patient all of a sudden resuming his speech, sometimes under the influence of an emotional shock, or it is gradual and partial: in such a case the patient can hear, but remains hard of hearing, and he speaks, but in a hesitating, stammering manner and in a low tone of voice; sometimes he ceases being mute, but remains deaf, or vice versa.

Either deafness or mutism alone may succeed, as just stated, the complete syndrome of deaf-mutism; but either may also exist alone from the beginning. In the cases of deafness, whether pure or combined with mutism, are frequently found auricular lesions (rupture of drum membrane, hemorrhages), due to direct effects of the explosion, but inadequate to produce the deafness presented by the patient (Roussy's three cases). The deafness is frequently complicated by buzzing in the ears, the nature of which, whether somatic or psychic, is difficult to determine. If psychic, then it constitutes a true hallucinatory phenomenon. It was thus in a case observed by Ballet in which the subjective noises, which the patient described as "humming," reproduced exactly the hissing sound of a shell following explosion.

Sensory disorders other than deafness: the least rare, without being common, is blindness, which generally disappears rapidly or abruptly.

Paralyses, contractures, generalized or localized in one limb, astasia-abasia.

Tremors, reproducing the infinite varieties of emotional trembling, of which they represent a fixation in the form of a sequela-this motor disorder having supervened upon the state of anxiety of which originally it was the expression.

Tics, of which the most frequent is a movement of the shoulder and jerking back of the head, expressing surprise (tic of surprise). Cataleptoid attitudes, similar to those seen in catatonia.

Choreic movements.

Myoclonic contractions.

I shall stop here this enumeration which, as said a moment ago, could be continued indefinitely without exhausting all possibilities.

Whatever the localization or form of these symptoms, we are dealing with functional disorders based on auto-suggestion, in other words, pithiatic disorders. The auto-suggestion may have for its starting point one of the manifestations of the emotional

shock: such is notably the case with tremors and certain tics (tic of surprise); or a fortuitous impression which, overlaid by the emotion, is transformed into a fixed idea: such is for the most part the origin of paralyses, contractures, deaf-mutism, amaurosis, etc. One man, thrown by a shell explosion, sustains a slight contusion about the knee, and develops a contracture of the lower extremity on the affected side; another gets a grain of sand in his eye, and remains amaurotic for weeks; a third maintains complete deafness following a slight and quickly healed lesion of the ear. These neuropathic symptoms may be associated with or take the place of purely psychic symptoms. In the first case the emotional psychosis becomes a psychoneurosis, in the second an emo

tional neurosis.

No greater importance should be attached to these distinctions in connection with the emotional war psychoses than with ordinary emotional psychoses, as they are based much more on appearances than on the nature of things. Emotional psychoses and neuroses do not represent distinct morbid entities, but different modalities of the same fundamental pathological state; the pithiatism which is the basis of the neuropathic symptoms is, indeed, nothing but a mental disorder which develops, like the component elements of emotional psychoses (asthenia, heightened emotional state, overactive imagination), upon a soil of emotional instability.

The diagnosis of emotional war psychoses should be based on the data of etiology (explosion or emotional shock) and upon the clinical syndrome, the characteristics of which are, as we have seen, among the most definite.

It should not be forgotten that a shell explosion can produce not only emotional phenomena but also, by secondary traumatism, concussion or fracture of the skull, and, by direct effect, cerebral hemorrhages. In these different cases the clinical manifestations are so entirely unlike those of emotional psychoses that an error could hardly be made, at least if one examines his patient carefully. Lumbar puncture alone, when the question is one of hemorrhage, establishes the differentiation. Here it should be mentioned that, as might be foretold from the purely psychic and functional nature of the symptoms in emotional psychoses, no important modification of the cerebrospinal fluid is found. In not one of the cases of so-called shell shock, i. e., sufferers from shell explosion, which

have been examined on my service was there any increase of intraspinal pressure, or in protein or cell content. It is true that the patients were not punctured until long (several weeks and sometimes months) after the explosion. Lumbar puncture done immediately after the explosion sometimes furnishes a slightly albuminous or bloody fluid. These slight changes, transitory and inconstant, could have no direct relation to the symptoms as marked and often tenacious as those of emotional psychoses (pseudo-concussion). It is a coincidence and nothing more.

In the period of confusion it will be easy to eliminate mental disorders of infectious origin (febrile delirium, infectious delirium) by the absence of fever or any other symptom of infection.

It may be more difficult to differentiate between emotional war psychoses in the psychasthenic period and the post-infectious psychopathic states, particularly as the former are quite often seen following typhoid fever.

The defect phenomena (weakness of attention, incapacity for mental effort, amnesia of reproduction and fixation) are apparently the same. The surest differential sign is the heightened emotional state, which is always very marked in the emotional psychoses and much less in the post-infectious psychoses. Finally, the history should generally remove all doubt.

We need not dwell long on the differentiation from demetia præcox, which might be thought of on account of certain stereotypies, tics, and cataleptoid attitudes. A little attention will suffice. for the discovery, beneath the appearances of stupor in emotional psychoses, of an exquisite hyperemotivity which contrasts radically with the indifference of catatonia or hebephrenia.

The differentiation between the functional disorders of pithiatism and corresponding organic symptoms (paralyses, contractures, speech disturbances, etc.), whether the latter be due to central or peripheral lesions, is established by the usual methods.

There can be no difficulty here except for paralyses and contractures of reflex origin, in which the disorders of motility, being out of proportion with the gravity of the lesion and independent, at least in appearance, of any anatomic systematization, resemble hysterical phenomena to such a degree as to have been for a long time confounded with them. The works of Ducosté. Babinski

and Froment, Guillain and Barré, Marie and Foix' have brought this confusion to an end. These authors have shown that the reflex paralyses and contractures differ from hysterical ones by their resistance to all suggestion and their association with a series of symptoms which suggestion could not produce (muscular atrophy, increase of mechanical irritability, softening of skeletal tissues, temperature changes, etc.). I would add that reflex paralyses and contractures are independent of emotional instability, which is the basis, as already said, of the suggestibility of pithiatism.

Upon the pithiatic nature of the symptoms being demonstrated, it remains to establish their etiological relation to the emotional shock, which is but a simple question of fact, easy enough to determine if one possesses a full history of the illness.

The finest points of diagnosis and, in some respects, the most important, are those arising in connection with the question of simulation.

Undoubtedly the disharmony, when the simulated state presents a certain complexity, the atypical character, the absurdity, the mobility of symptoms, would tend to expose the simulation, and in certain cases, where the simulator is particularly awkward, the diagnosis imposes itself. But it is not always thus. There are clever simulators who take note of all they see about them and very rapidly acquire an experience sufficient for a passable imitation of the emotional syndrome. Even tachycardia may be added to the simulated symptoms, and this is quite intelligible: the simulator is as likely as any one to be affected at the moment when he knows he is being examined, and this suffices to increase the beating of his heart. Finally, the disharmony, absurdity, and mobility are wanting when the subject simulates a monosymptomatic state: paralysis, contracture, deaf-mutism, etc.

'Ducosté. Les deux lois des contractures dans les lésions des nerfs périphériques. Gaz. hebd. des Sc. méd. de Bordeaux, July 18, 1915. Les syndromes cubitaux. Ibid., Aug. 15 and Sept. 5, 1915. Les contractures dans les lésions nerveuses périphériques. Soc. de Biol., July 24, 1915, Guillain and Barré. Soc. méd. des hôp., Jan. 21, 1916, Marie and Foix. Sur une forme spéciale de parésie paratonique des muscles de la main. Soc. méd. des hôp., Feb. 4, 1916. Babinski and Froment. Contractures et paralysies traumatiques d'ordre réflexe, Presse médicale, Feb. 24, 1916,

No. II.

In these cases simulation cannot be established except upon two elements: confession (accompanied, of course, by disappearance of symptoms) and the subject being caught flagrante delicto. (Roussy.)

The one and the other are in the end equally convincing. Catching the subject in the act, in other words the detection of unquestionable fraud-for example, a subject claiming to be paralyzed is caught walking normally, a total amnesic reminding his comrade that he has long owed him a franc, a deaf subject who blinks his eyes upon a pistol shot-establishes the diagnosis of simulation. The same is true of confession-or, what is equivalent, a cure sudden and without cause, which may be considered a tacit confession. To my mind it is best to combine the two and, even where a man is caught in the act, to make every effort to obtain a confession, even at the price of a formal promise of impunity. This is the method recommended by Sicard. It seems to me excellent. It is in fact the only one which makes indulgence practicable; for the mere catching in the act, without confession and with persistence of the simulation, renders prosecution imperative. It is better from every point of view to send a man back to his company for duty than bring him before Court Martial.

The natural course of emotional war psychoses, as of emotional psychoses in general, is toward recovery. It is necessary, however, to make some reservations.

I have seen, in four cases, chronic psychoses follow an explosion of a projectile or a mine: two general paretic syndromes, classical in their clinical manifestations, one dementia præcox, and one chronic hallucinatory psychosis. It is quite possible that in cases of this sort we are dealing with simple coincidences. An individual about to develop general paresis, dementia præcox, or a chronic hallucinatory psychosis may, like any other, become the victim. of a shell explosion and show emotional phenomena. As the latter disappear, the signs of the chronic psychosis appear and develop. If the explosion has played a part in the etiology, it is infinitely probable that the part is but a contributory one. It has but opened the way for a morbid process long prepared either by an infection (syphilis), or by a constitutional predisposition, or by any other pathogenic factor. This interpretation