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Shell-shock: Epilepsia larvata.

Case 81. (Juquelier and Quellien, May, 1917.)

A soldier, 29 (father alcoholic, died in hospital for the insane), a decorative painter without plumbic history, non-alcoholic, non-syphilitic, was wounded once, September, 1914, but returned to the front in 1915.

May, 1915, a shell burst near him. He lost consciousness, regained it a few days later at Brest, and was so far recovered that he could go on leave in seven days. While on leave, he had short attacks of delirium, followed by a total amnesia; there was, however, no crisis, fall, or convulsion. After the first attack, he had for 24 hours malaise and headache, but got well and went back to his dépôt. Shortly afterward more attacks of this sort recurred, and he went to hospital and thence to the neurological centre at Tours. Whence, August 9, 1915, he got a two-months’ leave for “mental disorder post-confusional, second état, probably hysterical (commotio cerebri), and organic hemiparesis.”

November, 1915, after returning to the dépôt, there were more spells and he went again to hospital. Invalided December, 1915, he passed a year at home, but the spells continued. Although the epileptic nature of these attacks was maintained by Francais at Évreux, he was placed in the auxiliaries, December, 1916, but had to go to hospital almost at once, and, February 28, 1917, entered the neurological centre of the 9th Region for the second time. Here, when called to be examined two days after admission, he was observed in an attack. He suddenly rose from the bench, made a few steps, seemed to be listening and anxious, as if he ought to be on guard. He looked up, seemed to be looking for something whose noise was approaching, lowered his head, made a slight jerking movement, and said, “Poum!” as if to express the noise of an explosion. He took a few more steps, the same movements were repeated, and the same “Poum!” was uttered. This lasted for about a quarter of an hour, during which the patient was unaware of his surroundings. He could be guided all about the hall without resistance, but did not respond to orders, commands, noises, or contact. In short, the patient was in the midst of a hallucinatory dream at his post in the trenches, undergoing a bombardment. He was placed in a chair; remained motionless for a few seconds, woke up, and answered questions. “Where am I? Oh, yes; I must have been sick because my head feels bad.” In answer to the question. “What did you see; what was there?”, he said, “I don’t remember anything. I never remember. I don’t know.” The patient was dull and weak after the spell.

These spells varied in number but occurred once a week. The patient was able to tell of certain attacks that had occurred while he was out of doors at home.

Now and then, there was another theme in the hallucinatory delirium, namely, a pencil drawing of a woman’s picture, of no great artistic worth but carefully done, at which the patient was much astonished on awaking.

It seems as if auto- and hetero-suggestion can be eliminated from the genesis of these attacks. Neither hysterical nor epileptic crises have preceded or ever alternated with these seizures. Nevertheless, on the organic side, the patient had a general increase of tendon reflexes on the left side, most marked in the knee-jerk, and fell to the left in voltaic vertigo. There was a left hemiparesis, apparently of organic origin, which had been determined as far back as July, 1915.

There was no true dementia. Past memories were but slowly recalled, and inattention interfered with the fixation of recent memory. He complained of troubles in his sleep and dreamed of war experiences somewhat analogous to those in his attack of amnestic delirium. After the seizure, there was a marked hebetude and mental inactivity, torpor, and a severe headache. The case was presented to a special commission as one of epilepsia larvata in a person hereditarily predisposed who had never before presented epileptic signs, suffering from a disease characterized by frequent short attacks of hallucinatory and delirious automatism, following shell explosion which had at the same time produced a slight left-sided hemiparesis and mental inhibition.