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would be almost incontestable as far as the general paresis cases are concerned, if it had been demonstrated that the shell shock! cases which had turned into paresis had had syphilis. Unfortunately in the two cases which I observed I had but scant personal histories and it was not practicable to do Wassermann tests.

However that may be, nothing in all that we know of the etiology of mental diseases would justify the proposition that a purely emotional shock or an explosion could have for its consequence general paresis, dementia præcox, or a chronic hallucinatory psychosis. One might at most attribute to it the value of a contributing cause, but one could go no farther than that.

It is conceivable that an emotional war psychosis, like an ordinary emotional psychosis, might develop into a delusional state centering about a prevailing fixed idea.

In such a case the idea of damage sustained through an explosion or any other cause would become the fundamental fixed idea upon which the delusional state would develop. I have as yet not met with a case of this sort and I know of none published in the literature. But it would surprise me if such cases did not develop. It is probable that they will be seen springing up after the cessation of hostilities.

Finally, it should be recognized that there are patients in whom the syndrome characteristic of the second period lasts a year or longer. I know a case of emotional psychosis—by purely emotional shock-which has lasted over two years without any appreciable improvement or change. Is it, then, possible for the course of emotional war psychoses to be toward incurability? I should withhold an affirmative answer. I should even say that I do not believe it.

There exists at the present time a factor by which the prognosis of emotional war psychoses is radically biased: it is the war itself. The prospect of returning to the front constitutes, for many of the emotionally unstable, an obstacle to recovery of such power that it is impossible to say if it alone might not suffice to keep up the neuro-psychic symptoms and to impart to the disease the appearance of chronicity which has been noted in some cases. The fate of these patients will not be settled until peace has been signed.

Emotional war psychoses raise certain medico-legal problems. The commoner ones—aside from simulation-are those of refusal to obey orders, assault, being absent without leave, and desertion. As stated above, the period of confusion is most fertile in manifestations of this sort. It goes without saying that, the diagnosis being once established, the subject's irresponsibility follows.

The diagnosis is simple when the medical examination takes place before the disappearance of the symptoms of confusion or when one is in possession of exact information concerning the mental condition of the subject at the time of the alleged criminal act: such is the case in assaults or refusal to obey orders, where the nature of the reaction itself generally brings in at once the intervention of others. But it is not always so when we are dealing with a fugue resulting in absence without leave or desertion. By the time the man is arrested or presents himself before the military authorities the confusion has generally vanished and there is no gross and evident mental disorder to indicate at once the pathological nature of the act.

In such cases one should make every effort to reconstruct by all means at his disposal the starting point and course of the fugue: minutely detailed questioning of the soldier, information from his organization and from the different places through which he passed, careful investigation of the least clue. But one should especially take account of the subsequent course of the symptoms. It is very rare for an emotional psychosis to end with the disappearance of the symptoms of confusion. In the immense majority of cases one has before him the psychasthenic period, the clinical features of which, as we have seen, are among the best defined and readily establish the diagnosis.

I have seen several cases in which the existence of the syndrome of asthenia, heightened emotional state, and overactive imagination indicated with certainty the pathological character of a fugue, as to the nature of which, owing to lack of sufficient data, it was impossible to form a judgment.

It is not to be denied, however, that there are cases in which doubts remain, especially when the history is either lacking or not explicit and when the physician has not had an opportunity of examining the subject until after the complete disappearance


of symptoms. One must then make up one's mind "to know how to doubt, to dare to say that one is in doubt" (Thoinot)which is a necessary attribute of an honest medico-legal expert- ー and, upon presenting the case in all its complexity, to leave the decision to the military authorities; such decision must surely be an indulgent one, as the doubt cannot be otherwise than favorable to the accused.

The treatment varies, naturally, according to whether the disease is in its first or second phase.

In the first phase—rest in bed, quiet, reconstructive medication : the treatment here suggests itself.

The indications are not so simple in the second phase, which we have designated the psychasthenic period.

At first these patients were treated like ordinary psychoneurasthenics, that is to say, medically, utilizing all the dietetic, medicinal, and physical therapeutic resources available to medical art. Now, it has happened that in the medical organizations at the front, where the equipment is necessarily meager, the patients recovered rapidly and, in the majority of cases, were at the end of a few days well enough to rejoin their company; whereas in the hospital units in the rear, which are far more completely equipped, in spite of diets, douches, and electric currents of all forms and all strengths, the symptoms dragged on tediously, the patients remaining months in the hospital and often, after a cure obtained with difficulty, relapsing either in the course of convalescence or shortly after return to duty.

This experience has been constant and, though apparently paradoxical, is readily explained.

First of all, that which has been found in ordinary emotional (pseudo-traumatic) psychoses holds true for these victims of the war. A treatment which is too medical, if not followed by prompt and notable improvement, results in anchoring in the mind of the patient the notion of a grave pathological condition and in the development of hypochondriacal tendencies which are so often a part of the emotional syndrome, whether the latter be due to a common occurrence in ordinary life or to an event of the war. The idea of a grave pathological condition becomes quite naturally associated with the idea of damage sustained for the future as well as for the present; and just as a subject of an accident in times of peace can become obsessed with the preoccupation with indemnity to be turned over to him, so the subject of a war accident, exaggerating, like the first, his physical and mental damage, worries about the future, is often upheld in his hypochondriasis by ill applied commiseration of those about him and the more or less interested pessimism of his relatives, and ends by hypnotizing himself with thoughts of retirement and pension: these then become obstacles to recovery, and in this way develops a sinister war case, in every way comparable with the sinister cases of ordinary accidents.

But aside from factors causing aggravation or preventing recovery, which are common to all sinister cases of whatever origin, we have to consider, in connection with emotional war psychoses, a factor peculiar to them alone. Recovery means more or less prompt return to the trenches. This prospect appears natural to the soldier who has remained at the front. It is otherwise with the one who has been evacuated to the interior. “By keeping the patient at the front one leaves him in the atmosphere of a combatant, in contact with the features which impart to this atmosphere its peculiar character: simplicity and sometimes even restricted conditions of material existence, rigid discipline, close proximity of danger. He remains in the environment to which he has, more or less fully, become adapted. By evacuating him to the interior one breaks this contact and destroys the adaptation. When, upon recovery, he returns to the trenches, he has to readapt himself. One can conceive how this re-adaptation, painful for many, may prove impossible for some. It will prove impossible notably for the emotionally unstable in whom a morbid imagination stirs up, amplifies immeasurably, and converts into obsession tragic spectacles of the war, causes him to live over again the fears once experienced, and projects into the future the terrors of the past. This is true of the graver cases of shell shock and explains the fact that recurrencies occur almost always at the end convalescence or shortly after returning to quarters, yet without one being thereby justified in speaking of simulation. The subject sees himself on the way back to the trenches and, owing to an emotional and imaginative erethism, this perspective revives the elements of the shell shock syndrome.”

This is the explanation at which Ballet and I arrived in our work published in Paris Médical. I am more than ever convinced that it is the true one. By keeping the patient at the front “one avoids a disadaptation and eliminates the necessity for a readaptation." Therein is all the secret of therapeutic success obtained in the medical organizations at the front.

Accordingly, subjects affected with emotional psychoses should be kept on psychiatric services at the front. The confused phase once passed, and the patient having become lucid and accessible to favorable suggestion, he must be convinced that he is due to get well, and that because he is due to get well he is not evacuated to the interior. This psychic therapy, associated where necessary with medication or such physical therapeutic means as may be available under the conditions (cacodylate in general weakness, electricity in deaf-mutism, paralyses, and all other pithiatic manifestations), will lead to a rapid recovery and an early return of the soldier to his company.

Nevertheless, there will always remain a certain number of subjects who, by reason of a particularly marked emotional instability, will not get well quickly. The first indication in these cases is to segregate them from the others, on whom they can have but a deplorable influence, or if their isolation is not readily practicable, to evacuate them.

The hospitals in the interior will consequently continue to receive victims of emotional shock. They should be treated as patients, but as nervous patients, subject to military discipline, and not as insane and irresponsible for their acts.

Noisy or dramatic manifestations, particularly hysterical crises and somnambulism, necessitate absolute isolation, in the first place because imitation by others must be avoided and the patient must be prevented from teaching others by his example, and further because absolute isolation constitutes in such cases a treatment of sure efficacy. I, for one, have never seen hysterical crises resist rigid isolation.

In the interior, as at the front, the principal part in treatment falls to psychotherapy: " The patient must be convinced that the

* J. Déjerine and E. Gauckler. Le traitement par l'isolement et la psychothérapie des militaires atteints de troubles fonctionnels du système nerveux. Presse médicale, Dec. 30, 1915, No. 64.


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