Chapter XXVII: Section D: Shell-Shock Treatment and Results (23)

A second operation was performed in September, 1916, to loosen the brain scar, and a large splinter of bone was removed. During the operation, under local anesthesia, there was a severe cortical seizure with complete disappearance of the reflexes. Ether was then administered. Later, in the same day, there were several minor cortical attacks.

After this operation the man’s emotional status changed; he was no longer irritable or exclusive, but became slightly euphoric and contented. He received during the next two weeks four tablets of Sedobrol and for a long time thereafter two tablets daily. There were never any phenomena of bromidism or any suggestive effects of the bromides.

The first attack after the second operation came in November, 1916, and was followed by slight dysarthria. Repeated attacks followed which were attributed to contractions in the scar. Accordingly, a third operation was performed and an attempt was made to bridge over a defect in the right frontal bone. The man’s emotional status remained good after the operation, but further attacks appeared six weeks later and there were spells of dizziness. Occasionally, in process of thinking, he said something stuck in between his thoughts. Sometimes thinking broke off sharply as if he had cut through a wire with an electrical current in it. There was a slight reduction in attention and a slightly increased fatiguability.

Hard service; shell explosion with loss of teeth: Vomiting. Cure by restoration of self-confidence.

=Case 495.= (MCDOWELL, January, 1917.)

A married reservist was called up at the outbreak of the war and went through Mons, the Marne, and the Aisne and was finally blown up by a shell at Ypres. Early in November, 1914, he lost his speech but got it back in time to get home for Christmas. A number of teeth had been lost in the injury. Vomiting began first in England. While on leave at home he vomited at every meal. Asked whether it was his food or his thoughts, he said, “You are quite correct, Sir, you know I have always been with thinking.”

Under medical care, June, 1915, he was found suffering from hesitating speech, general tremulousness and emotionality. He worried a great deal on account of money matters at home. He lay awake thinking. A child became ill and died, and all the while he got worse, “thinking all the time.”

It was explained to him that the vomiting was a matter of emotions. The lost teeth were replaced by false ones. As he began to get control of his emotions, he vomited less and increased in weight. Finally he was boarded for discharge and was sick again on the day of the meeting. A fortnight later when sent to sign discharge papers he vomited once more.

According to McDowell, the vagus may possibly be incriminated as a cause of these gastric disturbances. Practically, the vomiting is a result of emotional stress. The cure is to produce insight on the part of the patient, the removal of worry and the restoration of self-confidence.

Michell Clarke cured such cases with milk diet.

Roussy and Lhermitte find hysterical vomiting to be relatively common and as a rule without difficulty in diagnosis; but they remark that there is often some underlying organic condition to be sought for and treated after the neuropathic element has vanished. They remark, also, that there is no tendency to spontaneous cure of the disease. They advocate a strict dietetic régime and psychotherapy.

Cure of self-accusatory (“started retreat from Mons”) and other delusions by “autognosis.”

=Case 496.= (BROWN, January, 1916.)

Capt. William Brown, in the discussion at the Section of Psychiatry of the Royal Society of Medicine, January 25, 1916, speaks of a method of treatment which he calls _autognosis_--a method of giving the patient self-knowledge, by revealing to the patient through his own confessions the cause of mental change leading to his symptoms. One of Brown’s examples is that of a sergeant in the firing-line during the retreat from Mons. He was admitted to Maghull with the delusion that people thought he had given the signal for the retreat from Mons on a silver whistle, a shooting prize of his. German officers used silver whistles that made a note like his own. In fact, he had other like delusions, such as that people thought him responsible for an Edinburgh railroad accident in connection with his troop-train. A German spy might have heard this.

In the process of procuring autognosis, Capt. Brown found that at the age of 12 this man had been falsely accused of stealing pork pies from a shop, and had been brought before a magistrate. In point of fact, he proved an alibi, but he was greatly worried by the charge. According to Capt. Brown, this incident of the insistence of the false accusation was the beginning of his tendency to delusions. In two months’ time there was a remarkable improvement.

_Re_ psychoanalysis, autognosis and various modifications, Forsyth remarks that when the acute stage is passed, the Shell-shock case becomes an everyday neurosis in which war experiences are merely the latest phases in the patient’s life, and that psychoanalysis may then become necessary. Eder regards the “mechanisms” of what he terms “war shock” as the Freudian mechanisms of hysteria, and has commended psychoanalysis for a few cases, preferring hypnotism for acute cases. Adrian and Yealland decry psychoanalysis on the score of time limitations.

Deafmutism in three men shell-shocked at one time.

=Cases 497, 498, 499.= (ROUSSY, April, 1915.)

There were three Zouaves in a first-line trench north of Arras, January 14, 1915, who were blown up by a bomb thrown from the enemy trench some hundreds of meters away, by a mortar, a _crapouillaud_. This projectile burst with a great noise, louder than that of a bomb, and made a very strong windage. A dozen men were blown under the trench wall, just after entering the trench; two were killed; and the others, most of whom had been buried to the neck, were pulled out and carried, trembling, to the nearest relief post. Two of the three Zouaves were bleeding at nose and ears, and all three were absolutely deaf and mute. Evacuated to an ambulance, and thence to Paris, they arrived at Val-de-Grâce, January 17, that is to say, three days after the shell burst. They communicated with the attendants by signs; one got hold of paper and wrote several hours in the day rapid notes about the accident. However, hysteria or pure simulation was suspected in these three Zouaves, and they were placed in small separate rooms. They were informed through the physician’s remarks to his staff that these were cases of nothing but simple nervous shock such as we had often observed, and the claim was made that they would be completely well either on the morrow or the day after.

On the morrow, two of them partially recovered hearing and got back their voices. They became loquacious and began to tell about the battle. The day after, the third patient began to speak. Two of them showed traces of auricular hemorrhage, and in fact, actual ear lesions were found in all three. One had a suppurative right middle ear, with perforation; another had both drums perforated and a suppurative middle ear, also on both sides. The third, who recovered his speech after the others, had perforation of the left tympanum with a little suppuration of the right ear tympanum and a slight tear of the right tympanum. In April, 1915, the hearing was cured.

These men had been under fire several months, and had taken part in the battle of the Marne. It was not a question of their first baptism of fire, and in fact, each of them had been previously wounded. According to Roussy, the story is, that the shell-burst produces by displacement of air tympanic perforation, and at the same time a violent nerve shock with loss of consciousness for a few minutes. The men come to, but the ear lesion, probably exaggerated by the nervous status of its bearer, creates a complete bilateral deafness. This deafness produces an absolute hysterical mutism.

_Re_ case groups of war neurosis, several writers speak of dangers of contagion, but also emphasize the values of contact of patients with one another in the securing of therapeutic results. What Mott has termed the _atmosphere of cure_ was no doubt present in the three instances of Roussy just cited. The cure of one may act heterosuggestively to produce the cure of a second, and so on. Functional deafmutes are somewhat refractory as a rule. H. Campbell states that there is some danger attached to allowing large numbers of functional cases to consort together too closely. He suggests making use of small wards and screens, and a process of sorting out patients so that they shall not affect one another injuriously. Steiner especially stresses the value of individual rooms in preventing psychic infection, of which, he says, the danger is large in open dormitories. The psychic contagion is as a rule that of hysterical seizures and tremors; but complaints about faulty hospital arrangements are also readily spread. Steiner advocates never questioning a nervous patient concerning his troubles in the presence of other soldiers. To reach 60 to 70 patients, Steiner had one examining and treatment room. Roussy’s institution at Salins in 1917 had a service limited to traumatic hysteria, from which, in three months’ time, 200 subjects had been discharged cured (see Boschi).

Dysentery: Milk diet persisted in: Vomiting, incontinence, inability to walk. Cure by persuasion.

=Case 500.= (MCDOWELL, December, 1916.)

A soldier, 25, a low menial when war broke out, developed “dysentery and gastritis” at the Dardanelles, although even before the dysentery his nerves had gone bad. He had diarrhoea and vomiting, was sick every day, found himself unable to walk, and found himself always wet with urine dribbling day and night. Arriving in England and treated in a hospital, he still had vomiting. He had lived on milk and custard and been kept in bed.

Capt. McDowell convinced the patient that his legs were not as weak as he supposed. He was encouraged to walk, put upon light diet and then upon ordinary diet. He became an active worker in the ward, later going for five-mile route marches. Two months later he went back to duty in good health, weighing seven pounds more than before. This man was weakminded and, when his dysentery was cured, did not dare to start eating ordinary food. He was a victim of hospital régime. Individual attention would have obviated much of the subsequent state.

_Re_ vomiting, see remarks under another case of McDowell (Case 495).

_Re_ incontinence, see Case 384, of Guillain and Barré.

Officer dies in convulsions: Servant develops hysterical convulsions, which vanish on being explained as such.

=Case 501.= (HURST, March, 1917.)

An officer and his servant were blown up by a shell. The servant ran to fetch a stretcher for the officer, to whom he was much attached, but on his return the officer made a few convulsive movements and died. Immediately after, the servant had a fit. During the next two months he had eleven more. Hurst made a diagnosis of hysterical fits resulting from emotion, explained his idea of their origin and nature to the servant, and the convulsions then ceased completely.

_Re_ hysterical convulsions, see remarks under Case 443.

Course of a case with crises of trembling.

=Case 502.= (ROUSSY, April, 1915.)

A soldier in the artillery, who had been in the lines from August as a kitchenman, looking after the food of the first line trenches, with which his shelter was connected by communication trenches, 800 meters away, was on January 17, 1915, with three other men placed in the shelter kitchen of the trenches but a short distance away from the French artillery. The firing passed over the heads of these men but they could feel the windage, which obliged them to lie down each time. The evening of that day, several hours after firing had ceased, the kitchenman had a shivering spell, with trembling that lasted all night; after which these crises came on every day. He had finally to be evacuated to the rear.

According to Roussy, such patients always have neuropathic taint and a history of previous crises. Such a patient ought to be handled with rather severe discipline. In this way, according to Roussy, the reappearance of a severe attack of convulsions can be prevented. But these patients cannot go back to the front.

_Re_ tremors, see Cases 224 and 225.

Two cases of lameness cured by persuasion: Russel.

=Case 503.= (RUSSEL, August, 1917.)

A man on crutches, paralyzed completely in the right leg, partially in the left, developed paralysis in the right arm from the use of the crutch. There were marked vasomotor changes in the right leg and arm together with anesthesia to pinprick. Assured that he could move the legs perfectly he said that he had tried and failed. After a persuasive talk in private he began to use the arm, and to walk perfectly. It seems that in the trenches he had a sharp pain in the right knee, after which he did not use the leg and it gradually became more and more useless. It had been paralyzed for three months. The reason he did not use this leg was not on his own account, but on account of his mother at home. He seemed really grateful for the cure.

=Case 504.= (RUSSEL, August, 1917.)

A sergeant in hospital for a year for shell-shock still had a marked shaking of the right leg whenever he raised it from the ground. He walked in leaning on a silver headed cane. The functional nature of his shaking was explained to him by Russel, whereupon he walked out normally saying he could do without his cane. Russel suggested that crutches and sticks thus given up were often donated to the shrine. The sergeant whose cane must have cost at least three pounds beat a hasty retreat carrying the cane in front of him.

_Re_ Russel’s general point of view concerning malingerers and psychogenic cases, see under Case 458.

Hard patrol work: Delirium; head tremor augmented by excitement: Virtual recovery on bandaging neck, isolation, open air, to-and-fro transfers to mental and nervous wards.

=Case 505.= (BINSWANGER, July, 1915.)

A metal moulder in civil life, 29, in military service 1907 to 1909 (no hereditary taint, moderately good scholar), became unconscious for a half hour after taking a cold drink following a somewhat long practice march, at some time during his first year of military service.

He was in several skirmishes in Belgium and Northern France early in the war, being once surrounded in patrol work (November 11) by Turcoes and Zouaves. There was a lively exchange of shots, in the course of which five of the eight men on patrol fell. The three survivors hid themselves for three days in a quarry, and on the fourth were found by the advancing troops, and immediately went into battle.

But during a pause while on the point of taking coffee, the man suddenly fell sick, tried to carry on, but lost consciousness and apparently remained unconscious for about three-quarters of an hour. It seems that he raved and shouted and tried to bite his fingers, being held with great difficulty by several comrades. He was removed to a dressing-station three km. distant.

At the dressing-station, his head began to shake, although he was unaware of this until his attention was called to it by his comrades. He said that he felt restless and that his head ached almost continually. He was carried to the reserve hospital, and from thence, December 9, 1914, to the nerve hospital at Jena, where he was unaware of the shaking of his head (which had now lasted for three weeks), and said that he felt a thick fog in his head (to say nothing of headaches), and was only free and clear in his head while standing in the open air.

His sleep was restless and poor; there were war dreams almost every night. In the process of getting to sleep, his arms and legs frequently twitched. He would soon tire and feel weak. Also since his dangerous experience, he had noticed a change in his speech: always fluent before, it was now hard for him to speak because one had to exert one’s head so much in speaking.

This head tremor was in fact the most marked symptom of his illness. It would increase on every active motion of the head, but ceased almost entirely when attention was diverted. The head would then be held bent to the right.

During emotional excitement, the shaking spasm would spread over the entire upper part of the body, but would remain more severe upon the right than upon the left side. The forearms would fall into a lively shaking movement of pronation and supination. The hands and fingers would be attacked by a less marked tremor. After calm had set in, a fine tremor of the right hand would remain plainly noticeable. The musculature of facial expression would frequently fall into spasmodic movement, the left corner of the mouth twitching, the lips set for whistling, or the upper lip making movements as if snuffing spasmodically.

Physically the man was of medium height, strongly built, with adherent lobules, and a somewhat pointed skull. The teeth were defective and irregularly placed. Both deep and skin reflexes were increased. Marked dermatographia and mechanical excitability of the muscles: periosteal reflexes strongly developed; numerous pressure points in the head. The right temple and back of the head were painful on percussion. The patient showed no disturbance in touch and pain sensibility. Outstretched tongue showed marked fibrillary twitching; speech was difficult, being slow, awkward, stumbling, and sometimes hesitating (suggesting the speech of general paresis). At other times, the speech was of a peculiar sighing, tremulous nature, reminding one of the speech of children complaining or asking for pity. Rest was secured by injections of salt solution. A few days later, the treatment was continued by a bandage about the neck. After this the tremor grew slighter and would even remain absent for some hours. The patient was told to rest in bed and not to speak much; being “seriously ill,” he was kept alone. He was often irritated, querulous, and subject to outbursts of profanity. He took food well and slept well, receiving sodium bicarbonate.

The bandage was changed after five days. The tremor was very marked. The patient was furious because visitors were refused to him. He was especially angry with his nearest relatives and his betrothed, and wrote defiant letters to all of them. He became one of the most troublesome patients in the psychiatric division of the hospital. He complained sometimes of anxiety and feelings of unrest. He received treatment by pantopon. He continued to be a very disagreeable patient, feeling himself opposed and not properly considered. He thought himself seriously ill, behaved much like a spoiled child, and was of the opinion that he would not get well in the hospital because they were grieving him so. His appetite became bad; he complained of pains in the loins and of rheumatism in the legs. A cord was found hidden in the bed. The patient expressed suicidal thoughts at various times.

At the beginning of January there was marked improvement. The headshaking ceased almost entirely; the patient walked in the garden some hours daily. However, in the middle of January, on refusal of furlough, the head-shaking began again markedly. At his request a bandage was placed on the head again for a few days. He seemed emotionally very tender; his head would shake at the sight of a dead rabbit.

He was transferred to the nerve division of the psychiatric clinic at the end of January. He had recently begun to complain of flickering before the eyes. The ophthalmologists established an existence of a choroiditis disseminata. The eye examination had a markedly depressing effect upon the patient, and the shaking spasm of the head appeared again. Upon being told that he would have to be sent back to the psychiatric section of the clinic, the shaking immediately disappeared (24 hours after it had begun).

Thereafter slow improvement followed. He stayed in the open a great deal and walked. March 2, he showed a vehement outburst of anger, quarreling and using violence with a comrade. He was brought back to the psychiatric section, and in transit had a severe hysterical attack with unconsciousness, crying fits, and stepping movements of the extremities. He was promptly taken to a section for those seriously ill. The next day, upon his assurance that he could control himself, he was put in a more quiet division. He began to take part in gymnastic exercises, worked as a coachman, and then as an experiment was sent to a gentleman’s estate for recreation. At last accounts he was feeling well except that he occasionally had headaches during work. He could not work so hard as before on account of the rapid onset of fatigue, especially when working in the sun. The head-shaking recurred but seldom and lasted for a few hours only when the patient became angry or when there was much noise about.

Rationalization of war memories: Returned to duty.

=Case 506.= (RIVERS, February, 1918.)

A young English officer was wounded just as he was extricating himself from burial in a mass of earth. He became nervous and sleepless and lost his appetite. After the wound had healed, he was sent home on leave, which had to be extended as he got worse. An out-patient in London for a time, he was finally sent to a convalescent home, still troubled with insomnia, battle dreams and concern about his recovery. He made light of his condition and was on the point of being returned to duty by the medical board, when his sleeplessness led to his being sent to Craighlochart War Hospital.

He could not sleep without a light in the room, else every sound attracted his attention. He tried hard all day long to banish all unpleasant and disturbing thoughts, but at night it took him a long time to get to sleep and then came vivid dreams of warfare. He did not, himself, feel that he could ever forget the war scenes.

Rivers, in general believing that the attempt to banish such experiences absolutely from the mind is poor psychotherapy, narrated his views to the patient. Rivers advised him no longer to try to banish the memories, but to try to transform them into tolerable, if not pleasant, companions. The war experiences and anxieties were talked over. That night the man had the best night he had had for five months, and during the following week the sleeplessness was no longer so painful and distressing. If unpleasant thoughts came, they had to do rather with home life than with the war. General health improved; insomnia diminished. He was at last able to return to duty.

Rationalization of war memories.

=Case 507.= (RIVERS, February, 1918.)

An English officer was buried by shell explosion and developed severe headache, vomiting and disorder of micturition, yet remained on duty for more than two months. Collapse came when he went out to seek a fellow officer and found the body blown to pieces, with head and limbs severed from the trunk. This vision haunted him in dreams. Sometimes the officer appeared as on the battlefield; again as leprous. The officer would come nearer and nearer in the dream, until the patient woke pouring with sweat and in utmost terror. Accordingly, he was afraid to go to sleep, and spent all day thinking painfully about the night to come. Advice to keep all thoughts of war out of mind merely brought the memories in sleep upon him with redoubled force and horror.

Rivers’ therapy was to draw attention to the fact that the terrible mangling proved conclusively that the officer had been killed outright and without pain. The officer said he would now no longer attempt to banish the thoughts and memories of his friend, but would concentrate on the pain and suffering his friend had been spared. No dreams at all came for several nights, but one night in his dream he went out into No-Man’s-Land and saw the mangled body, but without horror. He knelt down, as he had in the original experience, and woke as he was taking off the Sam Browne belt to send to the relatives. A few nights later came another dream in which he talked with his friend. There was but one more dream in which horror occurred.

Rationalization of war memories: Eventually unfitted for military service.

=Case 508.= (RIVERS, February, 1918.)

A young English officer, after doing well for a period, was rendered unconscious by shell explosion. The first thing he remembered was being led by his servant towards his base, thoroughly broken down. He had headaches, sleeplessness, war dreams and spells of terrible depression appearing with absolute suddenness, unlike ordinary “blues.” For ten days in hospital no such attack appeared, but one evening he came to Rivers pale and anxious. A few minutes before, he had been writing a letter in his usual mood, when this causeless depression came on. In the afternoon he had walked about on some neighboring hills. The letter dealt with no depressing matter. In ten minutes the depression vanished. Nine days later another came as he was standing idly looking out of a window. The attack lasted for several hours, as no physician was present to meet the issue. If he had had a revolver he would have shot himself.

Rivers was inclined to interpret these gusts of depression as due to a forgotten but active experience. As there was no definite tendency to dissociation, Rivers hesitated to plunge in with the hypnotic method, nothing short of which, however, served to recall the incident. The man was gravely apprehensive about fitness for further service, and was repressing his fear, as he thought it either was cowardice or would be called cowardice. The patient, by his discussions with Rivers, had already become familiar with the idea that the gusts of depression might be due to a submerged experience. Perhaps, however, there had been no experience, and the patient was advised that possibly the thing repressed was the idea about fitness for service. Accordingly, the patient agreed to face the situation. One transient attack of morbid depression occurred, after an operation. Then the man fell into a state of anxiety neurosis such that he was passed by a medical board as unfit for military service.

Rationalization of war memories: Commission relinquished.

=Case 509.= (RIVERS, February, 1918.)

An oldish English officer lost consciousness while looking at the havoc wrought by shell explosion. Probably there was a second shell that sent him off. He was eventually admitted to an English hospital with paresis and anesthesia of legs, severe headache, sleeplessness and terrifying dreams. Hypnotic drugs and advice neither to read nor to talk about the war were the measures adopted and after two months in hospital he was given three months leave. He buried himself in the heart of the country, away from relatives, with aspirin and bromides. He began to sleep better and had less headache. When the president of the medical board asked a question about trenches at the end of his period of leave, however, he broke down and wept. He again repaired to the country for two months’ leave, for the chosen treatment by isolation and repression.

An order was then given that all officers must be either in hospital or on duty. He was sent to an inland watering place and treated by baths, electricity and massage, whereupon he rapidly became worse, especially as to sleep. He was transferred to Craiglochart in an emaciated state, with an expression of anxiety and dread, paresis of legs, sleeplessness and war dreams.

He was now advised to give up repressing, to read and talk a little about the war, and to accustom himself to thinking about war experiences. He did this but half-heartedly, as he thought the ideal treatment was what he had so long followed. Nevertheless, he got distinctly better and the content of the war dreams was altered to home scenes. He was still loath to acknowledge his improvement and thought that he would have recovered if he had not been taken from his retreat and sent to hospital. As it was obvious that he would be of no further use in the army, he was allowed to relinquish his commission.

Rationalization of war memories, without redeeming feature as nucleus.

=Case 510.= (RIVERS, February, 1918.)

An English officer was flung by shell explosion so that his face struck the ruptured and distended abdomen of a dead German. The officer did not immediately lose consciousness and got distinct impressions of taste and smell and an idea of their source. After a period of unconsciousness he came to, vomiting and much shaken. He carried on several days, still troubled by vomiting and haunted by taste and smell images. Several months later he was observed by Rivers suffering from horrible dreams, in which the battle experience was faithfully reproduced. He got no relief except when he went into the country, far from every suggestion of war. Rivers’ psychotherapeutic plan of finding a redeeming feature in the experience, upon which the patient might concentrate, failed because there was no redeeming feature. Accordingly, it was thought best that the man should leave the army and seek the conditions that had given him slight relief.

_Re_ psychoanalysis and its modifications, see remarks under Case 496, under which several favorable opinions were mentioned. Boschi in his report on French conditions gives no reference concerning psychoanalysis or hypnosis. Bruce has found blended with the war dreams many episodes quite alien to the war, and considers that the patient’s ante-bellum history is of importance, since ante-bellum emotions may be revivified by the war. Craig states that he has not been impressed favorably by the results of psychoanalytic treatment. Arinstein from Russian experience gives preference to Dubois’ psychotherapy over hypnosis and psychoanalysis. Nonne states that the data of the war prove that hysteria is neither a degenerative disease according to classical theory, nor a disease based upon Freudian principles.

Post rheumatic “paraplegia” (or abulia?) cured by removal of crutches, after question of discharge “unfit” had been raised.

=Case 511.= (VEALE, November, 1917.)

A soldier, 23, had fever with swelling of several joints and temperature in 1915, and was furloughed to England. He complained of pains in the limbs and shortness of breath, and was put in hospital. As he did not improve, he was sent to a special hospital for baths and electricity. There he remained from August, 1915, to March, 1916, with D’Arsonval baths, cataphoresis, electric treatment and massage.

He was now sent to the second Northern General Hospital to see whether he should be discharged permanently unfit. Here he shuffled along on two crutches, very tremulous, and sweating, and suffering from palpitation on exertion. He wanted to take poison if he could not be cured.

The crutches were taken away. He was asked to walk up and down. He had to be supported at first and fell several times. The exercises were continued. Massage and drugging were stopped. The next day he was able to stand alone. In twenty-four hours he walked by himself. The other patients in the ward encouraged him on account of the genuine exertions he was making to get well. April 7, he returned to duty, smart and well set up.

Babinski and Froment always give the suspected subject the benefit of the doubt, never uttering the word simulation in the presence of the soldier, and proceed to psychotherapy; for psychotherapy will act to cure simulation or exaggeration just as it acts to cure hysteria. They say that in their experience, all these disorders of doubtful nature--that is, that lie diagnostically between hysteria, exaggeration, and simulation--are as a rule cured by resort to psychotherapy provided that the due amount of energy, tact, and perseverance is employed. See also remarks under Case 453. Veale’s case (511) never showed _mauvaise volonté_, and nothing more than aboulia.

“Trench foot,” “neuritis,” a year of astasia-abasia or at least of complaint of inability to stand or walk. Treatment by a “cruel though justifiable” process.

=Case 512.= (VEALE, November, 1917.)

A regular army man, 38, well built and muscular, in Flanders the first winter, returned to England in January, 1915, with “trench foot.” “Neuritis” then developed, with loss of power to walk. Baths, electricity, massage, sympathetic wheeling about in a chair by women, all failed.

January 11, 1916, he still complained of inability to walk or stand. The reflexes were exaggerated. He was able to get into a wheel chair from bed by jerks, associated with palpitation, tremors, flushing and sweating.

He was told that he had now recovered from the neuritis. Crutches, sticks and wheelchair were removed. He flopped about and then lay on the bed exhausted. In a few days he began to shuffle about and was put on the stationary bicycle. January 29, he left the hospital well, remarking that though the treatment at first seemed cruel, it was fully justified.

_Re_ genuine polyneuritis, Mann gives German experience regarding neuritis as somewhat frequent and affecting a special form which he terms polyneuritis neurasthenica. He states that the commonest instances of mononeuritis developing in the war are the sciatic and trigeminal. The neuritis often outlasts the other symptoms. The treatment was rest, tepid baths, and electricity. Naturally, alcohol and syphilis must be excluded in the diagnosis.

Nonne also described non-alcoholic, non-syphilitic, and non-infectious polyneuritis in neurasthenics, which he, however, finds most common in the ulnar, median, radial, anterior crural and posterior tibial nerves.

_Re_ “spa” treatment, Turner thinks there may be easily too much massage, electricity, bathing. He prefers segregation in special hospitals to “spa” measures in general hospitals, prefers occupation to rest, and calls attention to the stimulating value of the gratuity to be paid on leaving the hospital.

Shell-shock paraplegia: Treatment by bed, cigarettes and chocolates altered to isolation, no tobacco, no visitors, faradization. Recovery.

=Case 513.= (BUZZARD, December, 1916.)

Early in the war, a lad, 19, was blown up by a shell. He was sent home paralyzed from waist down, and was seen by Capt. Buzzard after he had spent ten months in various hospitals, “carefully nursed, on the water bed, constantly using a bed urinal, smoking innumerable cigarettes, and eating countless chocolates.” He could not move his legs. They were wasted and flaccid. The knee-jerks could be got with difficulty. Plantar reflexes flexor. Complete anesthesia from umbilicus downwards, but preservation of abdominal reflexes. The navel did not shift downwards when the patient attempted to sit up. The incontinence was not real; urine was passed into the urinal at appropriate intervals.

Buzzard directed treatment “not to his spinal cord but to his mind; isolation; the stoppage of tobacco and all visits; the assurance that he would rapidly get well, together with some suggestive faradization of his legs.” This brought about a cure in a very short period. The atrophied legs eventually grew strong enough to walk.

_Re_ cigarettes in Shell-shock, Mott decries the over-liberal gifts of cigarettes that induced cigarette habits in both officers and men. Of course, the cigarettes are still more detrimental to cases of soldier’s heart than to other cases of neurosis. Mott remarks how over-frequent are the social tea-parties, joy rides and drives given by well-meaning ladies for the “poor dears,” actually perpetuating neuroses.

_Re_ atrophy, Babinski and Froment again bring up the question whether muscular atrophy can be brought about by a hysterical motor disorder. In point of fact, Charcot and Babinski were the first to describe the true hysterical amyotrophy, but this hysterical amyotrophy is exceptional in hysterical paralysis, and is slight when it occurs.

Shell-shock blindness, mutism, deafness: Blindness spontaneously vanished, 24 hours. Mutism, 2-3 months. Deafness cured by “small operation.”

=Case 514.= (HURST, September, 1917.)

A lance corporal, 26, became blind, deaf and dumb, though without losing consciousness, when blown up by a shell, August 29, 1916. His sight returned next day. On reaching England he talked in his sleep. Encouragement, electricity, etherization failed to effect improvement. One night in November he woke up and asked the sister for a drink; thereafter he talked normally.

Seven months after the shell explosion he was transferred to the neurological section at Netley, March 21, 1917. Deaf to air and bone conduction, a loud noise behind him caused a slight tremor of hands, with blinking and dilatation of pupils; but further stimuli of the same sort failed to produce such reactions. Normal nystagmus and giddiness on functional tests of vestibular nerve and canals. The internal ear was then probably free from organic changes. Since shell-shock mutism is always hysterical, it was probable that the deafness was hysterical. Under hypnosis (staring at lines for fifteen seconds) he showed no change. During natural sleep, also, a shout of “Fire” and metallic noises failed to wake the patient or to produce contraction of eyelids. Electric suggestion (despite the patient’s belief in electricity) and reëducation failed.

April 16, he was told that a small operation would have to be done April 20. To this he readily consented. Two small incisions were made behind the ear under light ether and suture was inserted. A loud noise was made during the “operation”; he heard this noise and jumped from the table. To his intense delight normal hearing returned in a few minutes. Next day hearing was tested and found normal to air and bone conduction. He was discharged to duty three weeks later and on his way to France, June 29, demonstrated his normal hearing to the physicians.

Deafness: cure by stimulating vestibular apparatus.

=Case 515.= (O’MALLEY, May, 1916.)

A private, 20 years of age, lost speech and hearing after the battle of Neuve Chapelle. Eight days later he came under the care of the laryngologist in a very excited state, pointing to lips and ears and carrying a note with information concerning his deafmutism.

Dr. O’Malley wrote on a piece of paper that he would restore the patient’s speech and hearing. Dr. O’Malley then used the mirror until the point of retching, and wrote, “You can speak now; count up to ten loudly.” He did.

Dr. O’Malley next used the cold water douche to the right ear to the point of giddiness, then shouting through a speaking-tube (see description below). The patient then found he could hear and the tears streamed down his face. Thereafter he was able to converse freely. Dr. O’Malley writes:

The treatment of functional deafness consists in exciting the
vestibular apparatus as follows. Cold or hot water is allowed
to flow in a steady stream into and out of the external
auditory meatus by means of a tube attached to a receptacle
placed about one and a half to two feet above the patient’s
head and continued until he becomes very giddy and an active
nystagmus is produced. A speaking-tube three feet long is then
used by placing the ear-piece in the ear so treated, and the
surgeon shouts into the mouth-piece the assertion, “You hear
now,” and the answer, “Yes” comes promptly. The tube is now
dropped and a conversation held as if no deafness ever existed.
So far I have found the treatment of one ear sufficient. The
patient is usually very emotional, as the disturbed vestibular
function, which in these cases responds easily and markedly,
causes him to feel as uncomfortable as a bad sailor on a
stormy voyage. This feeling, however, rapidly gives way to one
of pleasure at the return of his hearing. Where functional
deafness and mutism co-exist it does not appear to be material
which is treated first. In two cases of this kind under my care
I treated the loss of voice first.

Bullet through mouth; Hysterical mutism. Treatment by operative manipulation.

=Case 516.= (MORESTIN, January, 1915.)

A Colonial infantryman, 32, was wounded December 17, 1914, at the Boisselle, being struck by a bullet which entered on the right side in the upper part of the neck and came out behind the left side of the mouth, having traversed the tongue, broken two teeth, and caused a good deal of hemorrhage by mouth. The patient felt his tongue swell, and from this time on he could not pronounce a word. He was sent to the ambulance, then to Mien, then to Saint Germain, and finally to Morestin’s surgical service. With wounds by this time healed, the patient found it hard to open his mouth. There was no trace of fracture of the lower jaw. The tongue could be only incompletely examined. The man swallowed liquids easily but could take no solid food. He tried hard to speak, made pantomime movements, grew emotional and lachrymose.

On the whole, however, it seemed that his inability to articulate sound could not be due directly to the lesion. There must be either simulation or hysteria. For four days he was attentively watched, and not once did he pronounce a word. He grew more and more stricken and humiliated by his plight. Rigorous diet did not cause his mutism to cease. Isolation and ennui did not decide him to talk. Accordingly, it was announced, in the man’s hearing, that an operation was to be done to restore speech. January 9, 1915, his face was copiously washed with alcohol and ether. Cocaine was injected to secure anesthesia and resolution of the muscles of mastication. Six c.c. of a 1-100 solution on each side. Shortly the surgeon began to open the jaws, against decreasing resistance. The tongue, which was not spastic, was seized with a tractor and rhythmic movements were executed with it. After a few of these movements, joy was painted on the features of the patient. He said that he wanted to speak and that he was about to speak. He shook the surgeon’s hands effusively and said, “_Merci_.” Although the first words came hard, little by little speech became free and a perfectly sincere elation at having recovered speech set in.

This man was neuropathic, having always been a rather strange, irritable and restless person, and given to nervous crises in anger, in which he lost consciousness entirely.

_Re_ pseudo operations as forms of disguised persuasion, almost countless methods have been used. See Cases 514, 515, 518, 519, especially 521, 560, 561. Sham injections under ethyl chloride have been made (Goldstein). See also under Case 484, _re_ continuous bath, and under Case 488, _re_ lumbar puncture. Very close to these methods are the methods of _torpillage_ of Vincent and the methods employed by Yealland in England and Kaufmann in Germany. See under Cases 574, 563, and 564, and 570.

Léri quotes Babinski as saying, “We cannot fight hysteria in trench warfare; manoeuvres are necessary.”

_Re_ treatment of mutism, Chavigny remarks that the principle of treatment for mutism is quite different from the principles of treatment of paralysis. The reëducation of mutism is psychic. Chavigny claims probably absolute success in the treatment of mutism through faradism to the larynx region simultaneously with a signal given to the patient to make an effort to pronounce the letter A. Garel modifies the treatment (in case the faradic apparatus is not at hand), by a vigorous and sudden blow to the patient’s epigastrium simultaneously with the patient’s endeavor to imitate the movement of the doctor’s lips.

Shell-shock: Impairment of vision (even commanded men to fire on kindred troops!) Improvement by verbal suggestion, faradization, injections.

=Case 517.= (MILLS, October, 1915.)

A sergeant-major, 29, in private life a bookkeeper, said that shrapnel struck the ground in front of him and burst as it struck. Unconscious for a moment, the sergeant-major thereafter saw everything imperfectly, led his men in the wrong direction, and even commanded them to fire in the direction of his own troops.

Seven days afterwards the eyes looked normal, fundi were normal, vision was reduced to the perception of hand movements; with a plus 10 sphere the right eye could count fingers at 5 c.m. and with a plus 8 sphere the left eye could count fingers at 3 c.m. There was a right frontal analgesia.

Treatment: Sweating; rest in bed for several weeks; assurance of complete recovery. There was a slow but constant improvement, aided by faradization and injections of strychnine sulphate into the temporal region, but the prospect of a return to the front retarded the improvement.

_Re_ injections into the temple, see also Case 521 of Bruce. _Re_ cure of blindness, Grasset has a case of a blind deafmute who was cured by a nurse. She put a pencil in his hand and guided the pencil while she wrote a question. The patient replied in very good MSS. In blind deafmutes sight is described as returning first, hearing next, and speech last.

For other cases of blindness, see especially under Section C, Cases 433 to 438, with discussions thereunder.

_Re_ retardation of improvement by the prospect of further military service, Lewandowski has insisted upon the strong factor of the wish in all such functional conditions. Lewandowski wants all functional cases, however, to be sent to duty in the rear or to be discharged as unfit.

Aphonia: manipulation in larynx.

=Case 518.= (O’MALLEY, May, 1916.)

A corporal, 28, had a bullet pass through his neck from a point in the middle line at the upper border of the thyroid cartilage to a point behind the right sternomastoid muscle, two inches below the point of entry. The corporal lost his voice at the time of injury, spat up a teaspoonful of blood, and thereafter was able to whisper only. The laryngoscopic examination betrayed no intralaryngeal lesion. Treatment as described below enabled the patient to speak. O’Malley describes his technique as follows:

The patient is placed in the common position for the
examination of the larynx, the tip of the tongue being
seized in a piece of linen by the left hand fingers and the
laryngeal mirror introduced with the right hand. The patient
is then requested to say “e” or cough, and if the cords do
not approximate, they can be made to do so by using moderate
friction on the fauces and pharynx with the mirror to excite
secretion. The latter begins to drop into the larynx, and
acting as a foreign body, a protective reflex is at once
excited which adducts the cords to prevent the secretion from
entering the trachea. At the same time an involuntary cough
is produced to expel the mucus, and if the friction and flow
of secretion are maintained and the patient is urged to cough
vigorously, voluntary coughing and a tendency to retching with
forced laryngeal notes will rapidly follow. It is usually
best to persist until retching occurs, as the cords are then
forced together to protect the larynx and trachea from the
possible entrance of regurgitated stomach contents. Involuntary
laryngeal sounds are thus produced and the patient is conscious
of laryngeal effort. Some of these cases are at the moment
very shallow breathers, which can be demonstrated by X-ray
screening, but the act of retching causes a wide excursion
of the diaphragm with a more pronounced expiratory blast,
to be rapidly followed by deeper inspirations. This method
of treatment is best carried out just before a meal, as the
stomach is then practically empty and the unpleasant effects
of the sudden regurgitation of food are avoided. When the
explosive sounds accompanying retching have occurred two or
three times the mirror is withdrawn, the tongue released, and
the patient is requested to swallow, take a deep breath, and
cough, and then urged to count up to ten, directing his voice
to a certain point on the ceiling. This method has given me
uniformly good results, and was rapidly effective in all cases
coming under treatment soon after the onset of the neurosis.

_Re_ methods for curing aphonia, Muck has a method called the “ball” method. A ball is put into the larynx to cause a temporary suffocation, which produces a reflex that starts the adductors. He would apply the method as soon as the man was well over the shock that produced aphonia. Muck states that he has applied the ball method, not only to cases of aphonia, but to cases of mutism and deafness, with success.

Tilly mentions a case in which the patient refused to open his mouth, so the device was adopted of passing an electrode through the left nostril so that it finally reached the larynx. A spasm was produced, which was carried to the point of considerable cyanosis, but the aphonia was relieved and for the first time in three months the man spoke. Incidentally he began to hear also.

_Re_ treatment of aphonia, Schultz has used the electric current externally over the larynx, all the while carrying on a laryngoscopy. Schultz remarks upon the fatigue that may come during the first few sittings. Roussy and Lhermitte remark that, although aphonia sometimes exists from the outset of shock, it is often a phase in recovery from mutism.

Liébault notes that, not only cases of true nervous aphonia but cases of laryngitis, apparently of infectious origin, and cases of true voice strain, may also turn up for treatment. Some men have been improperly discharged from the army for aphonia actually due to voice strain.

Hysterical aphonia in a mechanician (war time contributory?). Cure by suggestive manipulation of larynx.

=Case 519.= (VLASTO, January, 1917.)

A mechanician was refitting an engine valve, when steam was suddenly put on and the drains were opened out. Some of the steam entered the throat of the mechanician, who rushed up, gasping, unable to speak. Oedema of the larynx was thought of; but there was no complaint except the inability to speak.

A month later he was discharged to the hospital ship at Plassy, where he got faradic treatment, the effect of which was to cause him pain without recovery of voice. The man could whisper well enough and cough fairly loudly. The vocal cords of the larynx appeared normal on laryngoscopic examination, but adduction of the cords was not be properly effected. He was now given rest and constant assurances that he would get well.

Ten days later, another laryngoscopic examination was made, with mild mechanical stimulation of the air passage. The patient remarked that he had never been so near being able to speak since his dumbness came on. The patient was now informed that his muscle of talking was going to be replaced and that the success of the operation depended upon his help, so that he was to shout out as soon as he became conscious of the physician’s working inside his throat. The patient was given ether lightly, into the second stage. When consciousness was about to return, the laryngeal mirror was placed lightly on the larynx. The patient was commanded and encouraged to count out loud and shout. Speech returned permanently.

It is to be noted that there was no specific war effect underlying the phenomena, unless we regard the fact of its being war time as contributory to the shock produced by an incident in every day engine room duties.

Gradual onset of mutism and amnesia without special occasion. Faradism. Dream.

=Case 520.= (SMYLY, April, 1917.)

A soldier was slightly wounded in the arm and returned to the trenches. Later he found himself in hospital at Boulogne, unable to speak and unable to remember what had happened to him from the time he was in the trenches. It appears that his voice and memory had gradually disappeared, according to what was told him by his comrades.

A month afterward, in a London hospital, the patient was roused suddenly from sleep, and then proved able to speak, although there was great difficulty in getting each word out. Two months later, he went to bed, feeling indisposed, in the night had a kind of fit, and remained unconscious until the following night; the next morning, his voice was again lost. The aphonia persisted for a fortnight, and the patient could hear only loud shouting when close to his ear. He was anxious to get well and requested electricity from the physician, Dr. Smyly, having heard probably of another case cured thereby. Dr. Smyly applied faradic current to the larynx externally, instructing the patient to blow at the same time. At first the patient spoke so low that he could not hear himself speak, but on suggestion succeeded in speaking up loudly enough. He was shortly able to speak and hearing improved. The climax arrived with a bad dream one night, from which the patient awoke in a fright and found himself able to hear and speak perfectly.

_Re_ nocturnal spontaneous cures, see observations by Mott under Case 473. Note also in this case the presence of what Mott has termed “the atmosphere of cure.”

_Re_ relapses, see Case 476 as well as remarks under Case 474. _Re_ special cases of mutism, Goldstein has insisted upon a greater individualization of treatment for functional mutes than even for other neurotics, and advocates the establishment of schools within the hospitals and aftercare institutions. He thinks the problem very serious.

Shell-shock blindness: Cure by a course of injections in the temple.

=Case 521.= (BRUCE, May, 1916.)