic tendencies and who, at the time of enlistment, 
 are ill-adapted to civil life. It would be well if the physician could reexamine 
 all the doubtful cases after a few months of training and, if they have improved, 
 give them a chance at the front. Another point of importance in prophylaxis 
 is that the soldier must frequently be relieved from duty and be given as many 
 distractions as possible. MacCurdy says: "At the present time the line officers 
 of the British Army are as acutely aware of the necessity for rest and distraction 
 as are the physicians, and the reason for this is that they have discovered that, no 
 matter how much men may be forced and no matter how willing they may be to 
 continue in the trenches, they nevertheless become inefficient when subjected to 
 more than a certain amount of fatigue. If at all feasible, a system of relief 
 should be worked out in a conference between psychiatrists and the staff. If 
 also practicable, a certain laxity in the arrangements should be left whereby 
 psychiatrists might be allowed the privilege of removing certain men from the 
 trenches earlier than they would their fellows. If possible, this would be of 
 great military advantage, as the histories of many patients show that, when they 
 have an opportunity to rest, they quickly recover from the premonitory symp- 
 toms of a war neurosis and return to fight again quite competently. Once the 
 disease has progressed beyond a certain point, however, there seems to be no 
 return except after a long period of treatment. ... It goes without saying 
 that all forms of comfort and distraction, particularly the presence of palatable 
 food and drink, are of importance from a medical standpoint in the present war 
 as they never have been before. Where every factor seems to operate in making 
 it hard for the soldier to maintain his adaptation — his pleasure in the service — 
 it is essential that his difficulties should be reduced to a minimum, and that, on 
 the other hand, he should be furnished with every possible means for giving him 
 that pleasure which would distract his mind from all that is unpleasant and 
 horrible around him. 
 
 "Finally, when men are sent back to rest camps in order to recover from their 
 fatigue it would be highly desirable that they should receive an examination 
 before they return to active duty again. As has been shown in a number of 
 
79 
 
 cases in this report, the prospect of returning to duty, when recovery has not 
 been complete, is frequently the occasion for utter discouragement and conse- 
 quent collapse. In a war that may last for years an extra week or even an extra 
 month of absence from the trenches is less loss to the army than is that which is 
 occasioned by the protracted convalescence wliich follows only a week, per- 
 haps, of efficient service. Here again the problem is reduced to a question of 
 adapting indi\'idual treatment to the miUtary necessities that consider all men 
 alike." 
 
 In the course of the article twenty-seven case histories are described in detail. 
 
 Neymann, Clarence A. Some Experiences in the German Red Cross. 
 Mental hygiene i : 392-96, July 1917 
 
 After a five years' residence in Germany the writer had just finished liis state 
 examinations at Heidelberg and entered the department of hygiene to study 
 serology when the war broke out. He was persuaded to join the German Red 
 Cross, where he remained untU the end of April 1915. 
 
 He states that during the early period of the war, in fact, until the battle of the 
 Marne, not a single mental case was received at the hospital where he was sta- 
 tioned. This, he thinks, was probably due, partly to the attitude of the German 
 army, buoyantly sure of speedy victory, and partly to the fact that, on account of 
 this feeling, no provision had been made for specialized treatment of any kind, 
 so that no attention was paid to soldiers who behaved in queer waj's. When the 
 fighting changed from open to trench warfare the whole situation was changed. 
 Hardly a transport of sick and wounded arrived but contained its quota of mental 
 cases. The psycliiatric clinic was used only for patients with serious mental 
 aflBictions so psychoneurotics had to be treated at base hospitals. When the 
 hospitals had no psycliiatrist on their staff, these psychoneurotics were looked 
 upon as nuisances, so were transferred to the evacuation hospitals, where they 
 "stagnated" for a while, and were eventually returned to the front. There all 
 their sj'mptoms returned immediately and they were returned to the base hos- 
 pitals. Sometimes single men made this circuit as many as three times. Fi- 
 nally the government took charge of the matter and assigned to each base hospital 
 a psychiatrist or arranged for regular visits from one in the vicinity. These 
 psychiatrists dealt also with cases of slackers. The government also issued a 
 proclamation warning against returning psychoneurotic patients to the front, 
 and recommending various duties for them in the rear or at home. This caused 
 a great improvement in conditions. 
 
 One t^-pe of psychoneurosis was particularly frequent and noticeable. It was 
 called Granatfieber, grenade fever. All suffering from it seemed poorly built 
 physically and constitutionally weak. They complained of indigestion, back- 
 ache, and headache, grew pale and trembled, and in some cases lost control of 
 their legs and fell to the ground whenever grenades were mentioned or expe- 
 riences on the firing line related. 
 
 Another class of cases consisted of individuals who had had very trying ex- 
 periences which had led them to simulate some mental or physical disorder for 
 which others had been sent to the rear. Sometimes this simulation was kept up 
 for months. "It is hardly to be wondered at that a man who naturally has not 
 much strength of character grows tired after months of trench life and quits, 
 either by purposely exposing himself to the fire of the enemy, or by simulating 
 some disorder. All such individuals were considered unfit for duty at the front." 
 
 A third tj^jc are those slightly deficient mentally. The trooi)s from Bavaria 
 are notably brave, yet among their wounded one finds many high-grade morons. 
 These individuals have as a rule not proven bad soldiers. 
 
 "Of course there were all sorts of individual reactions. Those patients who 
 had gone through depressions in previous years again became depressed. Hypo- 
 
80 
 
 manic individuals became very wild and lost almost the last remnants of civili- 
 zation. . . . After a rest in the hospital for a period of time they usually 
 calmed down again and became manageable." 
 
 Salmon, Thomas W. Use of Institutions for the Insane as Military 
 Hospitals. Mental hygiene i : 354-63, July 191 7 
 
 The British War Office asked the Board of Control in January 1915 to co- 
 operate in an attempt to provide 50,000 beds for wounded soldiers. A plan 
 was formulated whereby ninety-two countj'^ and borough asylums were divided 
 into ten groups and one institution in each group vacated for military use. 
 Major Salmon quotes in full "Circular A — Use of Asylums as Military Hos- 
 pitals", describing a scheme prepared by the Board of Control for the general 
 administration of vacated asylums and the details of reimbursement which the 
 War Office undertook to make to receiving and vacated institutions of this kind. 
 This is followed by "Circular B — Use of Asylums as Military Hospitals", giving 
 in detail observations by the War Office supplementary to their general con- 
 firmation of the scheme described in Circular A. The first employment of this 
 plan made about 12,000 beds available, and by July 1, 1917, 27,158 beds were 
 ready for use by the War Office. Even when a military hospital was to be used 
 for insane soldiers, the name was changed from "asylum" to "hospital" so that 
 the patients should escape the "stigma" of having been treated in an institution 
 for mental disease. 
 
 A list of these converted institutions follows. The total cost of turning over 
 these hospitals was not ascertained. In the case of the Norfolk Asylum it 
 amounted to $90,000. The capacity of the institutions was almost invariably 
 increased. 
 
 Major Salmon next describes the changes in personnel and administration 
 necessitated by the new use to which the institutions were put. Most of the 
 buildings were of the cottage or small detached building tj^pe. 
 
 This article is embodied as Appendix II in Major Salmon's report upon the 
 "Care and Treatment of Mental Diseases and War Neuioses ("Shell Shock") 
 in the British Army." 
 
 Yerkes, Robert M. Relation of Psychology to Military Activities. 
 Mental hygiene i : 371-76, July 1917 
 
 The article describes briefly a few of the many lines of service for national 
 defense open to the psychologist. The WTiter says: "Since the psychologist 
 deals especially with the conscious activity of men, he should be a master in the 
 description and valuation of human nature and an expert in the measurement of 
 significant aspects of human response. In this capacity, recruiting offers him an 
 important special task; that namely, of classifying men according to their mental 
 characteristics, and of indicating their degree of adequacy for military training 
 or special tasks in the military organization. By means of especially developed 
 and adapted methods of psychological examining, it should be possible to gain 
 information concerning each individual upon which may be based important 
 recommendations to medical or to line officers." 
 
 Major Yerkes believes that certain grades of mental defectives need not be 
 excluded from military service, but that suitable places may be found for them 
 in military as well as industrial organizations. Another point realized by psy- 
 chologists is the unsuitability to military requirements of many of the current 
 methods for psychological examination, and the necessity for preparing new and 
 specially adapted methods. "In connection with the preliminary handling of re- 
 cruits, it is the prospective function of the examining psychologist first, to aid 
 in the elimination of those who cannot safely render service worth their hire; 
 second, to indicate various degrees and kinds of special ability and to relate 
 
81 
 
 them to the tasks of army and navy, so that each individual shall be placed in 
 a position of maximum usefulness; and third, to detect those who, by reason of 
 mental instability or psychopathic condition, demand the attention of the 
 medical expert. Such individuals should be referred to the staff of the neuro- 
 psychiatric hospital unit for special study." 
 
 In conclusion the writer outlines a few of the military applications of psy- 
 chological measurements, such as in the study of gunnery, and the examination 
 of aviation recruits. 
 
 Journal of Amer. med. assoc. 69: 1458, Oct. 27, 1917. The War and 
 General Paralysis (Paris Letter, Sept. 27, 191 7) 
 
 The three Paris societies which are devoted to the study of mental diseases, 
 the Societe clinique de medecine mentale, the Societe medico-psychologique and 
 the Societe de psychiatric, recently held two joint meetings to discuss two im- 
 portant questions in military mental medicine; the discharge of men with gen- 
 eral paralysis; and shell shock with its special etiology, evolution and sequels, 
 A whole session was devoted to each of these questions in turn, with M. Justin 
 Godart, undersecretary of state for the military medical service, in the chair at 
 one meeting, and Dr. Simonin, medical inspector, presiding at the second meet- 
 ing- 
 
 The discussion on the discharge of soldiers with general paralysis was brought 
 about by the extremely severe rule voted by the Societe de neurologic in Decem- 
 ber, 1916, on this subject, and by the too literal application of tliis rule by the 
 medical men entrusted with the task of passing on the candidates for discharge 
 from the army. The society had officially declared that every soldier with 
 general paralysis should be granted discharge no. 2, except when he had been 
 the victim of traumatism of the brain, in which case discharge no. 1 should be 
 granted with an incapacity rate of from 10 to 30 per cent. 
 
 Dr. Pactet, in the leading address, demonstrated that a doctrinal question 
 was responsible for the vote of the Societe de neurologic, namely, the belief that 
 general paralysis is exclusively syphilitic in its origin. But to be syphilitic is not 
 enough to bring on general paralysis. Can any one affirm that the fatigues, the 
 emotions, the dangers of the war do not play a part in localizing, aggravating 
 and accelerating the production of the meningo-encephalitis? Instead of re- 
 garding en bloc all the cases of general paral^'sis, each should be given a separate 
 examination, and in each individual case the effort should be made to estimate 
 the part for which the circumstances of war are responsible, just as is being done 
 for the tuberculous. The military authorities must be asked for the data as to 
 the services imposed on the patient, and if the general paralysis seems to have 
 been influenced by them, then grant discharge no. 1, with a. pretty high rate of 
 incapacity. Dr. Lepine, professor of nervous and mental diseases at Lyons, de- 
 clared his views as entirely in accordance with those of Dr. Pactet. Dr. Dupr6, 
 agrege professor at Paris and hospital physician, insisted on the exclusively 
 syphilitic origin of general paralysis, and demanded that discharge no. I should 
 be reserved for cases in which some grave war mishap could be invoked. 
 
 Dr. Marie, physician-in-chief to the public Asiles of the Seine deparlment. 
 and Lortat-Jacob, Paris hospital physician, gave a description of the general 
 paralysis of wartime as running a much shorter course, with no interniission, 
 with repeated sudden attacks, and with an early fatal outcome, skipping the 
 stage of helpless dementia. Dr. Vallon, physician-in-chief of the Asile Sainte 
 Anne, reiterated that the interests of the patients must not be sacrificed to too 
 absolute theories — "fragile, like all theories." In the question of discharge from 
 the military service, as in all medicolegal problems, each case must be studied 
 separately, and the men on active service should not be treate<l any less favor- 
 ably than workmen becoming paralyzed after an industrial accident. 
 
Dr. Rubinovitch, physician-in-chief of the Bicetre and Salpetriere hospitals, 
 expatiated on the lessons to be learned from the Russo-Japanese War, which led 
 to recrudescence of cases of paretic dementia in the army. Dr, Colin, physician- 
 in-chief of the insane asylum at Villejuif, presented an array of exact data re- 
 garding the cases of general paralysis in soldiers that he has had in his charge. 
 He remarked further that wounds of the brain are spoken of always as authoriz- 
 ing discharge no. 1, but in this connection it must be borne in mind that general 
 paralysis has never been observed in men wounded in the brain. The physicians 
 on the military discharge commissions interpret in the narrowest sense the term 
 traumatisme enciphalique. The restrictions in question will not be applicable to 
 more than a small proportion of the patients — not over 15 per cent — the majority 
 of cases being among the territorials, the noncombatants. He then specified 
 some cases in which the routine application of discharge no. 2 would constitute 
 a revolting injustice. 
 
 The following rule was finally definitely adopted by a unanimous vote. For 
 men with general paralysis, accord discharge no. 2, except in special cases in 
 which a careful inquiry would demonstrate in times of peace, and more especially 
 in time of war, the aggravating influence of military service. The rate of dis- 
 ability should then be from 60 to 80 per cent. 
 
 Mayer, Alfred G. On the Non-Existence of Nervous Shell Shock in 
 Fishes and Marine Invertebrates. Proc. U. S. National acad. 
 sciences. 3: 597, Oct. 1917 
 
 Mayer's experiments at Tortugas, Florida, during the summer of 1917, 
 indicate that the nervous system of fishes and invertebrates are remarkably 
 resistent to the injurious effects of sudden explosive shocks transmitted 
 through the water. Many experiments were made on the Scyphomedusa 
 Cassiopea Xamachana. The medusae were paralysed by removing their mar- 
 ginal sense organs, and then a ring-shaped strip of sub-umbrella tissue was set 
 into pulsation by an induction shock, thus producing a single neurogenic con- 
 traction which travels through the circuit-shaped strip of tissue at a uniform 
 rate of speed, provided that temperature, salinity, and other factors remain 
 unchanged. It is thus possible to ascertain accurately not only the rate of 
 nerve conduction, but also the peculiar individual characteristics of the wave 
 in each pulsating ring. These rings were placed in a light silken bag immersed 
 about ten feet below the surface of the sea; and then half a stick of dynamite was 
 exploded within three feet of them. This, however, produced no effect either 
 upon their rates or the characters of their pulsation waves, although fishes pos- 
 sessing swim-bladders were killed within ten feet, and injured so that they turned 
 ventral side uppermost within twenty feet of the exploding dynamite. When 
 the pulsating rings were placed in glass jars or tin cans, partially filled with air, 
 the containers were crushed or shattered by the explosion, and much mechanical 
 injury suffered by the medusa rings, which, however, could at once be restored 
 to normal pulsation by an induction shock if their pulsations had ceased. It 
 was also observed that the lacerated area regenerated at a normal rate. Experi- 
 ments proved that fishes with swim-bladders are more sensitive to explosive 
 shocks than those without swim-bladders; thus a half stick of dynamite exploded 
 within 3 feet of a small shark, which has no swim-bladder, produced no apparent 
 injury: this applied also in a lesser degree to such taleosts as lack swim-bladders. 
 Dr. Ball dissected some of the swim-bladder fishes killed by the explosion; he 
 found that the swim-bladder had burst, and the tissues were crushed in around 
 it, the vertebral column being often broken. It seems, then, that in the lower 
 forms the injurious effects of dynamite explosions, when present, are due to 
 mechanical laceration of tissues, and especially the crushing inward of air-filled 
 cavities. "It seems possible, therefore, that the cavities of the middle ear and 
 
88 
 
 Eustachian tubes may be a source of clanger to men standing near exploding 
 shells." The writer thinks that his experiments with the pulsating rings of 
 Cassiopea negative the suggested hypothesis that the sudden reduction in atmos- 
 pheric pressure close to an exploding shell might set free dissolved gases in the 
 blood and elsewhere, thus vacuolating the tissues and producing pressure and 
 other effects upon the nerves; for no injurious effects other than those of simple 
 asphyxiation were produced by a sudden exhaustion of the air surrounding the 
 animals; and recovery, when they were placed in normal sea water, was almost 
 immediate. He holds that these results are in accord with the conclusions of 
 Grasset, Eder, Babinski and Froment, and others, that war shock is predomi- 
 nantly a psychic phenomenon, and being hysteria it can be cured by hypnotic 
 suggestion. — L. J. Kidd, Rev. of neurology and psychiatry 15: 335-37, Aug.- 
 Sept. 1917. 
 
 Salmon, Thomas W. Care and Treatment of Mental Diseases and 
 War Neuroses ("Shell Shock") in the British Army. Mental 
 hygiene i: 509-47, Oct. 1917 
 
 The article consists of sections of Major Salmon's report on his recent visit to 
 England, together with an appendix entitled "Facilities Needed for Efficient 
 Treatment of Mental Diseases in a Modern Public Institution." For abstract 
 of the full report see p. 92-96, 
 
 Hammond, Graeme M. Neurological and Mental Examination of 
 State Troops of the National Guard. Address at meeting of the 
 New York Neurological Society, Nov. 13, 191 7 
 
 Major Graeme M. Hammond, M.D., M.R.C., gave a general review of the 
 work he had been doing in examination of the troops of the National Guard in 
 this city and at the camps. When he received orders in August from the Sur- 
 geon General to examine all the militia in the vicinity of New York City, he 
 was at first unprepared to act, for he realized his own efforts could be so small in 
 such a tremendous task. So he enlisted the interest and assistance of twelve 
 able neurologists and psychiatrists who agreed to help him in the work and they 
 formed themselves into an examining board. 
 
 The troops were scattered throughout the armories here and in camps in the 
 Bronx and Van Cortlandt Park, but the work was started, beginning with one 
 regiment. The army surgeons with the troops could give little information as 
 to the mental soundness of the men, though they knew all about their physical 
 conditions, but it was soon discovered that the non-commissioned oflScers could 
 give a certain amount of such information, so these men, usually sergeants, were 
 asked to make lists of the men whom they believed would not make good sol- 
 diers. That helped a great deal. Soon experience showed that many of the 
 candidates could be passed at a glance on the appearance they presented, but 
 others were given a more careful examination. The intention was to dispose 
 of those who would not make good soldiers, who would not obey orders, or who 
 could not understand them, those with no idea of discipline, those with organic 
 disease of the nervous system, and the mentally unstable cases. Certain regi- 
 ments were found to have higher types of men than others; very few were re- 
 jected from some regiments, but in one, from a distant part of the country, 
 sixty-three per cent were rejected. After the Rainbow Division left, nearly 
 4,000 men had been through this examination. 
 
 At the camps the work was not easy, for large numbers had to be examined 
 in a day, though some of these men were of an exceedingly high class and one 
 had no difficulty in deciding that they were all right. But some were delin-. 
 quents, though not mental defectives; others were manic depressives; there were 
 
84 
 
 cases of dementia precox, epilepsy, and migraine, a few spinal cases, some of 
 progressive muscular atrophy, though only one of cerebrospinal syphilis. No 
 cases of tabes were seen. In some regiments there were many cases of goitre, a 
 few of them exophthalmic, but unless they presented constitutional symptoms 
 they had not been rejected; only when they showed evidence of tremor or of 
 physical weakness so that they could not keep up with their work, were they 
 considered unfit for duty. 
 
 One could hardly realize the amount of work this meant. The large number 
 of men that had to be rejected proved a revelation. The army was full of in- 
 competents who should have been stopped before they entered if the men on the 
 exemption boards had done their duty, and it was deeply to be regretted that 
 such a state of affairs should exist in this age and at this crisis. In the officers' 
 training camp there were many whom it was found necessary to reject, men of 
 the highest type, college men, and those who had held important positions, men 
 of affairs. Those from the West compared very favorably with those from New 
 York State, but in one regiment of men from a large city, many of the men had 
 been in jail or a reformatory. The cases of migraine were of interest, mostly 
 all giving a significant family history, usually the mother having suffered from it. 
 Those who had slight attacks were passed, but those in whom the attacks lasted 
 two or three days accompanied by severe pain and prostration, were rejected. 
 Epileptics were not rejected unless they were seen during a seizure by a member 
 of the Board, or by some one on whose testimony the Board could rely. A 
 proportion of those would probably be heard from later. There was no doubt 
 that a certain number of cases of all kinds that should have been rejected got 
 through. In recognition of the Surgeon General's opinion that such men were 
 not desirable, they had been careful in going over the neurasthenics and those 
 with hysteria. 
 
 As far as the militia, the volunteer, regiments were concerned, they would 
 undoubtedly prove a high type of soldier, but in regard to the National Army 
 as a whole one could not be so enthusiastic. In one day seventeen men were 
 dismissed from the service who had been under observation in the psychiatric 
 hospital at one camp for a number of days. This was where the heroin cases 
 were seen, some of them coming in voluntarily because they could not obtain 
 the drug and others sent in by the commander. It was a matter of astonishment 
 how frequently these men were supplied with this substance by visiting friends 
 and relatives. Of the seventeen rejected men referred to, four were cases of 
 dementia precox; four, epileptics; eight, heroin habitues; and one was undiag- 
 nosed.— N. Y. med. j. 107: 764-65, April 20, 1918. 
 
 Hunt, J. Ramsay. Exhaustion Pseudo-paresis ; Address at a Meeting 
 of the New York Neurological Society, Nov. 13, 1917 
 
 Dr. J. Ramsay Hunt presented a resume of the results of special neuropsy- 
 chiatric examinations in one of the large training camps for officers, composed 
 of 1,500 men, and out of this number eleven cases were found presenting slight 
 but definite symptoms of incipient paresis, preparesis, or early cerebral syphilis, 
 a diagnosis confirmed by examinations of the blood and cerebrospinal fluid. 
 Generally speaking the clinical symptoms were not very marked, consisting of 
 pupillary changes, tremors of the face and hands, and shght disturbances of 
 articulation on repeating test phrases. The usual cerebral symptoms or evi- 
 dence of mental deterioration were so slight as to be practically negligible from 
 the diagnostic standpoint, and in studying this very important group of cases 
 the examiner was almost wholly dependent upon those silent but well established 
 somatic symptoms of early paresis so characteristic to the trained observer; i. e., 
 tremors, absent or feeble reactionto light and disorders of articulation of the 
 paretic type. 
 
85 
 
 As directly bearing on this subject, emphasis was laid upon the occurrence of 
 another group of cases which had come under observation, tj;ie formal recogni- 
 tion of which was of importance because of the close similarity of the somatic 
 symptoms to those of early paresis. This condition was apparently dependent 
 upon an exhaustion of the cerebrospinal centres as a result of the unusual strain, 
 both mental and physical, to which men undergoing the intensive course of 
 military training were subjected. Four cases were reported in detail, presenting 
 slight mental and cerebral disturbances, inequality of the pupils, with extremely 
 feeble and sluggish reactions to light, coarse tremors of the hands, face and 
 tongue and a dysarthric disturbance -of speech on repeating test phrases very 
 similar to that observed in the early stage of paresis. The pupils in all of the 
 cases were unequal and showed a very feeble and sluggish reaction to light. In 
 some of the cases there was so little response as to suggest a true loss of the light- 
 reaction. The reaction on accommodation was preserved and the sympathetic 
 response was also elicitable; the impression of an Argyll- Robertson pupil was, 
 therefore, produced. The tremors of the face and tongue were coarse, with 
 associated movements of the facial muscles on speaking. In addition, fairly 
 coarse tremors of the hands and fingers were present and handwTiting was 
 tremulous. Syllable stuttering and the dysarthric speech of paresis were closely 
 simulated. 
 
 Clinically, the diagnosis of incipient paresis seemed assured, but the serological 
 examinations of the blood and spinal fluid were entirely negative. There was 
 no increase of globulin or cells, and the colloidal gold reaction was negative. 
 Furthermore, all the sjTnptoms cleared up after a week or ten days' rest. In 
 the absence, therefore, of positive findings in the blood and spinal fluid and the 
 rapid improvement under rest, it seemed clear that the condition had been 
 produced by an acute exhaustion of the central nervous system, with somatic 
 symptoms strongly suggestive of early paresis. 
 
 As there was association between fatigue and the production of certain toxins 
 which act upon the central nervous system as well as upon the muscles, in addi- 
 tion to the theory of nerve exhaustion, a lowgrade intoxication of the nerve 
 centres had to be considered as a possible explanation. Among these toxic 
 products of fatigue might be mentioned such substances as carbon dioxide, 
 paralactic acid and monopotassium phosphate. . . . Some observers, 
 notably Weichardt, had also long maintained that a specific fatigue intoxication 
 existed, and was the essential etiological factor in the production of its character- 
 istic manifestations. 
 
 Among the recognized mental symptoms of fatigue was a diminished power 
 of attention, a lack of ability to concentrate, a slow reaction to mental stimuli, 
 slowness in reasoning, as well as errors and slowness in mathematical calculation. 
 If these symptoms were present in any marked degree and associated with the 
 somatic symptoms mentioned above, they might well lead to error. 
 
 It is well known that fatigue is a frequent cause of tremor, and tremor after 
 prolonged muscular activity is well recognized. The unusual degree, wide 
 distribution and persistence of it in these fatigue cases were probably dependent 
 upon the prolonged mental and physical strain and a special disposition to 
 exhaustibility of the nerve centres. 
 
 As the mechanism of speech requires a delicate coordination of the higher 
 cortical centres and muscular activity, it is perhaps not suqirising that the 
 disturbance of arti(,'ulation noted in this group of cases should have oc-curred as 
 a manifestation of extreme fatigue. 
 
 More difficult of explanation were the pupillary phenomena. It was well 
 known that during the convulsive crises of epilepsy, and even hysteria, the 
 pupils diluted and were rigid to light. Also, in simple exhaustion, the ]>upils 
 were dilated and might be sluggisii to light, witii reservation uf the reaction on 
 accommodation. Perhaps the suspicious pupillary phenomena observed in these 
 
86 
 
 exhaustion cases were of a somewhat similar nature, possibly dependent upon a 
 disturbance of the sympathetic innervation of the pupil by fatigue or the toxins 
 of fatigue. The pupils, while definitely unequal, with sluggish or absent reac- 
 tion to light, presented no irregularities of contour, and this might constitute 
 an important point of difference from the true syphilitic pupil which not infre- 
 quently displays marginal irregularities. 
 
 Dr. Hunt stated that he had not observed a similar condition in civil practice, 
 which he ascribed to the unusual etiological conditions furnished by life in a 
 training camp, and thought that the formal recognition of a fatigue syndrome 
 simulating early paresis was worthy of earnest consideration. Furthermore, it 
 was not unlikely that under still greater conditions of stress and strain this 
 group might be the forerunner of more severe types of the exhaustion neuroses 
 and neuropsychoses. — J. A. M. A. 70: 11-14, Jan. 5, 1918. 
 
 Salmon, Thomas W. Neurology and Psychiatry in the Army; Address 
 at a meeting of the New York Neurological Society, Nov. 13, 191 7 
 
 The address consisted chiefly of an account of the work in neurology and psy- 
 chiatry already done in armies, and that which is being planned for the future. 
 Many illustrations from the present war were given, showing the great signifi- 
 cance of the problem of mental disease in military services. This country has 
 profited by the experience of foreign armies in their attempts to solve the prob- 
 lem, for Surgeon General Gorgas made appropriations, even before the partici- 
 pation of the United States in the war, for the organization of neurological and 
 psychiatric work in the Army upon a scale never before attempted. The Med- 
 ical Reserve Corps, assisted by the War Work Committees of the National Com- 
 mittee for Mental Hygiene, of the American Medico-Psychological Association, 
 and of the American Neurological Society, has commissioned 222 specialists in 
 nervous and mental diseases to serve in the various camps in this country. Med- 
 ical ofiicers stationed at all officers' training camps conduct examinations of all 
 candidates for commissions, with the result that many cases of organic nervous 
 disease and some of psychoses and psychoneuroses have been rejected for disa- 
 bility. At each of the National Army cantonment camps is a neuropsychiatric 
 board composed of three medical officers to examine cases referred to them by 
 line and medical ofiicers. In addition to these tests, a system for the examina- 
 tion of civilians in training has been inaugurated. This will weed out cases of 
 unfitness before the forces are sent abroad, consequently decreasing greatly the 
 number of those who would otherwise have to be returned to this country for 
 treatment and disability. Up to the time when the address was delivered, sev- 
 eral thousand men had already been rejected for various forms of mental and 
 nervous unfitness, including mental defect, epilepsy, and almost all the psychoses. 
 Seven American specialists are in England studying shell shock and methods for 
 its care and treatment. The expeditionary forces in France have several others, 
 one is attached to each base hospital abroad, one to each military prison, and 
 one will be in each delinquency battalion, when such are formed. 
 
 Special intensive com-ses in neurology and psychiatry have been taken by 
 several of these medical officers who felt that they needed special training or 
 review of previous theoretical or laboratory work. 
 
 A brief description was given of the arrangements to be made abroad for the 
 care of functional nervous cases from the expeditionary forces, and of those likely 
 to be returned to the United States. Major Salmon announced, with the Sur- 
 geon General's permission, the opening in the near future of the first military psy- 
 chiatric hospital in this country at Fort Porter, Buffalo. Others will be opened 
 according to future need. A special neuropsychiatric unit, with a personnel of 
 216 trained physicians, nurses and special workers with actual experience in the 
 care and treatment of nervous and mental cases, has been organized and will sail 
 soon to take charge of a special neuropsychiatric base hospital abroad. 
 
87 
 
 In conclusion Major Salmon spoke of the great influence that this work in 
 military neuropsychiatry is bound to exert upon the application of neurology 
 and psycliiatry to civil problems and conditions after the war. 
 
 Anderson, John E. Psychological Tests in the National Army; Ad- 
 dress at a Meeting of the Boston Society of Psychiatry and Neu- 
 rology, Dec. 20, 1917 
 
 As Lieutenant William S. Foster, of Camp Devens, was unable to present a 
 communication on the above topic, Lieutenant John E. Anderson discussed the 
 examinations of the men at that camp. He said that a psychological examina- 
 tion had been made on practically every man in camp. The object of the exam- 
 ination is two-fold: to classify the mental ability of the men as an aid to their 
 superiors in the selection of men for appointment as non-commissioned officers 
 and for special duties, and secondly to weed out the unfit. 
 
 The men appear for the examination in groups of from one hundred to two 
 hundred. First a very brief literacy examination is given wliich separates the 
 illiterate from the literate. The latter then take a forty-five minute test cover- 
 ing quite varied abilities. The illiterates are given a "skill examination" con- 
 sisting of the putting together of disassembled implements, such as locks, 
 wrenches, electric bells, and so on. Those doing poorly in either examination 
 are recalled and examined individually. If their performance is poor enough 
 to warrant it they are sent to the psychiatrist who examines them with a view 
 to rejection. 
 
 On the basis of these examinations the men are grouped in five classes : the 
 very superior, su|>erior, average, inferior, and very inferior. The company com- 
 mander receives a report on each man, to be used in any way he sees fit. He 
 is advised that these tests get at the "intelligence factor" only, and that the 
 final selection of a man depends also upon such qualities as resourcefulness, 
 leadership, and courage, which cannot be measured by tests. But the tests do 
 bring a number of the men to the fore who otherwise would pass unnoticed and 
 so serve to give the officei the material from which to select. This has been par- 
 ticularly noticeable in the cases of quiet but efficient men. Each company com- 
 mander submits a return report to the psychologists in which he comments on 
 the usefulness of the test ratings and any irregularities he has noticed. These 
 reports have been very encouraging. 
 
 Although the personnel work {i. e., the ratings submitted to the officers) is of 
 primary importance, the elimination of the mentally unfit plays a large part. 
 The psychologists and the psychiatrists cooperate in this work. 
 
 Asked about the details of the examinations. Lieutenant Anderson said that 
 about 150 men could be examined an hour in the groups. The examination in- 
 cluding the seating and arrangement of the men takes an hour. The individual 
 examination, given to the culls from the entire system of examination, takes 
 between forty minutes and an hour. The scoring of the group examinations, 
 which is done by clerks with stencils upon wliich the correct answers are desig- 
 nated, takes very little time. The tests include such things as the carrying out 
 of simple commands, memory for digits, the rearrangement of sentences, arith- 
 metic prololems, etc., all aimed to give ratings on general intelligence. 
 
 Asked about the cost of the examinations. Lieutenant Anderson said that it 
 was very small as compared with that of otlier examinations in the army. He 
 said that a considerable number of the illiterates had been found. Many of 
 these are foreigners who have difficulty with the English language. Asked 
 about the possibility of coaching before the examinations, he said that five dif- 
 ferent forms are in use, and that the examination is such that even a repetition of 
 it gives only a slightly liigher rating. — J. nerv. and raeut. dis. 47: i2^3-!i4. March 
 1918. 
 
88 
 
 Salmon, Thomas W. War Neuroses ("Shell Shock") ; Lectures, Illus- 
 trated with Motion Picture Films, Prepared by Direction of the 
 Surgeon General for Use in the Medical Officers' Training Camps. 
 N. Y. Natl. comm. mental hygiene, 1917. Also in Mil. surg. 41: 
 674-93) I)ec. 1917 
 
 Major Salmon treats his subject under two main divisions: "Nature and 
 importance of the neuroses in war"; and "Diagnosis and treatment." 
 
 "Military life," he says, "has well been called 'the touchstone of insanity'. 
 Not only in actual war, but even in peaceful mobilizations, such as that of our own 
 Army along the Mexican border last year, there is a higher rate of mental disease 
 among soldiers than in civil life. The discharge rate for mental diseases in the 
 United States Army in 1916 was three times the admission rate for these disorders 
 in the adult male population of the state of New York, one-tenth of all discharges 
 for disability being for mental diseases, mental deficiency, epilepsy, and the 
 neuroses. When it is remembered that the later decades of life, in wliich mental 
 diseases dependent upon organic changes in the brain are so prevalent, are not 
 represented in military forces, it is seen that the rate in the army is greater even 
 than is indicated by such statistics." 
 
 After a brief discussion of the peculiarly difiicult problems in adaptation 
 created by military life for neurotic or psychopathic individuals, the extraordi- 
 nary prevalence of the neuroses, fairly common in civil life, but a major medical 
 problem in war time, is commented upon. Although no new symptoms or 
 diseases are exhibited by cases of war neuroses, or shell shock, the magnitude of 
 the problem makes it necessary that every medical officer should become familiar 
 with it from the point of view of diagnosis, management and military juris- 
 prudence. 
 
 Since the term "shell shock" has unfortunately been applied rather loosely to 
 practically any nervous condition in soldiers exposed to shell-fire, which is in- 
 explicable by a physical injury, and has even been used to include types of mental 
 disease, a division of these conditions into some etiological and clinical groups will 
 help to clarify the subject. Cases in which the soldiers have been actually ex- 
 posed to the effects of high explosives include : 
 
 1. Cases of death without external signs of injury. Apparently death in such 
 cases is sometimes due to damage to the central nervous system. 
 
 2. Cases exhibiting severe neurological symptoms in characteristic syndromes 
 suggesting the operation of mechanical factors, such as concussion, aerial com- 
 pression, the rapid decompression following it, "gassing", etc. 
 
 3. Cases in which the symptoms are those of neuroses familiar in civil practice^ 
 but distinctly colored by war experience. Much controversy exists as to the 
 mechanism of such cases of shell shock. 
 
 4. Cases in which even the slightest injury to the nervous system from the 
 explosion is improbable and in which the war experience has not varied at all 
 from that of hundreds of comrades who have developed no symptoms. 
 
 There is still another group of cases in which soldiers who have not been ex- 
 posed at all to battle conditions develop symptoms almost identical with those 
 in men who are supposed to be suffering from the effects of actual shell-fire. 
 Farrar calls these "anticipatory" neuroses. 
 
 "It is the opinion of most psychiatrists and neurologists who have been study- 
 ing and treating 'shell shock' in the British Army, that the last two groups named 
 are by far the largest and most important and that, whatever the unknown physi- 
 ological basis, psychological factors are too obvious and too important in these 
 cases to be ignored." In support of this view Major Salmon states a series of 
 significant facts based upon observations. 
 
 "The psychological basis of the war neuroses (like that of the neuroses in civil 
 life) is an elaboration, with endless variations of one central theme — escape from 
 an intolerable situation in real life to one made tolerable by the neuroses. Either a 
 
89 
 
 function is lost, the absence of which releases the patient from the intolerable 
 situation, or one is lost which interferes with successful adaptation. The function 
 may be mental or physical." Major Salmon outlines several cases from civil 
 life illustrating the mechanism of these neuroses. Needless to say, the same 
 conflict, in an exaggerated form, takes place in modern warfare. Among avenues 
 of escape from intolerable situations are wounds, capture and malingering. The 
 last is " a military crime that is not at the disposal of men governed by the higher 
 ethical considerations. . . 
 
 " One of the most important features of the wide employment of the term 'shell 
 shock' to denote the nevu-oses in war is its implication of a cause acting suddenly." 
 Major Salmon then shows how "shell shock" is really the culmination of a train 
 of symptoms, arising often from various preexisting conditions, such as strain and 
 exhaustion, personal misfortunes, or a neurotic or psychopathic temperament. 
 
 These constitutionally predisposed individuals naturally contribute most 
 heavily to the neuroses among soldiers, but men with apparently sound constitu- 
 tions and no previous mental or nervous breakdowns are also often stricken 
 after exhausting or distressing war experiences. Thus in shell shock the situa- 
 tion, apparently a very simple one in which mechanical factors predominate, is 
 often in reality exceedingly complex and closely involved with the life experience 
 of the individual. 
 
 In discussing the symptomatology of war neuroses, Major Salmon includes 
 neither cases of organic damage to nerve tissue nor those suffering from transitory 
 nervous symptoms which are curable by a short rest. The distribution of the 
 various types of war neuroses varies according to rank. Officers generally suffer 
 from neurasthenia, excessive fatigue both of body and mind, irritability, anxiety, 
 and fears not directly connected with war experiences. Less common are forms 
 of hysterical paralysis or tremor. The most striking war neuroses are those 
 presenting the classical symptoms of hysteria in a new and often dramatic setting. 
 "No symptom fatniliar to the neurological clinic is lacking among the hundreds of 
 cases of shell shock to be found in the military hospitals in France and Eng- 
 land. ... In those cases, which have as their starting-point a definite shell 
 or mine explosion, there are often symptoms which suggest concussion. Uncon- 
 sciousness, dizziness, deafness, motor incoordination, and such physical symp- 
 toms as amnesia, confusion and hallucinations of hearing make up the so-called 
 concussion syndrome. " Psychical symptoms are transitory delirium, amnesia, 
 mental confusion, hallucinations and vivid "battle dreams". Among speech 
 disorders are aphasia, stammering, mutism and aphonia. Sensory symptoms are 
 anesthesia, pain and hyperesthesia. IJlindness, night-blindness, deafness, 
 hyperacusis and anosmia are frequently found, also disturbances of gait, con- 
 tractures, and many forms of paralysis and tremor. Disturbances of involuntary 
 functions include tachycardia, enuresis and diarrhoea. 
 
 The C[uestion of diagnosis is most important, not only in promoting the interest 
 of the patients but also that of the military service. It is often very difficult to 
 distinguish organic disease and also malingered symptoms from the somatic 
 manifestations of hysteria. Major Salmon mentions a few of the more impor- 
 tant features in differential diagnosis. "Hysterical speech disorders usually pre- 
 sent few difficulties in diagnosis. Aphasias are always paradoxical and accom- 
 panied by other hysterical symptoms. Stammering comes on su<ldenly with no 
 history of similar speech disturbance in youth. Aphonia may be shown to be 
 functional by a careful laryngological examination. Visual symptoms do not 
 correspond to any organic cerebral lesions and the eye is found to b«' normal ex- 
 cept for contraction of the visual fields, especially the helicoid form so churacter- 
 istic of hysteria. In the rare instances in which disturbances of taste are found 
 there is a complete bi-latcral ageusia — a syrnptom unknown except in hyslena 
 or unilateral loss corresponding with skin anesthesia, a condition which dues not 
 occur in organic disease. 
 
90 
 
 " Gait disturbances not accompanied by paralysis usually simulate abnormal 
 locomotion from physical disease or injury. Thus the gait may resemble that of 
 congenital dislocation of the hip-joint, anchylosis of the knee or ankle, or hip 
 joint disease — all conditions which can very readily be excluded. 
 
 "Paralyses may resemble superficially any type seen in organic nervous 
 lesions, but never accurately. Sometimes difficulties are presented, but usually 
 a careful neurological examination will make the situation clear. While atrophy 
 may exist in hysterical paralyses of long duration, such cases are unlikely to come 
 to attention in military practice except in the examination of recruits, and the 
 electrical reactions will present error. The reflexes, especially the plantar and 
 bladder reflexes, are of the greatest value in determining the nature of a paralysis. 
 The distribution of local paralysis seems never, even by accident, to correspond 
 exactly with that due to lesions of nerve roots or peripheral nerves. The pos- 
 ture of the paralyzed limb is rarely similar to that in a paralysis due to an organic 
 lesion. This is especially well shown in the gait in hysterical hemiplegia, the 
 foot being dragged with the inner instead of the outer border of the sole scraping 
 along the floor. The enormous predominance of left-sided symptoms in hys- 
 teria should be borne in mind. 
 
 "The anesthesias of hysteria usually present no serious difficulties in diagno- 
 sis. Although it is not possible to detect all of them by such a simple expedient 
 as asking the patient to say ' yes ' when he feels the pin and ' no ' when he does 
 not, the actual reactions elicited are often quite as paradoxical. It is helpful to 
 remember that the patient with hysterical anesthesia never suffers from his 
 disability. You will not find cuts or cigarette burns which have been received 
 without knowing it, as in organic cases. 
 
 "In the examination of hysterics it must be remembered that pain, anesthesia 
 and other sensory symptoms are true hallucinations. They are often as real to 
 the patient as hallucinations of vision or hearing, but they are subject to as 
 wide variation in intensity and frequency. Finally one should be mindful of the 
 fact that rarely hysteria and organic disease may exist together. 
 
 "The sudden appearance of marked incapacity without signs of injury, in a 
 group of men to whom invalidism means a sudden transition from extreme dan- 
 ger and hardsliip to safety and comfort, quite naturally leads to the suspicion 
 of malingering. The general knowledge among troops of the more common 
 symptoms of 'shell shock' and of the fact that thousands of their comrades 
 suffering from it have been discharged from the army sometimes suggests its 
 simulation to men who are planning an easy exit from military service by feign- 
 ing disease. It is therefore of much military importance that medical officers 
 be not deceived by such frauds. On the other hand, especially before the clinical 
 characters and remarkable prevalence of war neuroses among soldiers had be- 
 come familiar facts, not a few soldiers suffering from these disorders were exe- 
 cuted by firing squads as malingerers. Instances are also known where hysterics 
 have committed suicide after having been falsely accused of malingering. Mis- 
 takes of this kind are especially likely to occur when the patients have not been 
 actually exposed to shell fire because the idea is firmly fixed in the minds of most 
 line officers and some medical men that the war neuroses are always due to 
 mechanical shock. 
 
 "The diagnosis between neuroses and malingering may sometimes be ex- 
 tremely difficult, but usually it is easy when the examiner is familiar with both 
 conditions. The difficulties arise from the fact that in both a disease or a symp- 
 tom is simulated. As Bonnal says, ' The hysteric is a malingerer who does not 
 lie.' The cardinal point of difference is that the malingerer simulates a disease 
 or a symptom which he has not in order to deceive others. He does this consciously 
 to attain, through fraud, a specific selfish end — usually safety in a hospital or 
 discharge from the military service. He lies and knows that he lies. The hysteric 
 deceives himself by a mechanism of which he is unaware and which is beyond his 
 
91 
 
 power consciously to control. He is usually not aware of the precise purpose which 
 his illness serves. This is shown by the fact that, in many cases, all that is nec- 
 essary for recovery is to demonstrate clearly to the patient the mechanism by 
 which his disability occurred and the end to which, unconsciously, it was 
 directed. 
 
 "There are a number of distinctive points of difference betw^een hysteria and 
 malingering, two of which it may be interesting to mention. 
 
 "1. The malingerer, conscious of his fraudulent intent and fearful of its 
 detection, dreads examinations. The hysteric invites them, as is well known to 
 physicians in civil practice. When he has the opportunity, he makes the rounds 
 of clinics and physicians, especially delighting in examinations by noted spe- 
 cialists. 
 
 "2. The hysteric, in addition to the symptoms of which he complains often 
 presents objective symptoms of which he is unaware. The malingerer, unless of 
 low intelligence, confines his complaints to the disease or symptom which he has 
 decided to simulate. 
 
 "Malingering may follow or prolong a neurosis. This is not infrequently the 
 case when mutism is succeeded by aphonia. In such cases the clinical picture 
 presents changes very apparent to the experienced psychiatrist, but it must be 
 remembered that malingerers, like criminals in civil life, are often very neuro- 
 pathic individuals. 
 
 "The gravity of malingering as a military offense in an army in the field justi- 
 fies the recommendation that no case in which the possibility of a neurosis or 
 psychosis exists be finally dealt with until the subject is examined by a neurolo- 
 gist or psychiatrist. If neuropsychiatric wards are provided in base hospitals in 
 France as well as in the United States, such an examination will be feasible in 
 practically all cases without causing undue delay. The knowledge that malinger- 
 ers are subjected to such expert examination always tends to discourage soldiers 
 from this practice." 
 
 As to treatment, Major Salmon emphasizes the fact that therapy is essentially 
 a psychological problem, the first step of which is a careful study of the indi- 
 vidual case. The attitude of the medical officer is also of great importance. He 
 must be immune to surprise or chagrin, firm in his control of the patient, yet 
 have a sane and understanding sympathy. "The resources at the disposal of 
 the physician in treating the war neuroses are varied. The patient must be 
 re-educated in will, thought, feeling and function. Persuasion, a powerful re- 
 source, may be employed directly, backed by knowledge on the part of the 
 patient as well as the physician of the mechanism of tlie particular disorder 
 present. Indirectly, it must pervade the atmosphere of the special ward or 
 hospital for 'shell shock.' Hypnotism is valuable as an adjunct to persuasion 
 and as a means of convincing the patient that no organic disease or injury is 
 responsible for his loss of function. Thus in mutism tlie patient speaks under 
 hypnosis or through hypnotic suggestion and thereafter must admit the int<'grity 
 of his organs of speech. The striking results of hypnotism in the removal of 
 symptoms are somewhat offset by the fact that the most suggestible, who yield 
 to it most readily, are particularly likely to be the constitutionally neurotic. In 
 such cases we are using to bring about a cure, a mental mechanism similar to 
 that which produced the disorder. 
 
 "Recovery within the sound of artillery, or at least 'somewhere in France,* 
 is more important and durable than that which takes place in Kiigland. This 
 is a very important fact and the brightest spot in the rather dismal ])i(turc 
 presented by these disorders. . . . For severe cases and those which t iirough 
 mismanagement have developed the unfortunate secondary symptoms of 'shell 
 shock' and in whom long-continued treatment is necessary, a rural ])lacc is best. 
 
 "Reeducation by physical means is a valuable adjunct to treatment in recent 
 cases, but particularly in chronic cases who have been mismanaged and in those 
 
92 
 
 who are recovering from long-continued paralyses, mutism and gait disorders. 
 While drills and physical exercises have their specific uses, occupation is the 
 best means. Non-productive occupations should be avoided." 
 
 Occupations may be divided into three classes: bed, indoor, and outdoor. 
 Under class 1 may be included basket and net making, preparation of surgical 
 dressings, and various minor finishing operations. "All occupations, especially 
 those which are carried on by patients seriously incapacitated, should be re- 
 garded only as steps in a process of progressive education. Every effort must 
 be made to prevent skill acquired in them from being considered as a substitute 
 for full functional activity. Herein is an important difference between the re- 
 education of neurotic and orthopedic cases." Indoor occupations include 
 carpentry, wood carving, metal and cement work, printing, bookbinding, 
 cigarette making, and electric wiring. Outdoor work may consist of farming, 
 gardening and building operations, wood sawing and chopping, and the care of 
 small stock not requiring much land. 
 
 "Before even the simplest occupation can be engaged in it is sometimes neces- 
 sary to reeducate paraplegics and ataxics in walking and coordination. Just 
 as soon as possible exercises should be replaced by productive occupations which 
 will accomplish the same results more quickly and more satisfactorily. Thia 
 is true of gymnastic exercises which in the early steps of treatment constitute a 
 valuable resource but which should be replaced by specially devised useful tasks. 
 Swimming has an unique place in the treatment of gait disturbances, paralysis 
 and tics. One of the first pieces of construction undertaken by the outdoor 
 patients at a reconstruction center should be that of building a large concrete 
 swimming tank. 
 
 " Hydrotherapy and electrotherapy have a distinct value when they are applied 
 with absolute sincerity and full realization on the part of the patient and medical 
 ofiicer of the role that they actually play in the treatment of functional nervous 
 diseases. 
 
 "The experience of English hospitals has demonstrated the great danger of 
 aimless lounging, too many entertainments and relaxing recreations, such as 
 frequent motor rides, etc. It must be remembered that 'shell shock' cases 
 suffer from a disorder of will as well as function and it is impossible to effect a 
 cure if attention is directed to one at the expense of the other. As Dr. H. 
 Crichton Miller has put it, ' shell shock ' produces a condition which is essen- 
 tially childish and infantile in its nature. Rest in bed and simple encourage- 
 ment is not enough to educate a chUd. Progressive daily achievement is the 
 only way whereby manhood and self-respect can be regained.' " 
 
 Salmon, Thomas W. Care and Treatment of Mental Diseases and 
 War Neuroses ("Shell Shock") in the British Army. N. Y., 
 Natl. comm. mental hygiene, 1917. 102 p. Bibliography 
 
 Major Salmon introduces his report as follows: 
 
 "No medico-military problems of the war are more striking than those grow- 
 ing out of the extraordinary incidence of mental and functional nervous diseases 
 ('shell shock'). Together these disorders are responsible for not less than one 
 seventh of all discharges for disability from the British Army, or one third if dis- 
 charges for wounds are excluded. A medical service newly confronted like ours 
 with the task of caring for the sick and wounded of a large army cannot ignore 
 such important causes of invalidism. By their very nature, moreover, these 
 diseases endanger the morale and discipline of troops in a special way and re- 
 quire attention for purely military reasons. In order that as many rnen as 
 possible may be returned to the colors or sent into civil life free from disabilities 
 which will incapacitate them for work and self-support, it is highly desirable to 
 make use of all available information as to the nature of these diseases among 
 
93 
 
 soldiers in the armies of our allies and as to their treatment at the front, at the 
 bases and at the centers established in home territory for their reconstruction. 
 England has had three years' experience in dealing with the medical problems of 
 war. During that time opinion has matured as to the nature, causes and treat- 
 ment of the psychoses and neuroses which prevail so extensively among troops. 
 A sufficient number of different methods of military management have been 
 tried to make it possible to judge of their relative merits. My visit to England 
 was for the purpose of observing these matters at first hand so that I might con- 
 tribute information which might aid in formulating plans for dealing with mental 
 and nervous diseases among our own forces when they are exposed to the terrific 
 stress of modern war. " 
 
 The report does not include any account of the treatment of organic nervous 
 diseases nor of injuries to the central or peripheral nervous systems, nor did 
 Major Salmon have time for any original clinical observations. 
 
 As to prevalence of mental diseases in military services the following quotation 
 will be of interest ; 
 
 "On March 31, 1917, about 1.1% of all patients in the military hospitals of 
 Great Britain were officially diagnosed as insane. The percentage among expedi- 
 tionary patients was 1.3, and among non-expeditionary patients 1.1. The enor- 
 mous prevalence of wounds in patients from the expeditionary troops reduces the 
 percentage of all other conditions, so the excess of mental cases among expedi- 
 tionary cases is much greater than is apparent. Among non-wounded expedi- 
 tionary patients the percentage was about tliree times that among the non-ex- 
 peditionary cases. The rate among officers was only one third that among men 
 in expeditionary patients and about the same in non-expeditionary patients. 
 This has an important bearing upon the fact that the rate for the war neuroses 
 ('shell shock') is four times as high among officers as among men. . . . It can 
 be estimated, from all the data available that the annual admission rate to the 
 British miUtary hospitals for the insane is about 2 per 1,000 among the non- 
 expeditionary troops and about 4 per 1,000 among expeditionary troops. The 
 rate in the adult male civil population of Great Britain is about 1 per 1,000." 
 
 Several special war hospitals for the treatment of mental cases have been es- 
 tablished in the United Kingdom through the taking-over for this use of county 
 and borough asylums. This subject is discussed in Appendix II of Major Sal- 
 mon's report. There were at the time of the completion of the report about 
 3,400 beds in strictly military hospitals available in Great Britain and Ireland 
 for insane soldiers. "No attempt has been made to care for the insane in France, 
 the policy of the War Office being to send all cases to the clearing hospital at 
 Netley and then to special institutions as soon as possible. There are available 
 in France only 125 beds, all for the temporary detention of mental cases. " 
 
 During 191G the number of mental cases passing through the 3,400 beds avail- 
 able for their care in Great Britain and Ireland was about (5.000. 
 
 No new clinical types of mental disease have been observed in armies. "There 
 are no 'war psychoses'. The clinical pictures familiar in civil life are seen, 
 colored often by the experience at the front, but for the most j)art unchanged in 
 their symptomatology, outcome and course. The distribution of tlic various 
 psychoses has been strikingly different from that in civil life, but this has been 
 chiefly due to the different age periods represented in patients from t lie army. 
 The absence of the organic mental diseases of the later decades of life, which play 
 so large a part in civil statistics, has resulted in abnormally high percentages for 
 other psychoses. " 
 
 About 18% of the patients admitted to military hospitals for mental diseases 
 have been found mentally defective. Major Salmon believes, in s])ite of argu- 
 ments advanced to the contrary, that experience in the present war has proved 
 that mental defectives should be debarred from military service except when the 
 last available man-power must be utilized. Under such circumstances, they 
 
94 
 
 should be kept at work at the rear under the supervision of non-commissioned 
 oflBcers specially trained in their management. 
 
 Cases of general paresis amounted to about 2% of the mental patients received 
 in special hospitals. Experience in the British Army and Navy has shown that 
 no person with the slightest indication of syphilis of the central nervous system 
 should be enlisted or commissioned for any military duty. 
 
 Manic-depressive insanity is present in about 20% of all admissions to military 
 hospitals for mental disease. 
 
 Alcoholic psychoses are now found almost entirely in patients on leave from 
 the front. Delusional types appear in older men stationed at bases where oppor- 
 timity is afforded to continue life-long habits of drinking to excess. Attempted 
 suicides are very frequent among alcoholics in military service. Alcoholics 
 should be debarred from the service. 
 
 Patients suffering from dementia precox constitute 14% of admissions. Most 
 cases appeared shortly after enlistment and the individuals were probably psy- 
 chopathic. 
 
 Many cases of epilepsy observed had had the disease before enlistment. 
 
 A very large number of cases of constitutional psychopathic states have been 
 received in the special military hospitals for mental diseases. 
 
 As to prognosis. Major Salmon says: "There are no statistics available to 
 show the outcome in the mental diseases treated in military hospitals. Dis- 
 charge is much more likely to be regulated by administrative considerations than 
 by clinical ones. Acute conditions seem to recover very quickly. Few return 
 'to first line duty'. The statistics indicate a much larger proportion than is 
 actually the case. The number of those who go back to the colors is made up for 
 the most part of patients who have recovered from delirium tremens and those 
 with war neuroses who have been incorrectly admitted to institutions for the 
 insane. Infective-exhaustive psychoses are much more likely to be regarded as 
 'shell shock' than as mental disorders. The hospitals for mental diseases fail, 
 therefore, to get these very recoverable cases and the recovery rate in such in- 
 stitutions suffers correspondingly. . . . 
 
 " For the United States, Great Britain's experience carries important lessons. 
 More important than all others is the result of careless recruiting. The problem 
 of dealing with mental diseases in the army — difficult at best — has been made still 
 more so by accepting large numbers of recruits, who had been in institutions for 
 the insane or were of demonstrably psychopathic make-up. The next most im- 
 portant lesson is that of preparing, in advance of an urgent need, a comprehen- 
 sive plan for establishing special military hospitals and using existing civil 
 facilities for treating mental disease in a manner that will serve the army effect- 
 ively and at the same time safeguard the interests of the soldiers, of the gov- 
 ernment and of the community." 
 
 Section II of Major Salmon's report is devoted to general observations upon 
 the nature of war neuroses or shell shock. This section of the report is virtually 
 a more detailed discussion of the same subject matter as the pamphlet by Dr. 
 Salmon entitled "War Neuroses (Shell Shock)" and abstracted on p. 88-92, so 
 the abstract will not be repeated here. 
 
 Section III is entitled "Recommendations for the United States Army." 
 Major Salmon says: "It seems desirable to consider separately in these recom- 
 mendations, expeditionary and non-expeditionary forces. It is necessary to deal 
 separately with mental and nervous diseases in the United States but not in 
 France. While facilities existing at home can be utilized for the treatment of 
 mental diseases, it is necessary to create new ones for the treatment of the war 
 neuroses. In France, where all facilities for treatment must be created by the 
 medical department, the distinction between psychoses and neuroses need not be 
 drawn so closely. Consequently, simpler and more effective methods of ad- 
 ministrative management can be devised". 
 
95 
 
 One important feature is to have at our disposal a personnel of specially trained 
 medical officers, nurses and civilian assistants and an eflBcient mechanism for 
 treating mental and nervous cases in France, evacuating them for continued 
 treatment, when necessarj', to the United States. 
 
 Most important is the rigid exclusion of insane, mentally defective, psycho- 
 pathic and neuropathic men from expeditionary forces. 
 
 JMajor Salmon next summarizes his recommendations as applied to the expe- 
 ditionary forces as follows: 
 
 " Overseas 
 
 1. Base Section of Lines of Communication 
 
 (a) A Special Base Hospital of 500 beds for neuropsychiatric cases, located 
 at the base upon which each army (of 500,000-600,000) rests. These 
 special base hospitals to be used for cases likely to recover and return to 
 active duty witliin six months. Other cases to be cared for while waiting 
 to be evacuated to the United States. 
 
 (b) One or more Special Convalescent Camps in connection with (and 
 conducted as part of) each Special Base Hospital. 
 
 2. Advanced Section of Lines of Communication 
 
 (a) Special Neuropsychiatric Wards of 30 beds in charge of three psychi- 
 atrists and neurologists for each base hospital having an active service. 
 These wards to be used for observation (including medico-legal cases) 
 and for emergency treatment of mental and nervous cases. 
 
 (b) Detail of a psychiatrist or neurologist attached to the neuropsychiatric 
 wards of base hospitals, to evacuation hospitals or stations further ad- 
 vanced as opportunities permit. 
 
 " United States 
 
 1. Mental Diseases (insane) 
 
 (a) One or more Clearing Hospitals for reception, emergency treatment, 
 classification and disposition of mental cases among enlisted men invalided 
 home. 
 
 (b) Clearing Wards (in connection with general hospitals for oflBcers or 
 private institutions for mental diseases) for reception, emergency treat- 
 ment, classification and disposition of mental cases among ofl&cers in- 
 valided home. 
 
 (c) Legislation permitting the Surgeon General to make contracts with pub- 
 lic and private hospitals maintaining satisfactory standards of treatment 
 for the continued care of oflScers and men suffering from mental diseases 
 until recommended for retirement or discharge (with or without pension) 
 by a special board. 
 
 (d) Appointment of a special board of three medical officers to visit all 
 institutions in wliich insane officers and men are cared for under such con- 
 tracts to see that adequate treatment is being given and to retire or dis- 
 charge (with or without pension) those not likely to recover. 
 
 2. War Neuroses {'shell shock') 
 
 (a) Reconstruction centers (the number and capacity to be determined by 
 the need) for the treatment and re-education of such cases of war neuroses 
 as are invalided home. Injuries to the brain, cord and peripheral nerves 
 to be treated elsewhere. 
 
 (b) Special convalescent camps where recovered cases can go and not be 
 subject to the harmful influences for those cases which exist in camps for 
 ordinary medical and surgical cases. 
 
 (c) Employment of the Spec-ial Board of medical officers, recommended 
 under '1 (d) ' to visit all re-education centers and convalescent camps 
 in which war neuroses are treated to see that adequate treatment is being 
 given and to retire or discharge (with or without pension) those not likely 
 to recover." 
 
96 
 
 This summary is followed by a detailed discussion of each recommendation. 
 A chart illustrates the career of disabled returned soldiers. 
 
 About the care and treatment of war neuroses and mental diseases in non-ex- 
 peditionary forces, Major Salmon says: "Facilities for the treatment of neuro- 
 psychiatric cases at the camps in the United States have been approved by the 
 Surgeon General and are now being provided. These will undoubtedly prove 
 suflBcient for dealing temporarily with mental cases developing in the non-ex- 
 peditionary forces. Their final disposition should be made by means of the same 
 mechanism recommended for expeditionary patients who are invalided home, 
 except that the functions of the clearing hospital for mental diseases can be per- 
 formed by the neuro-psychiatric wards of divisional hospitals and that of the 
 special board by the Board of Survey composed of the neurologists and psychia- 
 trists stationed at the camps." 
 
 Appendix I is a list of references in English to mental diseases and war neuroses 
 and their treatment and management, including 141 entries. 
 
 Appendix II describes the use of institutions for the insane as military 
 hospitals.* 
 
 Appendix III consists of a directory of special military hospitals for mental 
 diseases and war neuroses in Great Britain and Ireland. 
 
 Appendix IV is a list of facilities needed for efficient treatment of mental 
 diseases in a modern public institution. 
 
 Bost. med. and surg. j. 178: 24-25, Jan. 3, 1918. Organic Lesions in 
 Shell-Shock (Editorial) 
 
 Recent observations on the various fronts tend to show that shell-shock 
 is the expression of a cell-exhaustion of the central nervous system. It is 
 generally accepted by neurologists that this exhaustion is accompanied by path- 
 ological lesions of the cytoplasm. It is, perhaps, doubtful whether this change 
 is invariable, and the laws governing it are still very imperfectly known, but, as a 
 broad fact, it is certainly true. Such lesions may be divided into two main 
 groups. First, those which are visible after proper staining of some particular 
 cells or substance of the brain. These have been observed recently, and they 
 seem to lie at the root of fatal cases of shell-shock. Secondly, those which con- 
 note a diminished potentiality for the development of nerve force of such a nature 
 as to impair the value of the cell. These are types of degeneracy which appear in 
 spite of a satisfactory military training and environment. It is this latter class 
 that alienists like Sir George Savage and Sir Robert Jones have described in the 
 Journal of Mental Science. These authors seem to understand by the disposition 
 to shell-shock a marked falling away, mentally, morally, and physically, from the 
 average condition of the soldier or race. Thus, among British soldiers, the habit- 
 ual criminal and the morally perverse, the mentally unstable and insane, the 
 physically weak and ill-developed are often spoken of as predisposed to shell- 
 shock. But there are also cases in which it occurs, in spite of hygienic sur- 
 roundings, the best heredity, and the most careful education. It follows that 
 shock or fear or the dread of the "unknown," of sufficient severity to over- 
 whelm the will, may cause in healthy men the whole syndrome of the affection 
 — ^the unconsciousness, aphasia, abasia, and pseudo-paraplegia. It is shown 
 by Nissl and by Nonne that the power to resist the highest degree of fear, as in 
 drumfire, explosion of mine craters, etc., necessitates the presence of the maxi- 
 mum nervous potentiality plus an optimum constitution. This is the meaning 
 of Dr. Mott's phrase that many cases of shell-shock are the neuro-potentially 
 unfit. 
 
 There are three chief views as to the causation, which have been fully discussed 
 by Wollenberg (Archiv fiir Psychiatric, 1916, p. 335), and more recently by two 
 
 * For abstract of Appendix II, see p. 80, Salmon, Thomas W. Use of institutions, etc. 
 
97 
 
 Italian neurologists, Lattes and Goria (Archivio di Antro-pologia Criminale, 
 April, 1917). The first is, that shell-shock is not the expression of a pathological 
 cell change, but the sign of a defect which exists in certain strains or stocks, and 
 which most writers describe as psychoneurosis, hysteria, suggestibility, and 
 degeneracy. On this view it is presumed that the innate nerve potentiality has 
 been impaired by congenital or acquired hysteria and neurasthenia; it includes, 
 besides, the types of degeneracy as seen in idiots, epileptics, and paranoiacs. 
 In modern armies these groups are found, which obviously shows the importance 
 of a minute family and individual history in the examination of soldiers. The 
 second view is that the syndrome of shell-shock is not the result of defects or 
 atavistic causes, but arises of itself; in other words, it is psychogenic. Most 
 writers agree that these cases — the functional, emotional, the hysterical in the 
 usual sense — are the most numerous. As Wollenberg says: "In the bulk of the 
 cases of shell-shock (Granatkontusion) the emotional factor far outweighs the 
 commotional." Dr. Mott and other British authorities take this view, but they 
 have considerably narrowed the definition of hysteria. 
 
 The third classification is that the causes of shell-shock — whether they have 
 existed ab initio in the soldier's nervous system or whether thej' are psychogenic 
 in origin — are physical processes, organic lesions, produced by the effects of long 
 exposure to the gases, and other results of the bursting of powerful shells. In this 
 place reference may be made to a recent work by Homburger (Die korperlichen 
 Erscheinungen der Kriegshysterie) . This author looks upon the question in a 
 twofold way; either the idea of pure hysteria must be abandoned, or this form of 
 hysteria must be sharply differentiated from hysteria with organic lesions. Most 
 neurologists at the front find it exceedingly difficult to believe in traumatic 
 hysteria (Oppenheim's) or molecular shock (Charcot's). Actual observers found 
 that of 74 men examined after an artillery attack, 67 showed unmistakable signs 
 of localized organic lesions of the central nervous system. 
 
 These lesions have now been studied post mortem by Dr. Mott and Captain 
 Hurst. They, as well as French, Italian and Russian neurologists have ob- 
 served: (a) Early generalized chromatolytic changes in the cells of the central 
 nervous systeip, (6) disappearance of the basophile substances, (c) extravasation 
 of blood into the substanceof the brain, (d) punctate hemorrhages with congestion 
 of the meninges, (e) minute hemorrhages and changes due to the effects of com- 
 pression and decompression, that is to say, as in caisson disease, with cerebro- 
 spinal fluid under high pressure, albumin, blood, and excess of lymphocytes. 
 It has been noticed by several observers that the clinical signs are those of or- 
 ganic changes; and Homburger, Morcher, and Nissl believe that the war has 
 altered our conceptions of hysteria though it has produced no new tyjie. Nissl, 
 in particular, appears to question the existence of the "hysterical personality." 
 Shell-shock is that condition of nervousness which results from the exhaustion of 
 the inherent vitality of the cells. They are unable to function because they 
 have come to the end of their physiological banking account. In fact, to Nissl 
 most cases are due to a completely human and normal weakness, and the organic 
 lesions, it miglit be added, arc equally likely to be due to the action of inorganic 
 poisons, as gas, and physical agents, concussion and commotion. 
 
 Bost. med. and surg. j, 178:60-62, Jan. 10, 1918. Shell-Shock and 
 the American Army (Editorial) 
 
 No medico-military problems of the war are more striking than those growing 
 out of the extraordinary incidence of mental and fuctional nervous diseases 
 ("shell-shock"). Together, these disorders are responsible for not less than 
 one seventh of all discharges for disability from the Britisli Army, or one third, 
 if discharges for wounds are excluded. A medical service newly confronted, 
 
98 
 
 like ours, with the task of caring for the sick and wounded of a large army, can- 
 not ignore such important cause of invaUdism. By their very nature, moreover, 
 these diseases endanger the morale and discipline of troops in a special way, and 
 require attention for purely military reasons. In order that as many men as 
 possible may be returned to the colors or sent into civil life free from disabilities 
 which will incapacitate them for work and self-support, it is highly desirable to 
 make use of all available information as to the nature of these diseases among 
 soldiers in the armies of our allies, and as to their treatment at the front, at the 
 bases, and at the centers established in home territory for their " reconstruction. " 
 
 England has had three years' experience in dealing with the medical problems 
 of the war. During that time, opinion has matured as to the nature, causes and 
 treatment of the psychoses and neuroses which prevail so extensively among 
 troops. A sufficient number of different methods of military management have 
 been tried to make it possible to judge of their relative merits. 
 
 Although an excessive incidence of mental diseases has been noted in all recent 
 wars, it is only in the present one that functional nervous diseases have consti- 
 tuted a major medico-military problem. As every nation and race engaged is 
 suffering severely from these disorders, it is apparent that new conditions of war- 
 fare are chiefly responsible for their prevalence. None of these new conditions 
 is more terrible than the sustained shell fire with high explosives which has char- 
 acterized most of the fighting. It is not surprising, therefore that the term 
 "shell-shock" should have come into general use to designate this group of dis- 
 orders. The vivid, terse name quickly became popular, and now it is applied to 
 practically any nervous symptoms in soldiers exposed to shell fire that cannot be 
 explained by some obvious physical injury. It is used so very loosely that it is 
 applied not only to all functional nervous diseases, but to well-known forms of 
 mental disease, even general paresis. If all neuroses among soldiers were included 
 in these groups the use of the term "shell-shock" might be defended. But 
 many hundreds of soldiers who have not been exposed to battle conditions at all 
 develop symptoms almost identical with those in men whose nervous disorders 
 are attributed to shell fire. The non-expeditionary forces supply a considerable 
 proportion of these cases. 
 
 The medical statistics of the war are as yet untabulated. Even if the records 
 contained the information desired it would be very difficult to state the preva- 
 lence of the neuroses on account of the defective nomenclature employed. It is 
 doubtful if there is another group of diseases in which more confusion of terms 
 exists. Nervous or mental symptoms coming to attention after the soldier has 
 been exposed to severe shell fire are almost certain to be diagnosed as "shell- 
 shock," and yet when such patients are received in England, well-defined cases 
 of general paresis, epilepsy, or dementia prsecox are often found among them. 
 This source of confusion tends to swell the number of cases reported under the 
 term "shell-shock," but there are many other sources of error which tend to 
 diminish the apparent prevalence of the war neuroses. It is the belief of those 
 who have made an effort to ascertain the prevalance of the war neuroses that the 
 rate among the expeditionary forces is not less than ten per thousand annually, 
 and among the home forces not less than three per thousand. 
 
 The experience of the British "shell-shock" hospitals emphasizes the fact 
 that the treatment of war neuroses is essentially a problem in psychological 
 medicine. While patients with severe symptoms of long duration recover in 
 the hands of physicians who see but dimly the mechanism of their disease, and 
 are unaware of the means by which recovery actually takes place, no credit be- 
 longs to the physician in such cases and but little to the type of environment 
 provided. In the great majority of instances the completeness, promptness and 
 durability of recovery depend upon the insight shown by the medical officers 
 under whose charge the soldiers come, and their resourcefulness and skill in 
 applying treatment. 
 
The resources at the disposal of the physician in treating the war neuroses are 
 varied. The patient must be reeducated in will, thought, feeling, and function. 
 Persuasion, a powerful resource, may be employed, directly backed by knowledge 
 on the part of the patient as well as the physician of the mechanism of the 
 particular disorder present. Indirectly, it must pervade the atmosphere of the 
 special ward or hospital for "shell-shock." Hypnotism is valuable as an adjunct 
 to persuasion and as a means of convincing the patient that no organic disease 
 or injury is responsible for his loss of function. Thus, in mutism, the patient 
 speaks under hj'pnosis or through hypnotic suggestion, and thereafter must ad- 
 mit the integrity of his organs of speech. The striking effects of hypnotism in 
 the removal of symptoms are somewhat offset by the fact that the most suggesti- 
 ble who yield to it most readily are particularly likely to be the constitutionally 
 neurotic. A mental mechanism similar to that which produced the disorder is 
 being used in such cases to bring about a cure. 
 
 The experience in English hospitals has demonstrated the great danger of 
 aimless lounging, too many entertainments and relaxing recreations, such as 
 frequent motor rides, etc. It must be remembered that shell-shock cases suffer 
 from a disorder of will as well as function, and it is impossible to effect a cure if 
 attention is directed to one at the expense of the other. As Dr. H. Crichton 
 Miller has put it, "Shell-shock produces a condition which is essentially childish 
 and infantile in its nature. Rest in bed and simple encouragement is not 
 enough to educate a child. Progressive daily achievement is the only way 
 whereby manhood and self-respect can be regained." 
 
 It is evident that the outcome in the war neuroses is good from a medical point 
 of view and poor from a military point of view. It is the opinion of all those 
 consulted that, with the end of the war, most cases, even the most severe, will 
 speedily recover, those who do not being the constitutionally neurotic and 
 patients who have been so badly managed that very unfavorable habit-reactions 
 have developed. This cheering fact, however, brings little consolation to those 
 who are chieflly concerned with the wastage of fighting men. The lesson to be 
 learned from the British results seems clear — that treatment by medical officers 
 with special training in psychiatry should be made available just as near the 
 front as military exigency will permit, and that patients who cannot be reached 
 at this point should be treated in special hospitals in France, until it is apparent 
 that they cannot be returned to the firing-lines. As soon as this fact is estab- 
 lished, military needs and humanitarian ends coincide. Patients should then 
 be sent home as soon as possible. The military commander may have the sat- 
 isfaction of knowing that food need not be brought across to feed a soldier who 
 can render no useful military service, and the medical officer may feel that his 
 patient will have what he most needs for his recovery — home and safety and an 
 environment in which he can readjust. 
 
 Although it might be considered more appropriately under the heading of 
 prevention than under that of treatment, the most important recommendation 
 to be made is tiiat of rigidly excluding insane, feeble-minded, psychopathic and 
 neuropathic individuals from the forces which are to be sent to France and ex- 
 posed to the terrific stress of modern war. Not only the medical officers but 
 the line officers interviewed in England emphasized, over and over again, the 
 importance of not accepthig mentally unstable recruits for military service at 
 the front. If the period of training at the concentration camps is used for obser- 
 vation and examination, it is witliin our power to reduce very materially the 
 difficult prol)lem of caring for mental and nervous cases in France, increase the 
 military efficiency of the expeditionary forces, and save the country millions of 
 dollars in pensions. Sir William Osier, who has had a large experience in the 
 selection of recruits for the British Army and has seen the disastrous results of 
 carelessness in this respect, feels so strongly on the subject that he has recently 
 made his views known in a letter to the Jovrnal oj the Avicricaii Medical Asso- 
 
100 
 
 ciation, in which he mentions neuropathic make-up as one of the three great 
 causes for the invariable rejection of recruits. In personal conversation he gave 
 numerous illustrations of the burden which the acceptance of neurotic recruits 
 had unnecessarily thrown upon an army struggling to surmount the difficult 
 medical problems inseparable from the war. 
 
 Neuroses are very common among soldiers who have never been exposed to 
 shell fire, and wiU undoubtedly be seen frequently among non-expeditionary 
 troops in this country. In England nearly thirty per cent of all men from the 
 home forces admitted to one general hospital were suffering from various neuro- 
 ses. Most of these men were of very neurotic make-up. Many had had pre- 
 vious nervous breakdowns. Fear, even in the comparatively harmless camp 
 exercises, was a common cause of neurotic symptoms. Heart symptoms were 
 exceedingly common. The same experience in oiu" own training camps can be 
 confidently predicted. 
 
 Bailey, Pearce. War and Mental Diseases.* Amer. j. pub. health 
 8: 1-7, Jan. 1918 
 
 The address outlines the methods used by the medical department of the 
 United States army in meeting the problem of mental and nervous troubles 
 arising in connection with military service. 
 
 A rather elaborately organized psychiatric service has been established to 
 eliminate the unfit and to care for mental and nervous cases. The large num- 
 ber of insane, epileptics, defectives, etc., recorded in the medical history of former 
 wars, the enormously larger porportion in the present war, and the early lack 
 of facilities to meet the problems created by these conditions led to the estab- 
 lishment of such a service by the Surgeon General of the United States army. 
 After the declaration of war by this country, specialists in these lines were called 
 for to take commissions in the medical reserve corps, and a large number of 
 volunteers presented themselves for the work. The number of medical reserve 
 officers holding such commissions was at the time of the delivery of the address 
 more than 200. Some were stationed at the various camps, some went abroad 
 to study in special hospitals, and others remained in the United States to do 
 work in special clinics. 
 
 The types of mental and nervous cases found in connection with military 
 service are, in the order of their frequency, mental defectives, epileptics, 
 ne'er-do-wells, psychopaths, and syphilitics. Mental examinations are now 
 being used at the recruit depots and in the training camps in the endeavor 
 to eliminate as many as possible of the above types of mental and moral defect 
 and psychopathic inferiority. "The volunteers coming to the recruit depots 
 have a large percentage — 3% to 5% — of unfit. The national guard and national 
 army have been mobilized for too brief a period to make it possible to say what 
 their percentage will be. We have watched with the greatest care the officers' 
 training camp. ... In that fine body of men . . . the finest lot of 
 young men in the world, from 1^% to 2% are nervously unfit for war." 
 
 All the above methods have been applied by the Surgeon General in elimina- 
 ting the mentally and nervously unfit for service. For the care and treatment 
 of cases of "shell shock" special hospitals have been built, special offices have 
 been created, and a special personnel of enlisted men has been collected. Nurses 
 specially qualified to care for nervous patients are being sent abroad and will 
 serve on the staffs of the regular base hospitals, the small hospitals and the rest 
 homes for suffering soldiers. 
 
 Colonel Bailey concluded his address with a discussion of the many lessons 
 that the civil community will learn from the war, especially along the lines of 
 neurology and psychiatry. 
 
 * Report of an address delivered at the General Session of the American Public Health 
 Association, Washington, D. C, October 19, 1917. 
 
101 
 
 Journal Amer. med, assoc. 70: 714, March 9, 1918. Mechanism of 
 Shock (Paris Letter, Feb. 7, 1918) 
 
 At one of the recent meetings of the Academy of Sciences, Dr. Marage dis- 
 cussed the grave phenomena observed among soldiers as the result of the explo- 
 sion of large shells. He said that while there was no apparent lesion, the wounded 
 presented the following symptoms, all of which might be present in any one 
 patient: loss of memory, of equilibrium, of vision, of hearing and of speech. 
 These symptoms disappear gradually in from six to eight weeks, or they may 
 persist for j'ears, and imless treated, they may become permanent. Marage 
 explains these symptoms as being due to the effects produced by the high ex- 
 plosives employed in this war. It is known that the velocity of the sound wave 
 is 333 meters per second under the atmospheric pressure; but in the neighbor- 
 hood of an exploding shell the speed of the shock wave may be as great as 2,000 
 meters per second, a velocity happily attenuated very quickly, for even at 60 
 meters the velocity becomes merely that of sound. But in that danger zone of 
 60 meters, the pressure is increased as high, even, as 200 kilograms to the square 
 centimeter, but this pressure lasts only 1 or 2 hundredths of a second. Further- 
 more, in the danger zone the increase of pressure is not uniform, and in the zone 
 of action there may be dead sectors. The intensity of these zones of action is 
 unequal, being stronger toward the sides than toward the front and rear. This 
 explains why soldiers in the same zone present extremely variable central lesions. 
 Under the influence of this enormous increase in pressure, the blood is forcibly 
 driven toward the center, hence toward the brain. This sudden tidal wave of 
 blood would be always fatal if the capillaries by their resistance did not check it 
 somewhat. Marage concludes from this that it is not by any means always the 
 middle ear which is the cause of war deafness, but that the whole body surface 
 is responsible. The ear protectors are very useful in certain cases, but unfor- 
 tunately they do not protect against this kind of deafness. 
 
 Gordon, Alfred. The Problem of "Neurotics" in Military Service. 
 Med. rec. 93: 234-37, Feb. 9, 1918 
 
 A. Gordon in a practical article emphasizes the very great importance of the 
 early recognition of this type of man, and points out the grave dangers of his 
 continuance in war service. He draws accurately the picture of this class of 
 cases which are most liable to become unbalanced under severe mental or physi- 
 cal strain, and the grave consequences of such breakdown to the man and the 
 service. The author suggests that a closer inspection of the family and personal 
 history would probably lead to the discovery before enlistment of large numbers 
 of these cases, and that if such cases were eliminated before they reached the 
 training camps, much expense to the Government would be saved and greater 
 efficiency result. The author's suggestions seem to be of great importance. — 
 E. H. R., Bost. med. and surg. j. 178: x, May 9, 1918. 
 
 Journal Amer. med. assoc. 70:866, March 23, 1918. War Tremors 
 (Paris Letter, Feb. 21, 1918) 
 
 At one of the recent meetings of the Societe de neurologic, Drs. Henry Meige 
 and Mme. Benisty presented a number of patients afflicted with tremors, and 
 emphasized particularly the clinical characters which permit of a differentiation 
 between tremors of organic origin and those of a neuropathic or emotional origin. 
 Among the organic, they insisted on the morphologic and physiologic objective 
 characters of the parkinsonian type, of which they presentetl a characteristic 
 example consecutive to traumatism. They also showed cases of nervous tremors 
 the result of wounds or of concussion, and also cases of tremors antedating the 
 
102 
 
 war, occurring among emotional subjects. They distinguish, besides true tremor, 
 clonic movements which are sometimes confounded with the latter, and which 
 are the result of certain lesions of the peduncular protuberance. In the clinical 
 diagnosis it is essential to examine with care the seat and the form of the tremor. 
 When it is confined to the fingers and is fine and rhythmic, it is nearly always of 
 organic origin. One frequently sees a nervous tremor involving only the flexors 
 and extensors of the wrist, or the pronators and supinators without any involve- 
 ment of the fingers. When studying a tremor it is essential to determine by 
 manual palpation the sensations experienced while mobilizing parts of the limb. 
 The waxy flexibility, flexibilitS cirreuse, of Parkinson's disease, is clearly distinct 
 from the cog wheel resistance, resistance a crans, perceptible in the majority of 
 nervous tremors, and evidenced by a succession of contractions and relaxations, 
 more or less brusque, occurring at regular intervals. 
 
 The evolution of a tremor is also of diagnostic value. It may be (1) progressive, 
 localized at flrst in one member or iu part of a member, but progressively involves 
 one or more of the other members. Parkinson's disease belongs in this class. Or 
 the tremor may be (2) retrogressive, generalized at first but tending gradually to 
 become localized in one member or part of a member. This evolution is charac- 
 teristic of tremors of neuropathic origin. There is further (3) the migratory 
 tremor, whose localization varies, as do likewise its extent and time of appear- 
 ance. The migration of the tremor may occur spontaneously. It can be ren- 
 dered more apparent by changing the position of the member, or if one or more 
 parts or segments are immobilized. 
 
 Meige and Benisty also called attention to the necessity of morphologic exam- 
 ination, wliich enables one to appreciate the state of permanent hypertonicity of 
 certain persons with tremor, a phenomenon to whose existence in Parkinson's 
 disease Paul Richet and Meige have previously called attention, and which may 
 also be seen in paratonic subjects. It is evidently a manifestation of desequili- 
 hration motrice congenitale. Dr. Tinel, chef de clinique a la Salpetriere, stated 
 that he had observed several cases of neuropathic tremor of a member since this 
 condition had been cured by intense faradic reeducation. He has also noted the 
 migration of certain tremors. The neuropathic tremors are at the same time 
 real, involuntary, persisting during sleep and even under the influence of chloral, 
 but, nevertheless, perfectly influenced by reeducation. There exists in these 
 cases a state of neuromuscular hyperexcitability associated with a persistent 
 emotional state. 
 
 Amer. med. 24: 306-07, May 1918. The Treatment of War Neuroses 
 (London Letter, March 26, 1918) 
 
 Two different conditions, wliich may be described as neurasthenic and hyster- 
 oid, either of which conditions sometimes receives the name of " shell-shock, " are 
 at the present moment the subject of the anxious attention of physicians and 
 psychologists at the front, in the base hospitals, and in the various home institu- 
 tions, general or special, for the treatment of chronic cases. On the etiology of 
 many of these cases, and therefore of their treatment, much difference of opinion 
 has been expressed, as is shown by the fact that quite recently one famous London 
 neurologist said that in his experience many patients suffering from so-called 
 "shell-shock" were "shell-shy", while another gave it as his experience that 
 deliberate malingering was very rare. The view of the writer of pensions, 
 Mr. J. Hodge, has been publicly expressed that the admixture of shell-shock cases 
 with "cheery chaps" in general hospitals would give good results, and Professor 
 Elliot Smith of Manchester has demolished it with delightful scorn. Such dif- 
 ferences of opinion indicate that different advisers find different courses advisable 
 for the patients, for, while it is obviously wrong to congregate malingerers in any 
 large institution where their form of weakness may spread to other patients, it is 
 
103 
 
 equally obvious that for subjects requiring real neurologic care, persons qualified 
 to give them that attention should be in attendance. Those British authorities 
 who agree so far as to acquiesce in the necessity of having neurologic centers, 
 differ on one point, as to the locality of those centers, some seeing no harm in 
 keeping the patients in towns, and others desiring to send them into the quietest 
 possible country districts. It is clear that it is easier to obtain a first-class scienti- 
 fic staff for an institution in a large urban center than it ever could be for homes 
 scattered up and down the countryside, a practical reason which has to a great 
 extent dictated the geography of the various institutions. 
 
 The question of receiving shell-shock patients into London institutions has 
 been complicated by the fact that London is subjected to aerial bombardment, 
 the effect of which upon the shell-shocked patient may well be regarded mth ap- 
 prehension. It is undoubted that in some of the hospitals in the London area the 
 raids have an ill effect upon those patients, although the amount of damage done 
 to them seems to have been considerably exaggerated, wliile the stories of panic 
 spreading from patient to patient lack all authority and are backed by no evi- 
 dence. On the other hand, categorical statements have been made by certain 
 medical officers that no ill effect of any marked sort can be observed among 
 the shell-shocked patients on the nights of German air raids, and that, where in- 
 dividual patients have shown signs of breakdown, it has been easy to restore their 
 equanimity, and noticeably that on later occasions in similar cricumstances that 
 equanimity was preserved. The arrangements for the treatment of discharged 
 soldiers and sailors are now made by the Ministry of Pensions and the matter of 
 reception and treatment of cases of war nem"osis forms a subject to which that 
 department is now giving considerable attention. But the medical profession 
 does not feel wholly satisfied with the arrangement made by the ministry to keep 
 in touch with first-class scientific opinion, and the view has been expressed in no 
 uncertain terms that the ministry ought to provide itself with an advisory com- 
 mittee of general physicians and surgeons, experts in various special directions, 
 so that errors which have certainly been committed in the treatment of soldiers 
 and sailors discharged under the heading of neurosis should for the future be 
 avoided. 
 
 Bailey, Pearce. Malingering in U. S. Troops, Home Forces, 1917; 
 Bulletin compiled from Reports of Medical Officers. Mil. surg. 
 42: 261-75, 427-49, March and April 1918 
 
 Malingerers in a military environment may be divided into two groups: (1) 
 those that feign symptoms with full knowledge, interest and responsibility, and 
 (2) the constitutionally inferior individuals who are never able to face disagreeable 
 situations without complaint and deceit. With the progress of medicine the 
 number of cases of group 1 has decreased whereas group 2 has increased consider- 
 ably. "One surgeon expresses himself as convinced 'that in almost all of the 
 cases in which defects were simulated or exaggerated, the patients were actually 
 defective either in a lesser degree or in a different affection or in both. Whether 
 the malingering took the form of mental or nervous or physical defects it was 
 based, in almost every instance, on an actual unstable or defective mental state. 
 
 Malingering is more frequent at the National Army camps than at the National 
 Guarfl divisions, but even here it has never exceeded 1% of the whole command. 
 The motives that lead men to feign disability are varied. By far the most com- 
 mon purpose is to evade service, and therefore the presence of malingering among 
 drafted men has been more marked than among those that have enlisted. 'J'liere 
 are some men who apply honestly for enlistment, but who later feign symptoms 
 in order to be dismissed; others apply with the deliberate purpose of being re- 
 jected for physical unfitness so that they may avoid being drafted into the service. 
 Every minor ailment is often exaggerated because the men wish to avoid un- 
 
104 
 
 pleasant duties. On the other hand boys of fifteen, sixteen, or seventeen often 
 pass as eighteen or over in order to enter the service. Sometimes men will 
 conceal disabilities and diseases in order to join the army. This is especially 
 true of alcoholics and epileptics. Often soldiers accused of delinquency will claim 
 a medical examination to obtain exemption from punishment. Less frequently 
 men will try to obtain transfers to different divisions, such as the Quartermaster's 
 Corps or the Medical Corps where they beheve the work to be easier and less 
 perilous. 
 
 Suggestion is an important factor in maUngering. This may come from remote 
 sources such as the idea of being weak or delicate before entering the army and 
 the probable breakdown resulting from the strain of army life, or the symptoms 
 may be transferred suggestively from one man to another in the same company. 
 To understand cases of this kind, the medical officer must establish relations 
 with the recruits whereby the real nature of the malingering is disclosed. 
 
 There are very few malingei'ers of the criminal type. Most malmgering is 
 done in a crude way and so is easily detected. For the detection and cure of 
 maUngering the examining ofiicer must both recognize the self-induced factitious 
 conditions and estimate the degree of exaggeration in complaints of actual or 
 preexisting diseases, conditions or injuries. A brief stay in the hospital is usually 
 sufiicient to disclose the self-induced symptoms. When there is a suspicion that 
 existing ailments are exaggerated, the medical oflficers must decide whether or not 
 the alleged suffering, compared with conditions actually found, is beyond medical 
 experience. After this point is determined, the motives which led to the exag- 
 geration must be discovered. This can be done best by studying the soldier's 
 personality, his home and school life, his business career, and his own ideas con- 
 cerning his health. 
 
 The various disabilities that are feigned may be listed under (1) disturbances 
 of vision, (2) disturbances of hearing, (3) general medical, (4) general surgical, 
 (5) nervous and mental conditions, (6) factitious conditions including wounds, 
 and (7) bed-wetting. Many tests for the detection of physical disabilities are 
 described m detail. However, in spite of the fact that most malingerers are 
 psychoneurotics, few of them ever feign mental or nervous diseases. Insanity, 
 however, is easUy recognized as feigned by the failure to produce any clinical 
 type or by absurd statements and actions. Mental defect is feigned frequently, 
 for the most part by illiterates and foreigners, who, because of their ignorance 
 of the language, feel that they can display an unnecessary amount of stupidity. 
 Knowledge of the home environment, and, in the case of foreigners, an inter- 
 preter are necessary for their detection. The discovery of simulation and man- 
 agement of cases that complain of pain and hyperesthesia is as follows: "Failure 
 to correspond in distribution with true clinical types. History often quite incon- 
 sistent with type of pain complained of. Absence of the ordinary traces of pro- 
 longed pain, and of the other symptoms which usually accompany type of pain 
 complained of. When referred to limited areas, absence of the sharply localized 
 painful points characteristic of neuralgias. Behavior of patient (when he thinks 
 himself unobserved) to be carefully noted." Tremors are frequent in the early 
 days of training, as a result of unusual exertions. If accompanied by other 
 symptoms the etiology should be determined. Anesthesia is frequently present 
 in neurotic persons. Complaint of this condition however indicates malingering 
 since genuine patients rarely realize its existence. "The most reliable means of 
 detection consists in its failure to reproduce the clinical picture of the various 
 diseases in which it occurs, and the faulty association with other symptoms." 
 Epilepsy is frequently imitated since it is a common cause of discharge from the 
 army, but the fits are usually imitated in a clumsy fashion, or when no physicians 
 are present. However it is doubtful as to whether men that can imitate grand 
 mal epileptic attacks can be made into desirable soldiers or not. It is probable 
 that they are constitutionally neurotic. A verified history of previous attacks is 
 
105 
 
 always necessary. In attacks of true grand mal, the pupil does not react to light 
 for a short time after the attack, the Babinski reflex is present and the knee jerks 
 are lost. In mahngering the initial cyanosis of the epileptic is wanting and the 
 tongue is seldom bitten. Frothing at the mouth is reproduced by filling it be- 
 forehand with soap suds. Hysteria is rarely chosen by malingerers although it 
 is difficult to detect as feigned. "The symptoms of hysteria never reproduce 
 those of organic disease but they come closer to it than is possible to any con- 
 scious simulator, and whenever there is a reasonable doubt as to whether a man 
 is really pretending or not, the chances are that a hysterical element is strongly 
 represented in the case." This question comes up most frequently in cases of 
 paralysis and of contractures of the muscles of the back. The use of the Faradic 
 current usually proves or disproves the presence of organic paralysis, either 
 peripheral or central by determining the t j-pe of symptoms and the way in which 
 they are associated. Cases in which the back is held stiffly forward or laterally 
 may require an X-ray examination for determining the absence or presence of 
 disease of the vertebrae. These contractures however are usually associated 
 with the belief on the patient's part that he has an actual disease of the spine or 
 kidneys and clear up rapidly under the usual methods of treating hystero-mahn- 
 gerers. 
 
 Pretended alcohohsm or drug addiction is sometimes made a basis for exemp- 
 tion from service. These cases are detected when, deprived of the drugs, they 
 show no deprivation phenomena. 
 
 Various other conditions are artificially created or simulated, such as amputa- 
 tions, self-inflicted wounds, teeth extractions, inflammations of the skin by the 
 use of irritating chemicals, retention of urine, etc. Bed-wetting is of frequent 
 occurrence since it is easy to assume, difficult to detect when simulated, and 
 often leads to discharge. 
 
 Major Bailey closes his report with a brief discussion of the conscientious 
 objector. 
 
 Med. rec. 93: 781, May 4, 1918. Convalescent Homes for Neuras- 
 thenic Cases (London Letter, April 4, 1918) 
 
 The Minister of Pensions, Mr. John Hodge, is finding himself in considerable 
 opposition to the best medical opinions in the attitude which he has taken up 
 with regard to the homes of recovery which are being instituted for neurasthenic 
 and shell shock cases. Mr. Hodge has official medical opinion to rely upon, 
 but either this opinion is not as well informed as it should be or he is preferring 
 to listen to the popular view. The popular view is that the neurasthenic pa- 
 tient requires cheering up by intermixture with other patients, and also that 
 as his condition can often be attributed to what is vaguely labeled "shell shock", 
 it is particularly important that the institution into wliich he is received should 
 be outside the area of possible or probable air raids. Of course, no patients ought 
 to be placed within a danger zone if it is possible to accommodate them outside. 
 But there has obviously been great exaggeration of the Ul effects displayed by 
 the shell-shocked patients after subjection to an air raid. So far from being 
 more agitated than any other members of the population, when judiciously han- 
 dled they bear the ordeal with perfect calm. A limited number of neuras- 
 thenic cases may improve when mixed up with a general hospital population. 
 Some also may only require ordinary treatment in a convalescent home, or can be 
 boarded out as country visitors, or may be added to the population of village 
 centers, but as a rule those suffering from functional nervous disorders require 
 special treatment which can only be given in special institutions. The scat tar- 
 ing of neurasthenic patients in various directions on the chance that a proportion 
 of them may get better is a policy directly opposed to that intensive treatment 
 of disease which has proved in every department of surgery and medicine to be 
 
106 
 
 the really efficient way of dealing with the pathological results of the war. The 
 War Office has taken a better line than Mr. Hodge, in the opinion of real neuro- 
 logists, when the military authorities issued a recommendation that all soldiers 
 suffering from a functional nervous disorder should be segregated for treatment 
 into special hospitals immediately on their home arrival, and that such hospi- 
 tals should be staffed by medical officers interested in and specially trained for, 
 the work. There is a strong feeling in medical circles that the Ministry of Pen- 
 sions should be provided with some sort of advisory medical council so that the 
 minister might be kept in better touch with scientific medicine. Undoubtedly 
 it is a popular belief that it does the neurasthenic patient good to be cheered up 
 by the merry convalescents from minor surgical injuries, but official support of 
 this belief may produce feeUngs of considerable anxiety among the relatives of 
 neurasthenic patients who are receiving the proper treatment on intelligent 
 segregation and individual scientific attention. 
 
 Journal Amer. med. assoc. 70: 1554, May 25, 1918. Special Commis- 
 sion for Surveillance of Outcome of Nervous and Mental Disease 
 in Soldiers (Paris Letter, April 18, 19 18) 
 
 Conforming to the plan adopted December, 1917, at the reunion of the chiefs 
 of the centers of neurology and psychiatry and by the Societe de neurologic, 
 the undersecretary of state for the Service de Sante MUitaire has decided on the 
 creation of a special commission for supervision of the results of treatment of 
 nervous and mental disease in soldiers. This commission is charged with the 
 technical control of the neurology and psychiatry centers, and also the solution 
 of medicolegal questions in debatable and rebellious neurologic or psychiatric 
 cases (convalescence, temporary or permanent invaliding, military sanctions, 
 etc.). The committee is called to functionate principally for cases treated in the 
 special centers for functional reeducation and exceptionally for other cases 
 which will be submitted by the undersecretary of state for the Service de Sant6 
 Militaire. As a rule, the commission will examine on the spot the cases referred, 
 to them. The commission is composed of Drs. Achille Souques, medecin des 
 hopitaux de Paris, Ernest Dupre, professor agrege a la Faculte de medecine de 
 Paris, et medecin des hopitaux, Henri Claude, professor agrege a la Faculte de 
 medecine de Paris et medecin des hopitaux, and Dr. Froment. 
 
 Journal Amer. med. assoc. 70: 1554, May 25, 1918. The Treatment 
 of Shell Shock (London Letter, April 30, 1918) 
 
 The large number of men discharged from the army because of shell shock 
 presents a new problem. They have been treated in a long series of military 
 hospitals, where every effort has failed, and finally they have been sent out into 
 the world physically sound but mentally broken down, incapable of work and 
 unfit even to go home to their families. Like many other new problems pre- 
 sented by the war, experience and energy have solved this one. Special hospitals 
 have been established for the treatment of such men with excellent results. 
 The patient is first put to bed in a room alone and the physician brings mental 
 influence to bear on him, for drugs are of little use. He is encouraged to regain 
 his lost will power. The next step is to put him in a room with suitable compan- 
 ions and rouse his interest in things outside himself. At first he is very imso- 
 ciable because he has lost self confidence; but sooner or later he begins to mix 
 with his fellows and then plays billiards, cards, or other games. In the gymna- 
 sium, systematic exercises are then performed under an instructor. Various 
 forms of work, of which carpentry and bootmaking are the most popular, are 
 next undertaken. At first the patients work only an hour in the day, then two, 
 and so on until six hours are attained. Other trades taught are engineering, 
 
107 
 
 ■electric light work, motor construction, and intensive gardening. Two thirds of 
 the patients return to their former work, and one fourth are made useful workers 
 in some other line. Thus complete recovery takes place in eleven out of twelve 
 cases. 
 
 Sexton, F. H. Vocational Rehabilitation in Canada of Soldiers Suffer- 
 ing from Nervous Diseases. Mental hygiene 2 : 265-76, April 
 1918 
 
 Although it was expected that many men in the armies would not be able to 
 endure the mental strain of war, hardly any one w^as prepared to find that so 
 large a proportion of discharges would be due to nervous troubles. "In England 
 nearly 20% of the 175,000 pensioners are suffering from functional nervous 
 disease and the greater part of these have not been actually wounded. In 
 Canada over 10% of all the 25,000 men who had returned up to October 1, 1917, 
 were classified as mental cases. This category included insanity, shell shock, 
 neurasthenia, etc. If those who were returned as over-age, under-age, and for 
 duty are excluded, the mental cases represent 15% of the invalids, and if those 
 suffering from actual wounds are not counted, the mental cases constitute 25% 
 of all those returned from the Canadian army in England and France. From a 
 purely military point of view this factor of war neurosis is liighly important where 
 so many men have to be discarded for mental causes. From an economic 
 standpoint, the treatment of so large a percentage of invalids in order to rein- 
 state them in productive work is a serious matter." 
 
 During the early part of the war mental and nervous cases were removed 
 from the front lines and even sent to England for treatment, but when German 
 submarines began to sink hospital ships, neurological centers had to be estab- 
 lished in France. These are usuallj' situated in the immediate rear out of range 
 of all but the largest guns. "A special shell shock hospital is run in conjunction 
 with a clearing hospital in each area. Each indi\adual soldier is looked upon as a 
 separate case. . . . The doctors, nurses and staff are all carefully selected for 
 their special abilities and personalities. The atmosphere of the institution is a 
 deliberately planned mixture of firmness and kindness. It has a mihtary tang, 
 but is not so impersonal and severe as the army. All the staff are expected to 
 radiate optimism and cheerfulness. The patients are kept as far as possible from 
 introspection. . . . Quick recoveries are the rule and a high percentage of the 
 men return to the trenches inside of a month or even a fortnight. An expert 
 French medical officer in charge of one of these centers reports that 91% of the 
 cases received in a four-month period were sufficiently recovered to send back 
 into the fighting line. , . . 
 
 "If the patients do not show signs of quick recovery they are sent to the base 
 or to England. If they are Canadians and will not be fit again for six months 
 they are sent home for further treatment before discharge. ... If the men 
 are suffering from a form of mental disease that treatment will not benefit, they 
 are sent to the hospital for the insane in the province to wliich they belong. 
 The government pays for their maintenance and if the man is married, his wife 
 gets the same pension for herself and her cliildren as if her husband were dead. 
 If the case is severe and needs more careful diagnosis and treatment, the man is 
 sent to the Central Hospital for Nervous Diseases at Cobourg, Ontario. . . . 
 From here, patients may be discharged to hospitals for the insane, to regular con- 
 valescent homes, or to civil life." 
 
 Sexton quotes statistics as to types of war neuroses from Cobourg reports. 
 "Hydrotherapy and electrotherapy are used with most gratifying results, but 
 some form of vocational training is depended upon to build up the will and ini- 
 tiative of the patient. . . . He is first told that his nervous disability does 
 not at all unfit him for success in some civilian occupation, but that it is severe 
 
108 
 
 enough to debar him from any further military service. This sets his mind at 
 rest about being retm-ned to the army, and directs his attention to the future." 
 He is then given some hght occupational work upon which he spends at first 
 only an hour or two a day, but the time is gradually increased until he is working 
 all day. Then he is promoted to classes requiring more skill and effort, and so on. 
 Judicious praise is employed, but no "mollycoddling" is allowed. If the patient 
 is much interested in liis work, very little attention is paid by the doctors to his 
 ailments, so that his mind may be kept entirely concerned with things other than 
 his own condition. . . . "When the patient is fit to return to civil life, he 
 goes back to his own job, or enters a course in another institution, or else is ap- 
 prenticed in industry to gain the knowledge and skill necessary for his success 
 in some regular occupation. 
 
 "The institutions most necessary for treatment of these men are convalescent 
 homes, not hospitals. . . . The homes are usually situated near large cities 
 so that expert medical services may be secured, and each has a capacity of from 
 300 to 1,000 patients. In order to make proper use of the time of the soldier 
 during the day, vocational training was introduced into every home, and now the 
 vocational building is an integi'al part of every new building plan." At first ad- 
 mission to classes was voluntary, but the treatment so quickly proved its value 
 that after a brief time vocational work was made compulsory for all men not 
 excused as unfit by the medical oflBcer. Instruction is given in English, French, 
 arithmetic, stenography, bookkeeping, tj^jewriting, telegraphy, woodworking, 
 shoe repairing, mechanical and architectural drawing, care and operation of 
 automobiles, machine-tool operating, electrical wiring, gardening, poultry- 
 farming, etc. The daily program requires from four to foin* and a half hours of 
 attendance. Each man is allowed to make his choice of classes. 
 
 To nervous cases the making of novelties and hand-wrought jewelry has 
 proved especially interesting. The articles made may be kept by the patient 
 if he pays for the raw materials, or they may be sold at reasonable prices as war 
 souvenirs. In this way many a patient has made enough to serve as a nest egg 
 with which to start life again when discharged. Very few nervous patients can 
 be interested in work requiring mental effort; they like best creative work with 
 the hands. Light woodworking and machine-tool operation have proved 
 popular with, shell shock cases. A machine shop is too noisy for most nervous 
 patients, but some have achieved great proficiency as macliinists in spite of this 
 drawback. Farming is beneficial to those who lived in the country before the 
 war, but former city-dwellers seem to find the isolation and quiet routine of farm 
 life an aggravation rather than a help. But no rules for choice of occupation can 
 be formulated. It is necessary to find the line of work in which the particular 
 case is most interested and then to furnish instruction in it. Mild cases should 
 be directed toward recognized wage-earning work as they will thus the more 
 readily regain initiative and self-confidence. Many cases have left the conva- 
 lescent homes fitted to take up work in which they have been more deeply in- 
 terested and in which they have received greater remuneration than in their pre- 
 war occupations. 
 
 "The vocational training in the convalescent homes is only incidental and sup- 
 plementary to the medical treatment. When a man becomes an arrested case 
 he is discharged whether he has finished a course or not. If he is then unable to 
 follow his old trade successfully he is a subject for vocational re-education. He 
 is brought before a Disabled Soldiers Training Board, composed of a special med- 
 ical officer, a vocational officer, and a layman who may be an employer, a labor 
 organizer, a business man, a professional man, etc., representing the public. 
 The man's desires and former occupation, together with his disability are care- 
 fully considered, and he is advised in regard to the vocations he may enter with 
 probability of success. He, however, makes the choice liimself so that he has 
 the greatest stake in his future training. The effort is made to keep him as close 
 
109 
 
 as possible to his former work so that his industrial experience and skill may not 
 be altogether scrapped. It is very evident that, if possible, he should be moved 
 up to a position of greater skill and responsibility where he must use his intelli- 
 gence more and his physical strength less. Thi^ is often possible, but is not 
 usually the case. The attempt is then made to place him in some occupation in 
 the same industry, but parallel w4th his former work where his disability is not a 
 serious handicap. If the central authorities at Ottawa concur in the recom- 
 mendation of the Disabled Soldiers Training Board, the man passes out of the 
 Army and becomes a civilian under the control of the Vocational Branch of the 
 Military Hospitals Commission. He receives special pay and allowances 
 running from a mimimum of $46.00 a month, if he is a single man with no depend- 
 ents, to a maximum of $93.00 a month in the case of a married man with five or 
 more children under sixteen years of age. This allows him and his dep>endents 
 to live respectably whUe he is getting his training. He may be sent to a technical 
 school, a college of pharmacy, an agricultural college, a business college, a navi- 
 gation school, or other special institution or he may be regularly apprenticed in 
 an industry. The courses usually last six to twelve months and are entirely free 
 of cost to the man. He is given an extra month's pay at the end of the course, 
 a position is found for him, and no deduction is made from his pension because 
 of any proficiency or wage-earning power he has acquired at the expense of the 
 government. 
 
 "Thus Canada is trying to place the disabled men on their feet again in 
 civilian life. The attempt is being made to eliminate the most pitiful by- 
 product of war, the 'old soldier'. Having before her the experience of the 
 United States after the Civil War, Canada is determined to have no crop of 
 'carpet-baggers', pension mongers, and government alms-takers with the con- 
 sequent commonplace fiJching of national funds and degeneration of civic hon- 
 esty. The gospel of the busy life for everybody is being preached and practiced 
 among the returned invalid soldiers. Salvation through honest work applies to 
 the hero home from France as much as to the mental defective or social delin- 
 quent. The satisfactory results already achieved in Canada stamp the voca- 
 tional training and re-education as the most hopeful activities in rehabilitating 
 the men who have placed their bodies and brains as a barrier against the horrible 
 flood of German ideas that threatened to overflow the world, and who have given 
 freely of themselves in this glorious service. The goal is to make the soldier's 
 disability his opportunity and to prove that his sacrifice will furnish him a staff 
 with whjch to support himself instead of a millstone to drag him down." 
 
 N. Y. med. j. 107: 850-51, May 4, 1918. The Mentally Defective Sol- 
 dier (Editorial) 
 
 For the first time in the lustory of warfare mental hygiene, as practised among 
 soldiers, lias been given the prominence it deserves, and, profiting by the ex- 
 perience of England and France in the present war, the Surgeon General was 
 impelled to inaugurate an elaborate organization, both in numbers and in plan, 
 to take care of any mental disturbances detected in the camps or among soldiers 
 during tlie war. This is a distinct innovation in medical army work, for the 
 subjects of mental hygiene and of mental and nervous disease in general as oc- 
 curring among soldiers in war time were for many reasons either shghtly treated, 
 or neglected altogether. 
 
 The outlook for those affected mentally during the war is rather brighter than 
 among those in civil life, and Lieutenant Colonel Pearce Bailey (American 
 Journal of Public Health, January, 1918) finds the rate of recovery varying up 
 to seventy per cent, (Doctor White's statistics of the Spanish war), as con- 
 trasted with the twenty per cent or twenty-five per cent as found among the 
 civilians. During peace the discharge rate from the army of those affected with 
 
110 
 
 various psychoses is three men in a thousand, as compared with six or even tea 
 in a thousand during the war, especially in expeditionary wars, that is, wars in 
 foreign countries, when the ratio rises as high as fifty per thousand, as happened? 
 in the German expeditionary forces in the Boxer campaign. Here evidently 
 homesickness is an important contributory factor. Insanity is the most fre- 
 quent cause for discharge in the army, even more so than tuberculosis, contrary 
 to the accepted belief. 
 
 The mental hygiene work is conducted by a staflf of qualified men, who re- 
 sponded eagerly to Surgeon General Gorgas's appeal for speciaUsts issued in 
 April and May of last year. Among the cases they handle are, first of all, the 
 mental defectives, whose conduct in the army may easily be compared to the 
 behavior of backward and feebleminded children in school. Their mentality 
 is passed upon by new and rapid tests specially adapted to the urgency of the 
 situation. The weeding out of these "stupids" is a matter of great importance 
 in the morale of the army during war, for many a case of apparent cowardice,, 
 for which the unfortvmate forfeits his life, is to be ascribed to feeblemindedness, 
 as the English have found in their experience during this war. Another class 
 is the pampered son and the ne'er-do-well, subjects without stamina or basis 
 of character or mind; the presence of such is of no value in an army, and, once 
 found, they should be gotten rid of. Still another t}^e is the individual who- 
 cannot possibly be made to fit within the rigid frame of the collective discipline 
 of an army; divorced from his habitual way of doing things, unable to orient 
 himself among the new surroundings for lack of adaptability, he soon collapses 
 under the strain and excitement of war horrors, and thus becomes a burden on 
 the army. It is especially important to keep in mind that all such may pass 
 a perfect physical examination, as presumably very desirable soldiers, and this 
 notwithstanding may be properly classified among the above enumerated cases. 
 Even in the officer's training camps, where are gathered some of the finest speci- 
 mens of young manhood, among candidates the two most important qualifi- 
 cations of the successful soldier, the ability to obey and the quality of initiative 
 and independence whenever the occasion demands, there are between one per 
 cent to two per cent nervously unfit for war. 
 
 Amer. med. 24:265, May 1918. The Reconstruction of Men (Edi- 
 torial) 
 
 The reconstruction of men and the industrial rehabihtation of the nation 
 involves a new phase of work for the medical profession. The real results of 
 medical care are not to be gauged by the physical restoration of the individual,. 
 but in terms of his psychologic and industrial restoration. A new type of med- 
 ical work will be developed combining medical experience, educational ability, a 
 knowledge of the psychology of work and workers, an understanding of the 
 nature and strains of various industries, together with a high degree of educational 
 resourcefulness. The occupational therapeutist will become a prominent factor 
 in the future development of the program for rehabilita.ting those disabled by 
 war. Unfortunately, inadequate attention has been given to the relation of 
 this problem to those crippled in the struggle for existence, those who have suf- 
 fered from the all too numerous accidents which have characterized our industrial 
 development. 
 
 The place of occupational therapy in the treatment of neurasthenia and 
 psychoses has been recognized and considerable progress has been made in this 
 direction. The problems of occupation involved as a result of bhndness, deaf- 
 ness, epilepsy, tuberculosis and similar handicapping defects and diseases have 
 received constructive consideration and moderate attempts have been made to- 
 secure the adjustments after due training required by such physical incapacities. 
 A broader view must now be taken, and the occupational therapeutist is already 
 
Ill 
 
 in demand with a supply so limited as to require the immediate institution of 
 training courses to remedy the lack. 
 
 The economic returns of rehabihtation are the ones which are usually urged 
 and stressed by those interested in the organization under federal auspices of a 
 reeducational program. From the public health standpoint, equally valuable 
 results are to be attained as a result of the strengthening of national vitahty. 
 Gross handicaps, unfitting for employment, are responsible for the reduction of 
 power and vitality. Industrial incapacity, with decreased economic rewards, 
 results in lower standards of living, with consequent limitation of physical, men- 
 tal and moral welfare. The health-giving environment depends upon an ade- 
 quate living wage. Rehabilitation is a health problem of no mean proportions, 
 and should engage the serious attention of the medical profession, not merely in 
 connection with war injuries, but with those arising in every phase of civil and 
 industrial life. 
 
 Pilgrim, Charles W. The State Hospitals and the War. N. Y. State 
 hosp. quar. 3: 223-24, May 1918 
 
 The statistics of the hospitals for the insane in New York State for the forty- 
 fom" months before the war showed 29,316 admissions; while in the forty-four 
 months that have elapsed since the declaration of war there have been 33,311 
 admissions. This was a marked increase, and, as a majority of the new cases 
 were of the dementia praecox and manic-depressive variety, it was only fair to 
 assume that the stress and excitement of war times was the cause. Another 
 interesting fact is that the admissions showed a marked increase in recurrent 
 cases. It was also noticed that many cases occurred among old people who had 
 delusions of a depressing character, such as that the end of the world was ap- 
 proaching, that everything was going wTong, etc., such as would be caused by 
 the present troublous times. Another reason for the increased admissions might 
 be that many people have gone into new employment where the work has been 
 more strenuous and where they have made a great deal more money and have 
 lived very different lives. 
 
INDEX OF AUTHORS OF BOOKS AND ARTICLES ABSTRACTED 
 
 Agostini, Cesare, 56 
 Anderson, John E., 87 
 Auer, E. Murray, 73 
 
 Babinski, J., 26 
 Bailey, Pearce, 100, 103 
 Barre, J.-A., 23, 25 
 Binswanger, Otto, 45 
 Boisseau, J., 23, 25 
 Buschau, George, 29 
 
 Campbell, Kenneth, 9 
 Cheyrou, 24 
 Collie, John, 10 
 Crinon, 23 
 Crouzon, 0., 25 
 
 Damaye, Henri, 24 
 
 Farrar. Clarence B., 73 
 Ferrand, Jean, 19 
 Forster, Frederick C, 13 
 Froment, J., 26 
 
 Gatti, L., 57 
 Gordon, Alfred, 101 
 Green, Edith M. N., 9 
 Guillain, Georges, 23, 25 
 
 Hammond, Graeme M., 83 
 Hartmann, Fritz, 41 
 Hoffmann, Rudolph, 47 
 Hoven, 22 
 HUbner, A. H., 34 
 Hunt, J. Ramsay, 84 
 
 Jolly, P., 33 
 
 Jones, A. Bassett, 13 
 
 Kastan, Max, 41 
 
 Landau, 21 
 
 Llewellyn, Llewellyn J., 13 
 
 Lowy, Max, 49 
 
 MacCurdy, John Thomson, 75 
 
 Maitland, E. P., 9 
 Mann, Ludwig, 46 
 Marburg, Otto, 38 
 Marchand, L., 19 
 Mauger, N., 25 
 Mayer, Alfred G., 82 
 Mendel, Kurt, 32 
 Meyer, Robert, 51 
 Meyer, S., 50 
 Mingazzini, G., 55 
 Mott, Frederick W., 13 
 
 Neymann, Clarence A., 79^ 
 Nonne, Max, 48 
 Nordlund, H., 69 
 
 Oelsnitz,[M. d', 23, 25 
 
 Pilgrim, Charles W., Ill 
 Pitres, A., 19 
 
 Redard, Paolo, 56 
 Redlich, Emil, 37 
 Riebeth, 44 
 Roussy, Gustave, 23 
 
 Salmon, Thomas William, 80, 83, 86, 
 
 88,92 
 Sandro, D. de, 56 
 Savage, George H., 14 
 Schultz, J. H., 51 
 Seppilli, G., 56 
 Sexton, F. H., 107 
 Soukhanoff, S. A., 65 
 
 Turner, William Aldren, 11 
 
 Van der Hoeven, H., 61 
 Viets, Henry, 12 
 
 Westphal, A., 34 
 Weyert, 30 
 Wcygandt, W., 48 
 Wolfsohn, Julian M,, 14 
 Wollenberg, R., 43 
 
 Yerkes, Robert Mearns, 80 
 
 113 
 
INDEX OF SUBJECTS 
 
 Alcoholism, 22, 23, 30, 33, 86, 37, 49, 
 
 50,94 
 Anesthesia, 90 
 Anxiety states. See War neuroses; 
 
 War psychoneuroses 
 Asthenia, 24, 25. See also Etiology, 
 
 fatigue 
 Auditory disturbances, 47, 101 
 
 B 
 
 Barany test, 51 
 Blood pressure, 9, 10 
 Brain injuries, 38, 39, 55 
 British literature, 7 
 
 C 
 
 Care. See Treatment 
 
 Classification, 88 
 
 Clinical studies, 35 
 
 Concussion. See Etiology, explosives 
 
 Contractures, 23, 25, 26, 5Q 
 
 Conversion hysteria. See Hysteria 
 
 D 
 
 Delinquency, military, 36, 42, 43. 
 
 See also Malingering 
 Dementia precox, 22, 31, 33, 42, 94 
 Diagnosis, 14, 31, 32, 48, 51, 77, 89, 90. 
 
 See also Malingering; Organic 
 
 changes 
 Dreams, 9, 10, 37 
 
 E 
 English literature. See British litera- 
 ture 
 Epilepsy, 23, 32, 56, 57, 74, 94 
 Etiology, 19, 22, 24, 29, 34, 41, 44, 45, 
 46, 47, 50, 73, 75, 88, 89, 96, 97. 
 See also Alcoholism ; Brain injuries; 
 Clinical studies; Nerve injuries; 
 Organic changes; Predisposition; 
 Syphilis; and names of signs, 
 symptoms and diseases 
 emotion. 13, 29, 97. See also Etiol- 
 ogy, fear 
 explosives, 35, 37, 50, 82, 88, 88, 101 
 fatigue, 75, 84, 85, 86. -S^;* also 
 
 Asthenia 
 fear, 73 
 
 French literature, 17 
 
 G 
 
 Gait disturbances, 90. See also Par- 
 alyses 
 
 General paralysis. See Paralysis, gen- 
 eral 
 
 German literature, 27 
 
 German Red Cross, 79 
 
 Granatfieher, 79 
 
 H 
 
 Hospitals. See Military hospitals 
 Hysteria, 25, 26, 33, 36, 45, 46, 50, 56, 
 75, 76, 77, 90 
 
 Indemnity and pensions, 12, 36 
 Insanity. See Mental diseases, etc.; 
 War psychoses; and names of dis- 
 eases 
 Italian literature, 53 
 
 M 
 
 Malingering, 13, 22, 86, 38, 69, 76, 77, 
 79, 90, 91, 102, 103, 104, 105 
 
 Manic depressive psychoses, 35, 36, 94 
 
 Mechanism, 47, 88 
 
 Mental defectives in armies, 42, 79, 80, 
 93,94,110 
 
 Mental diseases in armies, 61, 88, 92, 
 93, 109, 110. See also Unfitness 
 for service; War psychoses; and 
 names of diseases 
 in the civilian population. 111 
 
 Military hospitals, 80. See also Rec- 
 ommendations for the U. S. Army 
 
 N 
 Nerve injuries, 38, 39, 40, 41. See also 
 
 Brain injuries 
 Netherlands, literature of, 5d 
 Neurasthenia, 10, 13, 33, 38, 44, 56. 
 
 See also War neuroses; War psy- 
 
 choneuroses 
 Neuropsychiatric service, 24, 106 
 United States, 86, 96, 100. Sec also 
 
 Recommendations for the U. S. 
 
 Army 
 
 ii/; 
 
116 
 
 O 
 
 Organic changes, 96, 97. See also 
 Brain injuries; Nerve injuries; 
 Pathology 
 
 Paralyses, 19, 34, 46, 50, 90. See also 
 Paralysis, general; Pseudoparesis 
 
 Paralysis, general, 81, 82, 94. See 
 also Syphilis 
 
 Paranoia, 32 
 
 Pathology, 20. See also Clinical studies ; 
 Mechanism; Organic changes; 
 Physiological changes; and names 
 of signs, symptoms and diseases 
 
 Pensions. See Indemnity and pen- 
 sions 
 
 Physiological changes, 23. See also 
 Asthenia; Etiology, fatigue; Path- 
 ology 
 
 Predisposition, 15, 22, 31, 35, 38, 43, 44, 
 46, 47, 51, 73, 89. See also Psy- 
 chopathic constitution 
 
 Prevention, 12, 13, 30, 36, 78, 79, 94, 
 99, 101. See also Psychology ap- 
 plied to military problems; Un- 
 fitness for service 
 
 Prognosis, 37, 47, 48, 50, 51, 99 
 
 Pseudoparesis, 84, 85, 86 
 
 Psychology applied to military prob- 
 lems, 10, 80, 81, 83, 87 
 
 Psychopathic constitution, 32, 33, 
 42, 49, 94. See also Predisposition 
 
 R 
 
 Recommendations for the U. S, Army, 
 
 94,95 
 Reconstruction, 14, 22, 107, 108, 109, 
 
 110,111 
 Recoverability, 19, 56, 94, 107 
 Russian literature, 65 
 
 Scandinavian literature, 67 
 
 Shell shock. See Organic changes; 
 
 War neuroses; War psychoneuro- 
 
 ses; War psychoses 
 Simulation. See Malingering 
 Soldier's heart, 78 
 Speech disorders, 56, 89 
 Statistics, 15, 22, 24, 25, 26, 29, 30, 31, 
 
 32, 49, 73, 93 
 Symptomatology, 13, 14, 19, 29, 30, 32, 
 
 33, 34, 35, 44, 45, 46, 49, 50, 51, 
 
 75, 76, 77, 85, 89, 90. See also 
 Clinical studies; Organic changes; 
 Physiological changes; and names 
 of signs, symptoms and diseases 
 Syphilis, 74. See also Paralysis, gen- 
 eral 
 
 Tachycardia, 25 
 Temperature, 9 
 Tests. See Psychology applied to 
 
 military problems; Prevention 
 Transportation, 33 
 
 Traumatic neuroses, 29, 35, 37, 38. 
 See also Hysteria; War neuroses 
 Treatment, 10, 11, 12, 23, 33, 34, 44, 
 47, 48, 49, 50, 51, 73, 75, 76, 77, 
 78, 79, 91, 98, 99, 102, 103, 105, 
 106. See also Clinical studies; 
 Military hospitals; Neuropsychia- 
 tric service; Recommendations 
 for the U. S. Army; Reconstruc- 
 tion 
 
 diet, 24, 38 
 
 electricity, 11, 38, 75, 92. See also 
 Treatment, reeducation 
 
 etherization, 5Q 
 
 hydrotherapy, 24, 44, 75, 92 
 
 hypnotism, 48, 49, 91, 99 
 
 isolation, 11,33,38,73 
 
 isolation, "psychic," 21 
 
 medicine, 10, 14, 24, 76 
 
 occupation and recreation, 12, 14, 
 22, 43, 44, 75, 76, 78, 92, 106, 107 
 See also Reconstruction 
 
 psychoanalysis, 11 
 
 psychotherapy, 11, 12, 14, 26, 34, 
 38, 46, 47, 56, 73, 76, 77. See also 
 Treatment, hypnotism; Treat- 
 ment, reeducation 
 
 reeducation, 19, 20, 21, 41, 75, 77, 
 78, 91, 92, 99. See also Treat- 
 ment, psychotherapy 
 
 rest, 14, 40, 73, 76, 80 
 
 segregation, 11, 31 
 
 surgery, 38, 39, 40, 55 
 
 swimming, 92 
 Tremors, 101, 102 
 
 U 
 
 Unfitness for service, 83, 84. See also 
 Prevention; Psychology applied 
 to military problems 
 
 United States, literature of, 71 
 
 Urinary disturbances, 25 
 
117 
 
 Visual disturbances, 9, 89 
 
 W 
 
 War neuroses, 34, 75, 76, 77, 78, 80, 
 88, 89, 90, 91, 92, 98, 99, 100. 
 See also Clinical studies; Neuras- 
 
 thenia; Traumatic neuroses; and 
 names of signs and symptoms 
 
 War psychoneuroses, 13, 65. See also 
 Clinical studies; Hysteria; and 
 names of signs and symptoms 
 
 War psychoses, 22, 29, 30, 33, 34, 48, 
 49,50,56,74,93. See afeo Clinical 
 studies; and names of signs, 
 symptoms and diseases 
 
Annex 
 
034!^ B812 
 
 suppl,i 
 Brown 
 
 furopsychiatrjr and the war • , , 
 
 Ani^