Chapter XXVI: Section D: Shell-Shock Treatment and Results (22)

MINOR
GUN-SHY, INSOMNIA, DREAMS, PHOBIAS, PSYCHASTHENIA,
HYPOCHONDRIA
STUPOR, ANERGIA, ACUTE DEMENTIA
PSYCHOSES (Civilian Forms)

After A. W. Campbell

D. TREATMENT AND RESULTS OF SHELL-SHOCK.

“E però leva su, vinci l’ambascia
con l’animo che vince ogni battaglia
se col suo grave corpo non s’accascia.

“Più lunga scala convien che si saglia:
non basta da costoro esser partito
se tu m’intendi, or fa sì che ti vaglia.”

“And therefore rise! conquer thy panting
with the soul, that conquers every battle,
if with its heavy body it sinks not down.

“A longer ladder must be climbed:
to have quitted these is not enough;
if thou understandest me, now act so that it may profit thee.”

Inferno, Canto XXIV, 52-57.

In previous sections we have already become acquainted with many therapeutic successes and failures: indeed it was almost necessary to detail treatment in certain cases to show the nature of the disease in hand or the correctness of a given diagnosis. In the present Section we approach the question more systematically.

After presenting a few examples of various spontaneous and non-medical recoveries, we bring into contrast the types of medical recovery that may be termed rapid (or miracle) cures and those that fall under the general head of reëducation. Admixed are cases of failure as well as of success: if it be remarked that the case method puts forward the best foot, it is probable that the same is true of almost any therapeutics as reported in early articles. As we go to press, trench reports indicate that at least one part of the profession is far more hopeful of successful psychotherapy even in the physiopathic group of disorders than their expounder, Babinski, could concede. The true statistical evaluation of the results must come years later.

Some neuropsychiatrists have been fond of saying that there is nothing new in Shell-shock, that specialists have long been familiar with the psychoneuroses, etc. Yet in the past, specialists have not learned overmuch about the true inwardness of the psychoneuroses. Even a casual inspection of the various therapeutic efforts here described shows how much novelty of observation and ingenuity of plan must eternally be shown in these ever-so-simple psychoneuroses!

Shell-shock: Deafmutism. Spontaneous cure.

=Case 473.= (MOTT, January, 1916.)

A British soldier, 25, a coal miner, had had a bicycle accident five years before, after which he was unconscious for 2½ hours, and gave up work for five weeks, with headaches, fainting-fits, and nervousness ever after and with a tendency to imagine he could see things when there was nothing to be seen.

September 19, 1915, he was under shell fire in trench and dugout. A sergeant and three men working with him were killed by an explosion, and he remembers his cap being lifted off his head. He came to in 46 Rest Camp, some time later, unable to see clearly, or to hear or speak, and with headache and insomnia. He brought a paper from a hospital in France, saying, “Doctor, I had an awful dream last night again; I was dreaming that I was in the trenches; I could see the men falling and the great big shells exploding. I could see the light from the bursting of the shells very plain. They fairly lighted all the place up. I woke up very anxious I can tell you. I wish I could give over dreaming, and I keep having pains in my head right across my eyes.”

October 15, while sitting by himself outdoors, he felt a slight crackling in his head, noticed that he could hear sounds faintly, and in a few minutes he could hear fairly well.

October 17, he was heard making inarticulate noises in his sleep. The corporal next him told him about the noises in his half drowsy state; he tried to speak and said, “Mother.” He then felt queer all over, with pain in his head, and afterward became able to talk very well with slight hesitation.

_Re_ spontaneous cures, Elliot Smith and Pear cite the cure of two mutes on hearing that Roumania had entered the war, and the cure of another by seeing Charlie Chaplin’s antics. Some workers (for example, Aimé), treat the functional mutes by simply leaving them to themselves, and maintain that they secure numerous spontaneous recoveries, regarding these as superior to cures by isolation, psychotherapeutic treatment, and the like.

CHART 16

METHODS OF PSYCHOTHERAPY

HYPNOSIS
VERBAL SUGGESTION
FIXATION
FASCINATION
VARIOUS

SUGGESTION (WAKING)
VERBAL
DRUG
APPARATUS

AUTOSUGGESTION

DISTRACTION

TERRORISM

INFLICTION OF PAIN

PERSUASION

WILL TRAINING

OCCUPATION THERAPY

ISOLATION

PSYCHOANALYSIS

_Re_ mutism spontaneously or non-medically cured, see also cases 476, 480, 481, 482. For various medical methods of treatment, see, _e.g._, cases 516, 518, 520, 526, 544, 579.

Mott had a case which had been mute more than six months, unable to whistle, phonate in coughing, or blow out a candle, though heard to shout in his sleep: This patient recovered his speech when pitched out of a punt on New Year’s Eve. The condition was in one sense physical enough, as the X-ray showed that the man’s diaphragm hardly moved even with the greatest effort. Mott regarded the inhibition of the breathing movements, especially the phonation, as caused by fear. Mott speaks of a case that recovered on being told by a comrade that he had talked in his sleep. The man was so astonished by this statement that he said, “I don’t believe it.” Other instances of cure under quasi natural conditions are related by Mott: In the presence of a functional mute, Mott speaks loudly to the patient’s sister so that the patient may hear: “This man must be kept on a No. 1 diet, and when he can ask loud enough for you to hear, he can have a bottle of stout and a mutton-chop.” Several mutes are reported to have gotten well the next day under this treatment.

These effects shade imperceptibly over into the manifestly suggestive, and probably no sharp line can be drawn between the effects of medical suggestion, non-medical heterosuggestion, and even autosuggestion. Adrian and Yealland rather decry the Micawber line of waiting for something to turn up. Zeehandelaar, a Dutch professor, studied Berlin methods (Lewandowsky), and found numerous cases (both of mutism and of deafness, paralyses, contractures, and tremors) lying about without special treatment. According to this observer, the expectant treatment was sometimes successful, and sometimes not; if unsuccessful, the soldier was sent home, and re-examined a year later; whereupon he might be found to have profited by this long waiting and to have gotten well enough to return to army duty.

A decorated officer, evacuated for Shell-shock on the third day of the Aisne, after four days returns to the front. Evacuated a second time, after weeks returns to the front without relapse.

=Case 474.= (GILLES, 1916.)

A young officer, with many decorations for brilliant Colonial service, was in the battle of the Marne, under six consecutive days’ shell fire, smoked phlegmatically a cigarette no matter whether walls were crashing or horses disemboweled beside him, and was uniformly able to stimulate his men to the heavy work by humor or heroic phrases.

A week later, on the third day of the Aisne, he had to be evacuated. He was another man--wild-eyed, shivering, jumping at the least noise, unable to eat or sleep, given to battle dreams. He had to be carried away from the battle zone and put in a bed in a town in the rear and given chloral. The nightmares continued. On being awakened he would ask where he was. He was kept in bed, given strychnine cacodylate, and dieted. He went back to the front in four days. Two days later he had to be evacuated a second time. After some weeks more in the rear, however, he went back to the front, and thereafter had not relapsed (April, 1916.)

_Re_ relapses, Wiltshire thinks their causes and frequency prove the psychogenic nature of Shell-shock. Ballard states that a severe case lasting six months does not recover in the army. Many that are said to recover in hospital break down at dépôts, often with symptoms quite unlike those which they originally presented, and it will be remembered that Ballard has an epileptic theory of the nature of Shell-shock. See Cases 82, 83, and 84 in Section A, III, Epileptoses. But another portion of Ballard’s contentions relates to a causation through fear suppressions released by perturbing events. According to Ballard, if the man endeavors to re-suppress the released fear, the fits occur. Ballet and DeFursac note the frequency of relapses--fewer after treatment at the front.

Vicissitudes in fifteen months of a Shell-shock case with mutism and amnesia. Attacks of mania. Hyperthyroidism?

=Case 475.= (PURSER, October, 1917.)

An Englishman, 21, in a rifle regiment, arrived in May, 1915, at the Dublin University V. A. D. Hospital, being dumb, impaired as to vision and hearing, having dilated pupils, tremors, restlessness and weakness, and giving the impression of visual hallucinations. Although suspicious, he was treated kindly for a few days, recovered his hearing, and wrote the few things that he remembered about home and the war, now and then tremulously and perspiringly writing down, “Asylum; do not lock up; I am not mad.”

With the idea of hypnosis, his bed was surrounded by screens, whereupon he grew so perturbed that the attempted hypnosis could not be executed. He learned the letters PP, TT, SSS, A-OOO, and finally AA-SS, AA-TT, T-OO, and after many weeks SS-SST-R and B-TT-R. His father visited him and probably was recognized.

At the end of September another dumb Shell-shock case recovered speech upon being given ether. Maj. Purser asked the sister to arrange for a like treatment for the first case, explaining that an examination of his throat might be painful. The cure of the second case by anesthesia got into the papers and before he was treated the account was possibly seen by the hitherto gentle rifleman. At any rate, he was seized with a sort of spasm, became furious and could only see Germans coming and carrying off his machine gun. He shouted for help. A half grain of morphine was given him and when it began to take effect the fighting spirit gave way to despair. He trembled over the loss of the gun, and remained in this state of despair for three days, remembering his regiment number and the like, but amnestic for his life during the past few months. He could not read now because print was indistinct. Words, when he had spelled them out, conveyed no meaning. He had a functional alexia. When he saw a picture of a bunch of flowers in a notebook of his, he had another spell of excitement and regained his power of speech, remembering about his experiences only that he had been locked up. He had now completely forgotten his father, who came to call.

By the end of October he was stronger, but his horizon was still limited to the hospital surroundings and a little newspaper reading. Headaches and impaired vision persisted. Sight temporarily left him early in November, and there was a suggestion of an epileptic fit one day early in that month. Tonic and sedative drugs and suggestive remedies were of no avail. Hypnotism made him worse, and psychanalysis was, perforce, ineffective through the amnesia. At the end of November depression and suicidal thoughts set in, with an elevation of blood pressure to 178 m.m., pulse 80 to 90. Maj. Dawson then thought he was a suicidal melancholic. Rest in bed and thyroid extract were given, but the latter threw up his pulse on the fifth day to 140. He grew better mentally on the treatment, however, and his blood pressure fell to 140 in three weeks. He was now over-emotional, unable to stand or walk or feed himself or to pull on his socks.

For change of scene he was transferred to Mercer’s Hospital in February, 1916. He suffered from astasia-abasia. The tremor became jerky, coarse and persistent. The thyroid gland grew a good deal in size during the spring and the pulse went up to 120 per minute. There was also well-marked dermographia and there was a suggestion of the clinical picture of Graves’ disease. Even a quarter grain of morphine had little or no effect upon an ineradicable insomnia.

Maj. Purser gave the case up as a bad job and the man was discharged and sent home September 2, 1916. During the next two months at home he improved in steadiness, though he flushed if dealing with strangers, and improved as to memory. He began to be able to read better. He had begun to be able to get about on his feet without so much support. The ultimate outcome could not be reported by Maj. Purser.

Shell-shock: Mutism. Cure after killing a snake.

=Case 476.= (JONES, 1915.)

An Australian soldier of 20 went to Egypt, thence to Gallipoli where, on July 29, 1915, he was almost completely buried by earth from the bursting of a high explosive shell. He was admitted to hospital August 5 and transferred to Malta, where he did not speak, stared into space and sometimes made, impulsively, attempts to get away. About September 17 he began to assist the orderlies and played draughts.

The diagnosis there was cerebral concussion. He was sent back to Australia by transport and had to be put in a padded cell on November 1, having become violent, noisy and destructive. He would assault anyone who beat him at the game of draughts and threw anything he could lay his hands on out of the porthole. Hyoscine he resented and threatened the givers by signs. He was at times restrained. He threatened to throw himself overboard. Diagnosis: Melancholia.

At Melbourne he was found in good physical shape, but dazed, mute, apparently deaf, indicating his wants by signs. With pencil and paper he would draw a ship or a gun and would copy any question put to him in writing. He played draughts intelligently and made friends with one of his shipmates. In four days’ time he began to communicate in writing, answering simple questions correctly. Asked to put a question, he wrote “Do you think I am mad?” On the appropriate answer he shook hands with the physician heartily.

He was then sent to a military convalescent home at Highton. Here he communicated often in writing, and had an appreciation of sounds without distinguishing words. At a picnic on December 4 he killed a snake. While returning in the dark he began to whistle a song the rest of the party were singing. At the end of the song he clapped his hands and said, “What is the next item on the program?” Thereafter he was able to hear and speak. Seen four days later he asked to join the officers’ training school. However, he was discharged as permanently unfit for the service.

Course in hospital of an oniric delirium.

=Case 477.= (BUSCAINO and COPPOLA, January, 1916.)

An Italian gun-maker, 27 (father neurotic; grandmother and mother, alcoholic; patient excessive onanist), was called to arms June 14, 1915, and went into artillery service in the Tolmino, early in September. Some time later, a shell burst about 30 meters away and killed his lieutenant. The patient, however, was not hurt and did not even fall. He became mute and inaccessible, and was sent to a military hospital, and thence to an asylum in Udine, where he was restless and hallucinatory. October 2, he was sent to Florence on two months’ leave for convalescence. He was still hallucinated, always seeing his dead lieutenant. He spoke rarely, slept little, and his conduct became more and more queer. Now and again, he would act exactly as if he were at the front. November 5, he started off to find his brother, but was met by a hospital attendant, who promptly took him to a clinic. Here he was inaccessible and lived in a hallucinatory way a soldier’s life at the front: in continual movement, shielding his eyes with his hands as if looking far into the distance, bending down to turn an imaginary lever, apparently taking part of his aim, crouching in a corner, clapping his ears with his palms, and obeying hallucinatory commands: “Ready,” “Fire,” and the like. As to his interpretation of the actual surroundings, he would give a military salute at the entrance of the physician, as if he were the lieutenant. Another patient near by was interpreted as a spy. Hypodermic injections, November 6, were interpreted as military antityphoid injections. On succeeding days he piled dry horse-chestnut leaves for a parapet, which became the scene of battle. November 12 he had become a little more lucid. November 14, he evidently heard whistling and made the leaves ready as a bed for horses. November 15, he rolled up his blanket in a military fashion and hid in a cell corner. He explained, November 16, that he was a sentinel and had not been relieved by the corporal. He had saved everybody’s lives by signaling from a tree the presence of four airplanes. He could not be convinced he was in an institution for the insane. November 20, he was virtually recovered but amnestic for what he had done since commitment. Headaches and dizziness. November 21, he remembered some of his dreams, especially one of being blinded and another of being tied by a German to a tree. By November 29 he had become lucid and oriented, but there was an amnestic gap for his stay at the clinic. Early in December the fields of vision were contracted; polyopia and a glaring and burning sensation before the eyes (after each test conjunctival and tear duct inflammation).

December 21, discharged well.

_Re_ the nature of oniric delirium, see discussion under Cases 333 and 450, Chavigny had but two cases out of 260 in which a _rapid_ curability was noted (90 per cent finally curable). Chavigny’s treatment consists of rest in bed, quiet, purgation if necessary, and warm or cold shower baths. Chavigny remarks upon the extraordinary transformation from apathy to lucidity in the course of a few minutes, brought about by arranging a slight but definite emotional shock to the patient, namely, by mentioning in his presence something about home or family. One bit of technic was to get the patient to write or dictate a letter home.

Régis remarks that battle dreams of this nature occasionally affect alcoholics in garrison or at home. The victim ought not to be hastily committed to an asylum, but should be treated in a military neuropsychiatric service with isolation chambers and open wards. Régis organized early in the war at Bordeaux a central psychiatric service along these modern lines. He remarks that the central service ought to receive not only patients from the military hospitals, but also patients from the temporary auxiliary hospitals of the city and district round about. A pooling of the military and civilian issue upon rational lines is here indicated.

Régis and others have remarked upon the necessity of differentiating these battle deliria from toxic and infectious psychoses.

Shell explosion: Deafmutism, recovery of speech with electrical treatment; deafness cured by suggestion in writing.

=Case 478.= (BUSCAINO and COPPOLA, January, 1916.)

A fusileer, 20 (mother neurotic, brother hemiparetic from infantile disease; patient had extreme otorrhea from an early otitis media), entered the army January 15, 1915. He was sent to the Isonzo in May and was slightly injured in the nape of the neck and the left calf by fragments of a shell that exploded near by. He was picked up unconscious and taken to the hospital at Servignano. There he was given electric treatment, and in a period of 18 days recovered his speech, passing through a phase of stammering. He was sent to a special hospital in Florence, still deaf, and passed into a state of mental excitement with visual hallucinations of soldiers. He was given chloral and bromide. He insisted that he was incurably deaf. August 22, he was admitted to Buscaino’s clinic, completely deaf, slightly stuporous, somewhat indifferent, and innocent of any effort to make himself understood (contrary to the habits of an organically deaf person). Simulation could be excluded. It was possible to awaken the patient during sleep by auditory stimuli, whereupon he opened his eyes but could not hear. He talked well and spontaneously, telling about his accident, reading and answering by signs. He was assured,--always in writing,--that upon the following Sunday his hearing would be restored. Upon that day, during the visit of a lady,--one of the patient’s friends,--hearing was suddenly and almost completely restored in the left ear. The patient was so moved by this that he cried when the physician came. Upon the following day, he gradually began to hear with his right ear. A slight diminution of hearing in the right ear persisted, however, until September 24, and was associated with headache and pains in the left ear--pains which the patient compared to his ear pains in childhood (remains of otitis with retraction of the tympanic membrane).

Paraplegia: Cured by administration of Iron Cross.

=Case 479.= (NONNE, December, 1915.)

After heavy shelling a soldier fell for two days into a clouded state from which he waked with complete paraplegia of the lower extremities, and total anesthesia from the pelvis downward (reflexes and electric excitability normal).

On the third day after his reception in Nonne’s wards, he was _about to be_ hypnotized when news came that he had been promoted to a lieutenantcy and had received the Iron Cross. He fell forthwith into hysterical convulsions, in the midst of which the hitherto paralyzed legs worked perfectly well! Even after the hysterical attack was over, the man could still move his legs in bed normally, but had absolute astasia-abasia. Next day, with deep hypnosis, markedly improved. After eight more days of hypnosis the new lieutenant got back his normal gait.

Shell-shock, burial: Mutism. Cure by getting drunk.

=Case 480.= (PROCTOR, October, 1915.)

A patient, 25, nine years in the service, was buried in a dugout by an explosive shell at Ypres, June 17, was taken out unconscious, and eventually reached the hospital at Versailles. Consciousness had returned a few days after the injury. There was ringing in the ears, difficulty in hearing, and inability to speak. He arrived at the Duchess of Connaught’s Hospital at Taplow, July 12, when, aside from the above-mentioned symptoms and a rapid heart action (108 at rest), he seemed perfectly well. About August 14, he began occasionally to refuse solid nourishment and remained in bed, eyelids closed but twitching at times, especially when spoken to. He resisted having his eyelids opened.

August 27, he was allowed to go to the village with companions, and got drunk, found his voice, for two days talked and sang incessantly. Discharged September 9, cured.

Shell-shock and burial: Mutism. Cure by work in a vineyard with wine to drink.

=Case 481.= (ANON, May, 1916.)

A correspondent of the _British Medical Journal_ reports a case of cure of emotional mutism. This robust young soldier at Verdun was buried by the explosion of a shell and was thereafter found unable to speak. A week later he arrived at the ambulance in the interior, and was still mute. He could understand what was said to him without difficulty, and was able to reply by signs. He did not even move the lips when requested to pronounce such words as _mamma_ and _papa_, but was eventually induced to whisper these words.

The laryngoscope showed complete paralysis of the vocal cords, which were in extreme abduction (it was possible to see several tracheal rings). There was no reaction on the part of the pharyngeal mucosa upon stimulation.

A fortnight passed without restoration of speech, though at one time, not having bolted the closet door, the patient was startled when a nurse rushed in, and he said, “Oh, pardon, Madam.” The mutism persisted. He was then given work in the vineyard, plenty of wine to drink, and hard work. After a time (not specified) speech suddenly returned. According to this correspondent, “this indeed is a universal experience, namely, that hard manual work is the best remedy for such functional incapacities of traumatic origin.”

_Re_ Cases 480 and 481, compare cures by anesthesia with chloroform, nitrous oxide, and the like.

_Re_ gradual cures as opposed to sudden ones, Dundas Grant deprecates violent measures in the treatment of mutism during the period of exhaustion after Shell-shock. However, Dundas Grant does not advocate an expectant treatment, but employs a gradual reëducation of the voice through imitation of the teacher. The voice is sometimes restored at a sitting, sometimes gradually; see, for example, Case 578 of Briand and Philippe, and Case 586 of MacCurdy.

Shell-shock, unconsciousness: Deafmutism: Spontaneous recovery of speech and gradual recovery (several months’ isolation) of hearing.

=Case 482.= (ZANGER, July, 1915.)

A musketeer was deafened and stunned by a near-by shell explosion. On coming to, he found no wound, but was deaf and dumb.

Speech returned after ten days, and hearing partially, but there was a tonic stuttering. He had to hunt anxiously for words, talked like a child in infinitives and telegram style, although he could express himself in writing perfectly well.

Hearing improved on the right side very quickly, but on the left side conditions varied from total deafness to subtotal deafness. There was a general hyperesthesia of the skin, pain on pressure on the temples, exaggeration of skin and tendon reflexes, marked tremor in both hands. The man was anxious, depressed, and irritable. During caloric tests of the vestibular apparatus in the course of the next few weeks, the man had an hysterical attack of crying twice, following which all the phenomena got worse.

Rest and isolation from all such influences procured an almost complete recovery in several months.

_Re_ differential recoveries, see also Case 585 of Liébault, in which speech was recovered by suggestion and reëducation, and hearing by a process of reëducation alone.

_Re_ isolation, Roussy and Lhermitte remark that in all the psychoneuroses of war, isolation is a valuable and indeed an indispensable aid to psychotherapy. The application of this old classical method of Weir Mitchell reinforces the persuasive talk of the doctor on the day of admission, allows the man to think over the promises made to the doctor, and permits longer observation. It depends on the case, whether rigorous isolation on limited diet shall be employed. See below a general discussion of the psycho-electric and reëducative method employed in French centres.

Marches; battles; slight shell wound of left upper arm: Hysterical anesthesia of the arm and tremors (NO paresis). Causes slight--disease obstinate (partly explained by furloughs among sympathetic friends).

=Case 483.= (BINSWANGER, July, 1915.)

A soldier, 26, without heredity, always well, in long marches and several battles early in the war, August 23 sustained slight shell wounds of thighs and left upper arm. He was unconscious about five minutes. In eight days, the wounds were healed, and all movements were free.

Immediately after the trauma the arms trembled, and at times the legs. Treatment was instituted (baths, drugs, massage, electricity), but without result. After a month’s treatment and a furlough at home, the patient was sent, January 3, 1915, to the Jena Nerve Hospital. He was a powerful man of middle size, with some small movable scars on the left upper arm, remains of the shell injury; two similar scars of the gluteus maximus. The deep reflexes were slightly exaggerated, as were the skin reflexes. The touch and pain sense in the left arm was absent as far as the shoulder in typical segmental fashion. Arm movements were free; there was an occasional tremor in both arms, especially the left. This tremor would pronouncedly increase upon intentional movements and with emotion.

He said that about two weeks before, at home, he had waked up in the night and lain down on the floor beside his bed, feeling giddy in his head. In a week the tremors had diminished, leaving only a very slight tremor of the left hand. The patient went to considerable pains to conceal his tremor, holding his hand in a military position at the seam of the trousers, on the medical visit. Sometimes he would succeed in making the tremor quite disappear. February 5, he was busy about the ward work, going errands and carrying trays. He would intentionally spare his left hand in this work. Upon trying gymnastic exercises, the tremors of the left hand and also of the right reappeared. After a few days these tremors again disappeared, only to come back on the 12th, when there was a constant tremor also when the patient was at rest. He had been affected when observing another patient (8[7]). Accordingly, he was separated from this patient and put in a psychiatric ward. The tremor remained of varying intensity, sometimes being absent for hours together.

[7] See Case 8 of Binswanger’s article.

Request for furlough at the beginning of March was refused with the statement that it would be granted when cure was complete. The patient was inaccessible to psychotherapeutic influence. He was always of a friendly, modest demeanor, sleeping well, and performing all bodily functions properly. On any exertion the pulse ran to 134. The heart was normal. There were outbreaks of perspiration.

March 26, he renewed his request for leave, desiring his Easter furlough. He was told he might expect it. March 31, the tremor was found to have quite disappeared. Upon his return, April 12, there was a marked tremor of the left arm, especially of the wrist joint, which again disappeared after some days. The middle of June he was released as capable of garrison duty with the recruits.

If there was a mechanical factor in this case, it must have been the shaking-up of the body by the shell explosion. His skin lesions were slight. The main factor was doubtless the emotional shock. The tremor supervened upon a very brief period of unconsciousness. It is hard, according to Binswanger, to explain the localization of the cutaneous anesthesia without the development of a corresponding paresis. May it be, inquires Binswanger, that the wound of the left upper arm at the moment of the setting-in of unconsciousness, or perhaps at the moment of waking from unconsciousness, directed the mind forthwith upon the left arm and in this way produced localized disorder of sensation? If so, why did the wound of the gluteal region not produce corresponding disorders of feeling and sensation of an hysterical nature? The obstinacy of the disease stands in striking disproportion to the slightness of the causative factors at work.

According to Binswanger, this is perhaps due to the long furlough which the patient had. According to Binswanger’s experience, as that of many others, home works badly for these hysterical patients; their friends sympathize with them too much.

_Re_ furloughs, Ballard states that severe Shell-shock cases should get analogous treatment to that of civilian psychoneurotics, namely, a complete removal from the environment in which the illness began. He advocates three months’ leave, after which the man is to be sent to a convalescent home, and thence to a command dépôt. He states that if a relapse then occurs, such a patient will never be a soldier. Ballard would allow the men to walk about with their “pals (not with escorts).” Cimbal remarks that German data show that home furloughs should be avoided in every instance where possible. Fiessinger remarks, on the basis of English experience, that a Shell-shock patient treated by rest, suggestion, and manual occupation may go back to the line “and on a subsequent occasion prove a hero.” (See Case 474 of Gilles.) But Forsyth remarks that it is probably injudicious to send any cases of Shell-shock, with few exceptions, back to the firing line, because their fighting value has been permanently deteriorated, and because, if the fear of return to the trenches is removed, recovery is more rapid. The experience here is not unlike that of industrial accident board cases with rapid recovery after the decree of compensation.

War stress in a volunteer banker: Hysterical seizures. Treatment by hydrotherapy.

=Case 484.= (HIRSCHFELD, February, 1915.)

A banker, a volunteer (articular rheumatism at three years; at 18, some form of lung and tracheal inflammation; tendency to fainting spells on cold days--heart disease was said to have been found), as a result of the strain and excitement of the war had hysterical attacks during a fortnight before observation in hospital, consisting of sensations suddenly developing in the region of the heart, stiffness of the whole body, disorders of movement, without loss of consciousness.

November 23, 1914, he was examined in bed in the dorsal position, with the muscles of the legs, back, and neck in a state of tonic contraction. He was unable to answer questions. The pupil reactions were normal in the seizure. The attack ceased in two minutes, as the result of hitting heavy blows on the chest with a moist handkerchief and the threat of a strong and painful application of the electric current. The patient then got out of bed at request, walked about a little incoördinately for a time, but after a few minutes was able to walk perfectly and to talk once more.

Examined, November 25, he was found to be pale, fairly well nourished, with a somewhat accelerated pulse, and a melancholy, slightly apathetic expression. A systolic murmur at the right apex; accentuation of secondary pulmonary sound; increased knee-jerks; trembling of the lids (Rosenbach).

By December 12, the patient was completely well. The seizures had not recurred. The treatment was by hydrotherapy. A preliminary treatment is advocated by Hirschfeld, to insure peripheral circulation, either by light baths, hot douches, or packs. More important than this preliminary treatment is the cooling off process by means of tepid douches or partial baths. These partial baths are given at 28°C. for the intense effect of the cold. Sometimes this treatment can be concluded with a dry pack. The patients are treated by Hirschfeld three times a week with both the warming and the cooling procedure.

_Re_ hydrotherapy, Mott has found the continuous warm bath of great value in Shell-shock cases coming back from France. He keeps the patient in the water from a quarter to three-quarters of an hour, or longer. A warm bath and a drink of warm milk at bedtime may permit a man to get on without hypnotics, or to get on with lesser amounts of hypnotics. The effect of these baths is doubtless largely somatic. Some writers stress the suggestive value of hydrotherapy as well as of electricity, radiant heat baths, and the like (Ballard). A neuropsychiatric center properly equipped with a hydrotherapeutic plant can do therapeutic work by means of the suggestion afforded by a cold shower, which may act quasi miraculously, like electricity (Roussy and Boisseau). In fatigue and exhaustion cases, along with adrenalin and strychnin, Aimé gives mild hydrotherapy without other sedatives. Laehr’s free sanatorium at Schönow treats the arrhythmia and tachycardia cases with rest and hydrotherapy.

Brasch reports rather poor results with hydrotherapy in the cardiac neuroses. Weichardt has used the continuous bath as a form of psychotherapy and permits the symptoms of psychoneurosis to subside therein.

Shell-shock: low blood pressure: Pituitrin.

=Case 485.= (GREEN, September, 1917.)

A lance corporal of the Expeditionary Force, 26, went to France feeling very fit, February, 1916. He was blown up by a shell July 1, and faintly remembered crawling out of some water. He came to in a dugout, dumb and partially deaf, and was blind for a few minutes. August 17, he was admitted to Mott’s wards at Maudsley, mute but with hearing normal. The hands were dusky, sweating, cold, and slightly tremulous. He was given to battle dreams and used to wake in a sweat and terror after a pantomime of bomb-throwing. He had headache and was depressed. He complained of feeling cold and the surface temperature was subnormal. The blood pressure was also subnormal (according to Green, nightmares are most marked in cases with low blood pressure; these are, in fact, severer cases of Shell-shock than cases with high blood pressure; only 10 of 27 cases with blood pressure above 120 showed nightmares).

September 25, he was able to speak in a whisper. The dreams had become less terrifying. The other symptoms had been slowly improving.

November 25-28, all of the symptoms returned upon hearing the death of his brother in action.

The man was now put on extract of pituitrin gr. 2, t.d.s. (better results are claimed by Green from pituitrin extract than from pituitary fluid injections, as these sometimes cause dizziness, of which no case treated with extract complained). As in other cases, the extract was immediately followed by an increase in blood pressure, a general improvement and a diminution of headache and depression. The bomb-throwing pantomimes still persisted, but the patient was less weak on waking. The treatment was continued for seven days, whereupon the surface temperature began to rise and the patient himself felt that he was much warmer. The pituitrin was discontinued after a month’s treatment, yet the improvement persisted. The man was boarded out of the army and in March, 1917, wrote that he was still feeling better.

SHELL-SHOCK, PITUITRIN, AND BLOOD PRESSURE (EDITH GREEN)

Various treatments of a contracture of hand.

=Case 486.= (DUVERNAY, November, 1915.)

A chasseur, 22, received a bullet wound in the anatomical snuffbox, the bullet emerging under the styloid process of the radius, having traversed the back of the hand without striking bone. Healing was rapid, but the hand assumed a peculiar position. The second and third phalanges of the fingers were extended, whereas the first phalanx was flexed. The four fingers were as if glued together. Both phalanges of the thumb were flexed, the wrist was in extension, and the tendon of the palmaris seemed contractured. The fingers could not be moved and the wrist was very mobile. There was pain on attempts to move the hand passively, and small clonic contractions were made by the fingers. There were no sensory disorders, but there was a maceration of the interdigital spaces.

Mechanotherapy accelerated the contracture, and massage, motor reëducation, bromides, and sedative drugs, had no effect. Under kelene-anesthesia the contracture would disappear. In January, 1915, the hand was put up in plaster in a position opposite to the contracture. The intense pain of the first days was treated by opium. The patient was sent on leave, and, at the end of two months, the plaster was removed; but the hand at once resumed its faulty position, and attempts to alter its position again provoked pain. Elastic traction was then tried for six weeks, and the bad position was somewhat modified but not improved by hyperextending the second phalanx on the first, and putting the third in slight flexion on the second. Hot compresses were unsuccessful also. May 14, 1915, the position was still irreducible; there was no R. D. or electrical hyperexcitability. This was not a question of radial paralysis, since finger extension was distinct; nor a paralysis of the median, since the thumb was flexed. The contracture, in fact, does not affect a special nerve territory, and the disorder is in the ulnar, radial, and median territories.

Orthopedic case.

=Case 487.= (SOLLIER, November, 1916.)

A patient suffered from a rupture of the peroneal nerve in its lower part, September, 1915, and had operation scars before and behind the external malleolus. He was immobilized for 45 days at first, and then for 30 days, with the foot in extension on account of the pain produced in the endeavor to put it into normal position. A 6 cm. atrophy was then found to affect the calf, and there was a fibrous retraction of the tendo Achillis and of the calf muscles. There was no anesthesia, the toes moved easily, the foot was fixed in equinus, with about 7 cm. of the heel above the ground. He was placed in various orthopedic institutions and was treated with mechanotherapy, but without result.

At the neurological center, however, in six weeks, he was got to walk, with his heel on the ground, by means of massage and manual mobilization. The atrophy diminished a centimeter and the foot became mobile in all directions.

According to Sollier, mechanotherapy by means of apparatus is apt to be ineffective, especially in contractures, because its action ceases the moment it ought to commence, namely, when the patient is beginning to react a little painfully after recovery from anesthesia. In cases of retraction, mechanotherapy with apparatus does not allow the proper combination of massage with progressive mobilization.

_Re_ orthopedic cases, Jones classes the conditions that create an orthopedic case under four heads (note especially the fourth):

1. Mechanical injury to bone, joint, muscle, or nerve.

2. Atrophy and disease of these structures primarily due to the injury.

3. Incoördination of movement due to disease of the brain--a result of atrophy and disease of peripheral structures.

4. Psychological conditions which can be overcome by reëducational processes.

MECHANOTHERAPY (COLOLIAN)

Favorable effects of lumbar puncture.

=Case 488.= (RAVAUT, August, 1915.)

An accountant, 20, in the 135th infantry sustained shock from mine explosion near his trench, March 6. He was kept two days at the relief station. March 8, at the ambulance, he did not appear to understand questions and had a fixed stare. He complained of a violent headache and kept pressing his head between his hands. He kept looking about him anxiously, and the slightest noise made him jump. He would mutter a few incomprehensible words, and in reply to a question would give only the last phrase which he happened to have been saying. Lumbar puncture showed a very slight excess of albumin. Next day, he answered his name. March 12, he could speak in monosyllables, and he began to understand what was said. After the lumbar puncture, the headache disappeared and did not set in again. March 13, he began to be able to write and say short phrases. March 16, expression was good though hesitant, and the patient wrote a letter to his parents, telling about his shock. Lumbar puncture showed that the albumin was now normal. From the rear, April 5, the patient sent Ravaut a postcard in perfect form, telling how he was ready to go back to the front.

_Re_ lumbar puncture, Imboden quotes Podmanizky as having used lumbar puncture as a method of suggestion for the cure of abasia. See also cases 560 and 561, in which Claude cured two cases of dysbasia by the device of stovaine anesthesia of the spinal cord. Pastine also has a case in which a slight improvement was produced on removal of cerebrospinal fluid, and a sudden and complete cure was brought about by the second puncture, a very painful tap. Pastine’s case is thought by him (1916) to be in part at least organic.

Bullet wound of forearm: Hysterical clenching of fist. Recovery by fatiguing the flexors.

=Case 489.= (REEVE, September, 1917.)

A soldier, 28, was thrice wounded between August 18, 1914, and July 14, 1916. The third time, a bullet passed through the fleshy part of the forearm, whereupon the hand became clenched and remained so after the wound was surgically healed. As a case of war neurosis, the man was treated by electricity, massage, passive movements, and fixation in a straight splint during a period of nine months, without result. He was admitted to Maghull Military Hospital, April 18, 1917.

Two days after admission a treatment was given whose principle consists in producing a condition of fatigue in the muscles responsible for contracture. This fatigue is produced by continuous passive movements in a direction opposed to the normal action of the muscles in question. Many hours of forcible movement are sometimes necessary in the case of the more powerful muscles before the limp, toneless fatigue condition is brought about. Relays of men are told off for this purpose. Patients are got to assist in the work, particularly such as have been cured by the treatment. Also, the patient is himself told about the nature of spasms and the relief which the method will bring. This patient was told that after the flexor muscles were fatigued they would no longer be able to pull the fingers into the clenched position, whereupon the antagonistic muscles on the back of the forearm would begin to work.

The fingers were forcibly opened without interruption for six hours, in each case as soon as the fingers closed into the palm. In a few hours they began to return more slowly, and at the end of the six hours remained extended. The extended position was still found the following morning. The extensor muscles were feeble in action, but improved day by day. The spasm did not return. The patient was discharged July 2, 1917, about two and a half months after admission to Maghull. The hand was now strong and useful.

Bullet through shoulder girdle: Hysterical adduction of arm. Treatment by induced fatigue.

=Case 490.= (REEVE, September, 1917.)

A man, 29, was in hospital more than two years before the Reeve fatigue treatment was applied to a functional contracture. This man had a bullet pass through the right scapula and out the pectoralis major, June 4, 1915, was (according to patient’s story) operated two months later, then further operated for drainage of septic wounds, and from August, 1915, had his arm fixed to the side, going into spasm at any attempt to move it passively. The elbow was extended and at first the fingers were tightly flexed and wrist extended. The finger flexion and wrist flexion cleared in March, 1917, and recurred in May. Electrical massage in June, 1917, yielded free movement, but the spasm returned.

The man was admitted to Maghull, June 12, 1917, that is, a little over two years after his injury. The arm sprang back to the side like a clasp knife on being released. The wrist and fingers were moved freely. Three days after admission the elbow was forcibly flexed for some hours, whereupon the spasm disappeared. Next day the arm was forcibly abducted and reabducted: for four or five hours the arm could be voluntarily abducted. Two assistants were necessary, such was the force of the adductor contraction. At the end of a week the patient was found able to lift his hand to the back of his head. There was no longer spasm.

_Re_ abrupt treatments, amongst which Reeve’s treatment by induced fatigue may be counted, Babinski and Froment consider that abrupt treatment is far superior to slower psychotherapy combined with isolation, whether or not we are dealing with a recent or an old disease. So far as psychotherapy goes, Babinski wants to obtain a definite improvement, if not a cure, on the first application of treatment. According to Babinski, the patient’s faith in his physician’s power to cure him is most active at this first meeting, whose emotionality favors the cure.

Burial and bruises of back: Hysterical cross-legs. Treatment by induced fatigue of contractured muscles.

=Case 491.= (REEVE, September, 1917.)

A man, 32, was buried by a shell and bruised about the back, August 2, 1916. He was bedfast until February, 1917. Every attempt to move the legs brought on tremors. He was then allowed up; but the attempt to walk caused one foot to knock the other, and his ankles became bruised, necessitating cotton wool pads for feet.

He was admitted to Maghull, June 12, with one leg crossed over the other and the thigh adductors spastic, especially on the right.

The fatigue treatment was carried out in dorsal decubitus, each leg being pulled by a man, and the separation repeated when necessary. Four hours a day for three days of this work finally reduced the spasm so that the patient was able to walk with assistance. On the sixth day he walked a mile without assistance. The spasm has not returned.

_Re_ leg contractures, Bérard got successful results by continuous extension combined with injections of 1 per cent novocain into the sciatic nerve trunk and the contractured muscles. According to Babinski and Froment, there ought to be an almost certain cure of any genuine hysterical state. They quote the observations of Souques, Meige, Albert Charpentier, Clovis Vincent, Roussy, and Léri as proving this claim.

The Reeve method, so far as it is psychotherapeutic, bears a resemblance to Clovis Vincent’s first stage of what the poilu calls _torpillage_, namely, the stage of crisis and of intensive reëducation. But Clovis Vincent uses in his direct and forcible reëducation the galvanic current.

Bullet wound of neck: Hysterical torticollis. Treatment by induced fatigue.

=Case 492.= (REEVE, September, 1917.)

A soldier, 20, had a bullet pass through the back of the neck, July 10, 1916, and returned to his dépôt surgically well October 1. A fortnight later a Zeppelin raid turned his troop out in the middle of the night, and on the morrow the man’s neck was twisted around and inclined upon the left shoulder.

Treatment followed in various hospitals, with fixation in the corrected position by plaster of Paris but without result. The patient was admitted to Maghull, April 18, 1917, with spasm of left trapezius and right sternomastoid muscles. Under hypnosis the deformity could be easily corrected. Unfortunately, it returned.

The fatigue treatment described by Reeve was started a week after admission to Maghull. The neck was forcibly straightened and restraightened upon return to its twist. In a few hours the contracting muscles had become fatigued; the neck was straight.

The next day the deformity returned slightly. The fatigue treatment was repeated. The patient was discharged well, July 2.

Burial by shell explosion: Abasia, tremors. Claw foot persistent two years cured by induced fatigue.

=Case 493.= (REEVE, September, 1917.)

A man, 24, buried by a shell, February, 1915, had had a functional “claw foot” for more than two years, cured by the Reeve fatigue treatment in less than a week. According to Reeve, claw foot is perhaps the most common of the war contractures, particularly intractable, and often seen out of hospital with an “inside splint.”

After his burial this man could not walk, had tremors, was in bed for four months and on getting up showed strongly inverted foot. Three months’ splint treatment, strong faradic currents, massage, passive movements, special boots with leather wedges to tilt the foot over, were methods of treatment tried, but unsuccessful. At Maghull from November 18, 1916, he was treated by exercises, passive movements, suggestive and reëducative measures, and after a few months got about without sticks.

The claw foot continued. Toward the end of June, 1917, the feet were forcibly flexed and everted for eight hours. The deformity disappeared, but returned slightly next day. Further fatigue treatment for eight hours caused the spasm to cease permanently. He was discharged quite normal, July 20, 1917. Reeve remarks that this fatigue method might be applicable to certain hysterical contractures in civil practice.

Skull trauma over right eye: Delirium, febrile? post-traumatic? exhaustive? Operation: Epileptiform excitement. Later, explosive diathesis: Operation: Euphoria. Seizures and slight mental change.

=Case 494.= (BINSWANGER, October, 1917.)

A soldier (brother choreic, sister infantile palsy) had had measles at 13 and in his fever climbed out of bed upon a couch, fell from the couch and was found by his mother lying on the floor. He was of moderate intellectual grade, of an emotional, passionate Saxon nature and had now and then been intoxicated.

In September, 1914, he was wounded over the right eye. He did not lose consciousness but concluded that he could not get back to his own lines on account of the enemy fire. Using a knapsack to cover his head, he lay down for twenty-four hours, until rescued by a passing body of the sanitary corps who were about to leave him for dead when he called loudly to them.

He was very weak in hospital and, towards the evening of the day after receiving his injury, he must have fallen into some sort of psychotic state lasting ten days. For this he remained quite amnestic, although he was told by comrades that he had hallucinations and had scolded and yelled, hearing voices. Apparently there were situation-deliria--the call to go over the top. Temperature, which had run to 38.8, after ten days sank to normal, and consciousness cleared up.

Was this a case of protracted febrile delirium? Or of psychosis due to _commotio cerebri_, that is, an effect of heightened intracranial pressure? Or was it exhaustion-delirium following loss of blood, sleep and food?

But this was not the end. The wound suppurated, and in May, 1915, eight months after the injury, operation was performed to relieve this abscess. Temperature immediately rose to from 38.4 to 38.6, the fever lasting three days, and a second psychotic phase with complete amnesia entered. He went into this phase immediately after recovering from the operative narcosis, looking wildly about and cursing the sister. The patient was violently excited and was put in a straight jacket on the second day. This phase may be regarded as one of epileptiform excitement with delirium. The operation may have played a part in the psychosis.

There were no further psychotic phenomena which could be attributed in any way to _commotio_. There were, however, attacks of cortical origin and emotional seizures. The patient became emotionally excitable and lost all inhibitions against expression of emotion, such as crying. Once he actually tried to suppress his emotion with a noose about his throat. He became seclusive and withdrew within himself--a victim of Kaplan’s explosive diathesis, or of Bonhoeffer’s emotional hyperesthetic defect condition.