Chapter XXX: Section D: Shell-Shock Treatment and Results (26)

He was put, December 15, in a reëducation room and by means of fatigue, induced by violent physical exercises, was (Ferrand states) “brutally conquered.” The contracture after a half hour of physical movement of flexion and extension of the leg ceased. The patient was shown how he could himself both flex and extend the limb himself; he was then caused to do this spontaneously. These active movements were aided and at times provoked by somewhat painful galvanic discharges. The patient then walked slowly, and flexed both knees to the maximum. He was cured after a treatment of 2½ hours. There were, of course, some (surgical) intra-articular adhesions in the knee and it was necessary for the patient to break these adhesions. An X-ray had shown the bone to be intact. A slight hydrarthrosis developed the next day, but a few days later he was able to walk as well as anyone. For five weeks he followed a training platoon in the reëducation work and was evacuated, January 23, 1917, to his station, though he had entered the neurological center with the idea that he was to be invalided with a pension.

He had a few relics of physiomotor disorder when he left, including the abnormal delicacy of skin and muscular over-excitability above mentioned. On the basis of this and similar cases Ferrand believes that, although the physiopathic group of Babinski exists, it does not signify a separate clinical syndrome and the occurrence of physiopathic symptoms does not contraindicate psychotherapy.

_Re_ this controversy, see remarks under Case 530.

Shell-shock: Paraparesis. Cure by electricity.

=Case 568.= (TURRELL, January, 1915.)

Turrell, in a paper on electrotherapy at a base hospital, narrates a case of spinal concussion which rapidly yielded to the persuasive influence of Bergonié’s machine for electrically provoked exercises. Turrell grants that such a rapid cure would probably be attributed to suggestion, but thinks that the term _demonstration_ might be preferred on account of the vigor and amplitude of the muscular contractions excited.

This soldier was driving an ammunition wagon at the front, when a shell exploded under the wagon, killing one horse and severely wounding the other. The patient himself was blown into the air, fell, dragged himself to a trench where he lay all night, and found himself in the morning unable to walk or stand. He recalls that pins were stuck into his legs by the examining medical officer and that they produced no sensation. When he was finally brought to the Third Southern Medical Hospital, he was unable to draw up or move his legs, or to stand up (yet neurologically normal).

After a few days’ rest in bed, he found himself able to walk a few steps with assistance, and was then transferred to the Radcliffe Infirmary for electrical treatment. This treatment consisted in electrically provoked exercises to the back (positive) and seat and thighs (negative). He was able to walk back to his ward, leaning on a wheelchair. Next day he walked to the electrical department with sticks, and after the exercises were repeated, he was found able to walk without assistance. On the third day, the Morton wave current was applied to the back, to clear up any persistent stiffness. The patient was then discharged on sick furlough.

_Re_ the Morton wave and similar applications of electricity, Zeehandelaar speaks of a high frequency hall fitted up at Berlin. Touching the walls of the hall with the finger elicited a powerful spark. The scheme appeared to be on a commercial basis, and it was proposed to start similar institutions for poor metabolism and neuroses in other cities.

A year’s field service, gunshot; typhoid fever: Astasia-abasia: Lourdes-like cure: Residual amnesia.

=Case 569.= (VOSS, November, 1916.)

A soldier in service from the outbreak of war, shot in September, 1915, afterward suffering from fainting spells, was treated in several hospitals. He developed a typhoid fever at Lindau, which was at first taken for hysterical fever. Eventually he came to the observation of Voss, unable to stand and falling hysteria-wise if compelled to walk.

Thorough examination was made. It was emphatically explained to him that there could be no reason why he should not stand or walk.

A miracle occurred. From the second day of his hospital stay he not only walked about but began to polish doors and windows with inexhaustible strength.

But when he was about to be told that he must now be looked upon as well, the miracle was not so manifest. It now transpired that he had serious gaps of memory and disorders in recognition, a sphincter disorder and ever since his typhoid incontinence with fluid feces.

In short, waking suggestion had caused a very prominent symptom to disappear, but the total personality remained sick. According to Voss, the procedures of Kaufmann are dubious just because they cannot stand the test of time. Yet so far as the cure of this man’s astasia-abasia was concerned, it was not at all unlike the cures wrought at Lourdes.

_Re_ miracles of this sort, see cases of Colin Russel (503 and 504) as well as those of Veale (511 and 512). Voss’ arguments run parallel with the contentions of various persons that the miracle cures (such as those by anesthesia, electric suggestion, and hypnosis), do not get sufficiently to the bottom of the affections in question. Buzzard, in the preface to Yealland’s book on the _Hysterical Disorders of Warfare_, remarks that the question of the ultimate prognosis in cases thus suddenly cured must be left unanswered.

Dysbasia after a fall: “Kaufmann” cure in six weeks.

=Case 570.= (SCHULTZE, August, 1916.)

Severe dysbasia, due to monoplegia of the right leg of sudden origin (a fall), was variously treated 64 weeks without effect.

July 15, 1916, the patient walked in on a stick, and fell down on trying to walk without. August 1, 1916, at 9 o’clock, he was rapidly examined: Anesthesia to pain and temperature; inability to lift right foot; the right knee could be lifted about a hand-breadth above the body if the foot was supported.

At 9:10, a small electrode was applied: sensibility became normal at once. Second application: leg raised much better. The man was told that he was better and that his hand could be put under the heel. Third application: Leg raised 8 cm. The patient showed pleasure at the advance. Fourth application (slightly increased strength): Patient able to stand and to lift knee with flexion at 135° while standing. Walking exercises under direction. At 9:30, five minutes recess was given for fatigue, whereupon the exercises were taken up again and transition made from stationary running to walking without aid as well as a variety of other associated acts (grasping handkerchief instead of physician’s hand, and the like). The patient became exhausted after 8 or 9 minutes running about, and another pause was given.

The large brush electrode with stronger current was now given to the back and to the back of the right leg. Practice in slow walking, lifting knee, and holding hip joint firm. The patient became tired, but remained very willing. Exercises in pulling on stockings, in climbing stairs--the whole concluded at 10 o’clock, whereupon it was found that the patient could walk alone for a distance of 50 meters. The patient was a very suggestible one. It was striking that the patient in the time between 9:35 and 9:40 minutes could walk better on the right (that is, the previously affected leg) than upon the left. Rest in bed and phenacetine were ordered, with the suggestion that in the morning he would walk much better. He became irritated after the treatment but grew quieter in the afternoon.

On August 3, he was found able to walk well, better when not observed than when observed. August 5, he complained that his leg was worse and used a cane, without permission. He was roundly scolded by the physician and threatened with being sent to bed if he did not practice earnestly. August 7, he was better, and confessed that he could not walk as well on command as he could alone; the exercises were nothing but a fraud and he could go out and beat everything up (_alles zerschlagen_) if he did not have to carry out such exercises.

August 15, he was much better, quiet, and satisfied. The lameness was practically gone. August 30, there was no sign of lameness, even when he was observed. According to Schultze, the Kaufmann method is not merely an Erb tradition, and rather special measures need to be taken in executing it.

_Re_ Kaufmann’s cure, Imboden sums up this “highly logical and brutal method” as a method in which powerful electric shocks and loud military orders to perform certain exercises secure results. Imboden suggests that relapses may follow, sometimes on the slightest provocation. Mann states that Kaufmann’s method of suggestion and electric shock forms very good treatment; yet Mann states there have been two deaths under this treatment: in both instances there was an enlarged thymus at autopsy. A better technique, especially the use of the faradic current alone, might have avoided these deaths. Mann himself prefers to Kaufmann’s _Ueberrumpelung_ milder methods, such as rest. Kaufmann keeps up the sitting until the man is cured, even if it takes two hours of electricity and staccato commands. For similar persistance, see the treatment by induced fatigue of Reeve (Cases 489-493).

Wound of shoulder: Heterosuggestion of BRACHIAL paresis. Electrical suggestion of muscular power. Recovery in five days.

=Case 571.= (HEWAT, March, 1917.)

A reënlisted soldier arrived at the Royal Victoria Hospital, as a case of ulnar paralysis. He had been wounded in France six months before by a bullet which passed through the fleshy part of the shoulder, above the middle third of the clavicle. Power in the right arm gradually diminished; yet two months after the wound he seemed fit enough to be sent to Egypt. The paresis developed, and in a month’s time he was invalided home. He had been unable to use a rifle for months.

The healed bullet wounds were found about the region of the brachial plexus. The patient was sure the bullet had damaged the nerves in that region. The right arm and hand were limp and over-inclined to blueness, and the muscles were flabby. Active movements of all sorts could be carried out with the arm but not against resistance. There was a definite anesthesia and analgesia throughout, and responses to touch and pain stimuli were irregular.

By way of treatment, the patient had the muscles of the paretic arm stimulated electrically, and at the same time he was told that no nerve of the neck had been injured. He was greatly surprised to see his palsied arm move vigorously.

A milk isolation treatment in bed behind screens was adopted, whereat the patient was angry, looking upon the Weir-Mitchell treatment as punishment.

On the next day, another electrical application secured complete power in the arm and abolished sensory disturbance. Three days later the man went back to full duty. According to Fergus Hewat, someone doubtless had suggested to this patient that he had received a nerve injury. He had become obsessed thereby and developed a typical functional paralysis. This was a “cortical misinterpretation,” which disappeared upon forcible demonstration of the error.

Exposure; intestinal disorder in weakminded neuropath: Camptocormia and hysterical paraplegia: Cure by psycho-electric treatment.

=Case 572.= (ROUSSY AND LHERMITTE, 1917.)

A French territorial, 45, was observed at the Centre Neurologique, August 28, 1916. He was a victim of hysterical paraplegia with tripod gait. There was a stiffness of the lumbar vertebral column which had lasted six months. This paraplegia had begun spontaneously after cold and an attack of diarrhoea followed by constipation. The camptocormia and disorder of gait had come on gradually in the ambulance. He came on a stretcher. He was found to be able to walk with great difficulty by leaning both hands on a cane. The two legs were tremulous in a pseudospastic gait. The next day, after a single psycho-electric treatment, cure was complete. This patient was mentally somewhat weak and a constitutional neuropath. He was discharged, cured, October 20, 1916.

Brachial monoplegia, hysterical (or feigned?). Found able to descend ladder with arms only.

=Case 573.= (CLAUDE, July, 1916.)

Claude had a case of a soldier with right-sided brachial monoplegia, which had lasted for 18 months and defied efforts to cure. There was a question of simulation, and Claude handed the case over to Vincent.

The case came on service, June 20, and was seen June 21. He was then treated and found able to descend a ladder applied to a wall with the help of his arms only. On June 24, he was found able to lift a weight of 10 kilos, and could now write with the right hand, although he had been writing only with his left. This man had looked like a simulator to many physicians. He may have been a simulator or an hysteric. In any case, he was cured.

Vicissitudes of treatment of hysterical brachial monoparesis (shell burial).

=Case 574.= (VINCENT, July, 1917.)

A French private was buried in a trench upon the explosion of a large shell, November, 1914. He said he had had a “fracture of the occiput” and had fainted away without regaining consciousness for several hours.

He was evacuated to Dunkirk, then Saint Nasire, and then to Sables-d’Olonne. He showed no paralysis or paresis of limbs. During the first month, he had violent pains in the head, spells and vomiting. There was a slight aphasic disorder. He was treated by cupping upon the head and by applications of ice.

After the visit of the inspector general, he was sent to Nantes to be trephined. Dr. Mathieu regarded an operation as useless. He was treated with bromides and the faradic current by Miraillé, applied to the right arm, which had become paretic.

June, 1915, he started on a three-months convalescent leave in Paris.

From October to December, he had electric treatment at the Grand-Palais.

December, 1915, he went to the Salpêtrière under P. Marie, where he was given electric treatment.

January 1916, he went to Maison-Blanche under Laignel-Lavastine, where he was given electricity 4½ months.

April 4 he went back to his dépôt.

Presented to the invaliding board, May 11, at Decize, he was sent to the neurological center at Bourges. He was there given massage and movements. Upon entrance he had a functional inactivity of the right arm. He should have been cured a long time before by the therapeutics employed. He was then sent to Vincent at the neurological center at Tours for special motor reëducation. Vincent found almost complete functional incapacity of the right arm, without atrophy, with normal reactions, no R. D., and normal arterial pressure. June 26, 1916, the patient was able to write, although slowly. He could sign a letter, and could lift a weight of 10 kilos.

The details of Vincent’s method mentioned under Case 566 are pursued, to use his own words, with _methodical ruthlessness_. This form of reëducation consists in manoeuvres that make the patients yield despite themselves. The galvanic current is used to force a man to react voluntarily or automatically. See, for example, Claude’s case of a hysterical brachial monoplegic (Case 574) found able to descend a ladder with the use of his arms only. After the physician’s victory is secured, then a sort of consolidation must be obtained by means of the execution of certain movements on the part of the patient for an hour or two. As another factor in the situation set up by Clovis Vincent, is the enthusiasm generated in the moral atmosphere in which the cure takes place. Mott has also insisted upon this atmosphere of cure, which Mott believes is in part responsible for the good results of Adrian and Yealland. Roussy and Boisseau, at Salins, started out with a process similar to that of Vincent, with a preliminary period of isolation. Roussy also uses the faradic current instead of the galvanic (see remarks of Mann concerning deaths with the Kaufmann method in Germany, under Case 570). Vincent’s three stages are given in Chart 19, page 897.

Struck by shell fragment; run over by shell; paresis and regionary sense disorder. Treatment by reëducation.

=Case 575.= (BINSWANGER, July, 1915.)

A German subaltern officer, 27, was wounded September 25, 1914, in a battle in France. He gave the following account:

“We had been firing without interruption four days, and then were sent back. While going back from cover we were under shell fire. Three or four horses fell. I got a glancing blow from a shell fragment in the back of the head, and fell down. I was not quite unconscious. I tried several times to get up, but I could not, for I had very bad pains in the head and a confused feeling in it, too. I remember also that a wheel ran over my foot, and that I got a sharp blow in the chest. Then I was unconscious for about an hour. When I awoke, there were two comrades busy over me and they pulled me back of the firing-line. Then I got to a field hospital.”

The man arrived at the nerve hospital (Jena), October 8, 1914, with insomnia, respiratory disturbance, sudden perspiration, feelings of cold in the right foot, and poor appetite. He had had nausea for a few days. Lungs and heart proved normal. X-ray of the right foot showed normal relations. The man was a small, powerfully-built man, well nourished, with lively reflexes, especially the knee reflexes, of which the right was greater than the left; slight patellar clonus, right; left plantar reflex greater than right; segmental disorder of touch and pain sense in the right foot and lower leg, a zone of analgesia lying above the zone of total anesthesia. Gait was lame on account of inability to move the right ankle joint. In walking, the right foot was trailed.

Treatment was suggestive and supported by active gymnastic exercises, breathing exercises, exercises in moving the right leg, massage, faradism and local hydrotherapy. The gait gradually improved, the cold feeling disappeared from the right leg, disturbances of pain and touch sense disappeared. The patient was released on the 2d of February, 1915, capable of garrison duty.

With respect to this man, who was married, he was from a healthy family and had healthy children. He is said, however, to have suffered from convulsions for a long time in early life, but thereafter had never been sick in any way. He was a good student and had been a post-office official since 1908. After two years’ military service, he became, in 1910, _Unteroffizier-Aspirant_. Later he was advanced to his subaltern position in the reserve.

This case seems to be a characteristic example of segmental disorder of sensations of both touch and pain, combined with a paresis in the same region. Mechanical and mental factors seem to have been present, and the case belongs in what Binswanger calls the “hysterosomatic” group.

_Re_ Binswanger’s so-called hysterosomatic group, he defines the cases as having emotional, mechanical, and toxic (gas) factors. On the whole, they are best classified as a kind of psychoneurosis. Binswanger finds all physical and drug treatment without result except as supportives. He has used hydrotherapy and electrotherapy with the perfectly clear conception that the procedures were of suggestive value only. In fact, Binswanger had before defined such procedures as _Realsuggestionen_ or material suggestions. Common verbal suggestion, says Binswanger, will work sometimes only when aided by these material suggestions. See also under Case 576.

Post-traumatic (ANTEBELLUM) seizures with unconsciousness: Further seizures, astasia-abasia, anesthesias, following no special period of stress in field service. Recovery by reëducation.

=Case 576.= (BINSWANGER, July, 1915.)

O. F., 26, healthy, of a healthy family, in military service, 1908-1910, a miner in October, 1912, had fallen into a shaft from a considerable height, and is said to have been unconscious for three days and two nights and to have had some sort of attack a short time after waking. Later he had another attack, beginning with violent headaches, running from the back to the fore part of the head, then dizziness, then a fall with unconsciousness. The whole attack lasted about four minutes and was followed by feelings of extreme fatigue.

It seems that in the spring of 1913 these attacks had begun to repeat themselves two or three times a week. In the spring of 1914 there had again been two attacks at an interval of two weeks. They had occurred on the way to work and had been introduced by the same symptoms as before. They lasted about half an hour.

He was in the war in France from August 6, 1914. While he was cooking, one day, in the middle of September, he had an attack and this without special occasion. The next attack occurred a little while afterwards, at the time of an assault. He said that he fell down and lost his senses. When he came to his senses again, he found he could not move his legs.

He was taken to a reserve hospital in Germany, and while there had several attacks with unconsciousness and spasmodic convulsions--the last on December 7, 1914. He was transferred to the Jena Hospital on the 11th.

The Jena examination had the benefit of an inquiry concerning the case. It seems that he had left the field hospital in the enemy’s country, in a half-conscious condition, and rode away therefrom aimlessly. It was only in Germany that he, on his own story, found his bearings again. However, upon admission the disturbance in walking was very noticeable, since the patient came hobbling through the garden of the clinic with the upper part of his body bent forward, and with the support of two canes. The legs were moved with difficulty; he seemed to take short, tripping steps, with the toes dragging on the ground. His inability to walk he explained through the violent pains which he would feel in the joints of the legs and an extraordinary weakness in his legs.

Physically, the man was a tall, strongly built and well-nourished subject. Neurologically, the knee-jerks were somewhat decreased and weaker on the right side than on the left; the Achilles reflexes were lively. The plantar reflex was not obtainable on the left side; decreased on the right. The abdominal reflexes were absent on both sides.

Most remarkable was the general diminution in sensitiveness of the skin to touch and pain, involving the whole body, up to the neck, where the sensory impairment abruptly ceased in a sharp line. The anesthesia was not everywhere complete. In a few places pencil strokes were successfully localized and recognized. Deep pin-pricks were everywhere recognized as itching. When the trunk was everywhere examined on both sides symmetrically, a strong pressure with a pin-head was felt as a strong pressure on the right side, but was felt not at all on the left side. Anesthesia and analgesia were total in the legs. Deep folds of skin could be punctured by needles without reaction.

The legs could be moved freely upon urgent request with the patient in dorsal decubitus. Still these movements were slow and difficult, as explained by the patient, on account of violent pains in the joints. If put on his feet, he would begin to sway greatly and permit himself to slide down to the ground, stating that he was quite incapable of standing or walking without aid. With two canes, however, he could move freely about in the ward and in the garden, and even with considerable speed, in a peculiar, dragging, shuffling way; in the execution he gave no sign of pain, contentedly smoking a cigar or a pipe.

While his status was being taken on admission, he became suddenly dull and irresponsive, with a staring look. He could not state his age or his birthplace. However, he became clear shortly, upon urging, and explained the spell by saying that the blood had risen to his head. A few days later, he was transferred to the psychiatric division. He was given strict rest in bed, smoking was forbidden, prolonged baths were used, and the legs were massaged. He felt very comfortable in the prolonged baths and could then move his legs without pain.

A few days later he was taken out of bed several times a day, the canes being removed immediately, and he was led about the day-room with the light support of two nurses. Being promised a cigar as a reward, he proved able to walk through the day-room supported by but one nurse. A week later the pains in walking exercises had disappeared. He had become able to walk alone, supporting himself lightly along the wall with one hand. Walking was still uncertain and slow.

December 20, the patient could stand free without support, swaying slightly; improvement became rapid. He could shortly stand and walk without support though his walk was still awkward and on a wide base with knees pressed in and body bent forward, soles were kept applied to the ground. December 22, the patient could walk in the garden without aid.

December 23, there was a spell of great weariness and complaint of being sick. The patient lay down on the bed, cried aloud, and had rhythmic twitchings and sudden movements with arms and legs. He scratched the right half of his face with his right hand. This spell lasted about a minute. It was repeated in the same way twice within the half hour.

He had complete amnesia for these attacks. The pupillary reactions were entirely normal in the attacks. He had been in bad spirits that day because a Christmas furlough had been refused. The attacks provoked no bad consequences and his gait improved. He was on furlough from the 30th to January 3; on the 4th he was transferred to the nerve department, but on the 12th of January he was reprimanded for a breach of discipline, whereupon at 9:15 he had an hysterical attack with the same coördinate rhythmic motions as before. This attack lasted about 20 minutes. Two hours before the attack he had complained of weariness and a boiling-hot feeling in the body. Long walks were taken. On February 15 he began to feel very happy. He was informed that the charge against him for leaving his troop had been dropped. He complained of sudden weariness and headache and was markedly depressed, but he had no hysterical attack.

After February 23 he took part regularly in gymnastics, executing the movements with joy and without special weariness. He wanted to be discharged. He was discharged as fit for garrison duty and he has since gone back to field service.

_Re_ gymnastics, Binswanger holds that they have a special value in overcoming inner psychic resistances and weak-willed persons. The _Realsuggestionen_ (see under preceding case, 575), such as hydrotherapy and electrotherapy, serve to concentrate the person’s attention on certain regions. These regional suggestions then smooth the way for the curative suggestion, namely, the constant and monotonously repeated assurance that recovery is advancing. At the next stage, according to Binswanger, gymnastic exercises may be brought in to overcome hopelessness, indifference, or exaggeration of morbid feelings. Binswanger sets methodical tasks for the attention and the will (a so-called _Uebungstherapie_). If these gymnastics lead to manifest improvement, then a proper educational therapy is prescribed, which is no longer a merely exercise therapy, but consists of actions of actual value in hospital routine. The convalescents are gradually led to carry on housework, food service, gardening (the latter under supervision). Hospital clerical work is a suitable occupation. _Re_ supervision over gardening, mentioned by Binswanger, Canadian experience indicates that the idea of supervision may be greatly extended. Particularly is this true in vocational reëducation. Kidner describes the functions of a vocational counsellor, who has to have an expert knowledge of industry and methods of industrial training, as well as an acquaintance with the varying demands for workers, a knowledge of the seasonal variations in employment, and a knowledge of occupational diseases. _Re_ occupational therapy, Todd estimates that from 0.5 to 1 per cent of wounded men in France will require vocational reëducation. Occupational therapy is the proper vestibule to vocational training. He lists the following forms of treatment used in institutions for vocational reëducation:

Active mechanotherapy.
Passive mechanotherapy.
Galvanic, static, and faradic electricity.
Vibration.
Hot air baths and blasts.
Water baths.
Colored light.
Massage.
Gymnastics.

Central specialized institutions such as those developed in France are necessary, and such centres should be large rather than small, according to Todd, and should contain not less than 200 beds. Todd insists that work is, after all, the most important measure of reëducation; and Turner, speaking of the home for neurasthenics at Golders Green, says that during a period of three months (the number of the patients is limited to 100, and three months is the limit of stay), the vast majority, even of the most obstinate cases, get well through the effects of sympathy and insistance upon work. Near Golders Green is the Maida Vale Hospital for nervous cases, so that in case of need the physicians there may treat the patients. Salmon gives a list of the occupations which are suitable for these cases.

Blown up by shell; wounds, right side, distention and bloody urine: Paresis of right foot and spasticity of hip; later rectal and bladder incontinence.

=Case 577.= (BINSWANGER, July, 1915.)

A Russian from the Ukraine was received at the nerve hospital, Jena, December 12, 1914. Through an interpreter it was established that he was a peasant, had been under shell fire in a skirmish at the beginning of November, and had been hurled (so he said) 1¼ meters into the air without loss of consciousness. There was a wound of the right shoulder and also, he thought, of the legs, from the air pressure. Becoming a German prisoner, he had been treated in various hospitals.

He was a strong man of medium height, with a healthy complexion. There were two healed wounds of the right shoulder, and near the twelfth spinous process a third similar scar. There were a number of ulcers and furuncles over the os sacrum.

Neurologically, the knee-jerks and Achilles jerks could not be obtained, and the plantar reflex, extinct on the left, was weak on the right. Sensitiveness to pain on both sides was lost from the knee downwards but there was hyperalgesia in the thigh. Inaccurate statements in response to tactile tests were made, apparently on account of lack of understanding. In lying down, there was a slight restriction in the movements of the legs, and active movements of the joints of the foot on the right side were impossible. Gait was ataxic-paretic, more markedly so right than left. He could walk only with two canes, and during walking the musculature of the thigh fell into a spastic tension. The tongue deviated to the left. There were severe rheumatic pains in the thighs.

It appears that some weeks before, this Russian soldier had suffered from severe rheumatic pains in both sides and was at that time absolutely unable to walk or stand. At that time, however, there was no question of a crural paraplegia of organic origin, since the man could move his legs well enough when in dorsal decubitus. There were no signs of paralysis of the rectum or bladder at that time.

Treatment at Jena consisted in regular walking exercises with support at the shoulders. The lower legs and feet remained weak and paretic. The decubital ulcers disappeared.

About the middle of December rectal incontinence began, the stool being discharged without the patient’s noticing it while being led to the bath. Later there was incontinence of feces in bed. Pains in the legs were constantly complained of. Nevertheless improvement in walking was maintained. The toes were dragged at every step and the knee-joints were thrown outward in walking. The musculature of the lower legs was weak. Knee-jerks could not be elicited more than before. He constantly complained of pains in the knees and right hip. The rectal disorder did not again occur during January.

Toward the close of January, the patient’s right lower leg and left foot would occasionally feel asleep; both legs felt cold and itched. In a general way, however, the pains had become less marked than they were at first. It seemed that he had no sensations at stool, and consequently had to resort to the closet at a definite time. Moreover, urine was discharged irregularly and involuntarily when he coughed. It appears that a few days after receiving his wounds in battle, there had been pains on micturition as well as blood in the urine, and it appears that he had been catheterized. It is probable that he had suffered from distention, as he described his abdomen, thighs and sex organs as swollen.

In February he began to be able to move alone with two canes through the ward, but he moved his legs from the knee downward very little, and dragged them after the rest of the body. Upon galvanic examination, the peroneal and tibial nerve trunks were found normally excitable. At this time the sensibility situation had changed somewhat, since complete analgesia was present only in the foot, and hypalgesia had developed upon the anterior surfaces of the lower legs. Pin-pricks were described as touches. The posterior surface of the left lower leg was normally sensitive. There was an oblong stripe about 3 cm. long, beginning in the popliteal space and stretching downward on the left side. The right lower leg was entirely insensitive. The posterior surfaces of both thighs as far as the gluteal folds were completely insensible to pain. The Wassermann reaction of the blood was negative. In this condition the patient was transferred to a prison camp hospital.

_Re_ bloody urine, see Section B, Case 202. _Re_ rectal incontinence, it might be inquired whether this was possibly functional. Roussy and Lhermitte devote a chapter to visceral disorders. They do not list rectal incontinence amongst the disorders noted in this war, nor have any cases of hysterical anorexia or disorders of sensation in the intestinal tract been seen during the war despite the occurrence of these latter disorders in the civilian group. The main digestive disorder that the war cases show is vomiting (see Cases 495 and 500).

Emotionality: Shell explosion; mutism. Recovery by reëducation.

=Case 578.= (BRIAND and PHILIPPE, September, 1916.)

A plumber, 27, went into the infantry. He was very emotional and was but a short time in the trenches when the explosion of shells threw him into a state of mutism. Deafness, rather curiously, did not manifest itself for several days. He had to go back on horseback, and, as he was a poor horseman, slipped off the horse, giving himself a bad fright. When he got up, he had lost his hearing.

He was sent to several hospitals and finally to Val-de-Grâce, in July, 1915. He recovered hearing in fifteen days, but the mutism persisted several months. According to Briand and Philippe, this is a typical case, except for the duration of the mutism. The first treatment was given this patient August 6. His respiration was examined and tracing was taken. August 15, on the morning visit, he was found able to whistle very distinctly the first bars of “Au Clair de la Lune,” and then began to sing the first verses, articulating distinctly, but stammering a little. He was now left to his own resources, without special exercises, from August 15 to September 26, and completely lost the benefit of his previous exercises. A week of special treatment allowed him to recover speech again, enough to take up every day life. The patient went out well.

The general lines of the examination in this case took up attitude in abdominal respiration and the question of respiratory pauses, especially pauses in abdominal respiration, which, in the above case, were exaggerated. Expiration was deficient and disordered. The normal adaptations that had been established during his childhood learning of speech had failed, and the patient would not have been able by himself to regain proper balance of respiration for speech.

The examination was continued to learn the difficulties of innervation of the muscles of phonation whose proper delicacy had been lost. Such a patient is a kind of bad gymnast, executing an exercise known to be hard by contracting all the muscles of the region, both the antagonist and the agonist muscles. Reëducation must, therefore, endeavor to sweep away the contractions that block sound. Then the patient must be made to perform the contractions necessary in phonation and articulation unconsciously. The methods used for teaching children might here be employed, but more elaborate and designed methods can be used with the adult, _e.g.,_

1. Breathing exercises, especially with the idea of making
respiration complete.

2. Blowing exercises.

3. Whistling.

4. Vowel sounding.

Séguin and Rouma, on the other hand, counsel beginning exercises with consonants in stammerers and dyslalics.

_Re_ tests for functional deafness, Ranjard states that on account of the complexity of Shell-shock deafness, exact diagnosis needs to be made. Examination of the hearing by speech alone, or by the watch-tick, yielded poor results; and an accurate mathematical acoumeter (_Sirène à voyelles_, Marage) is recommended. See especially chapter on the functional examination of audition in Bourgeois and Sourdille’s _War Otitis and War Deafness_, a work translated and highly recommended by the English otologist, Dundas Grant.

Three days’ skirmish on East front: Unconsciousness, later delirium, still later (six weeks) stammering, hysterical stigmata: Recovery by isolation and reëducation.

=Case 579.= (BINSWANGER, July, 1915.)

A traveling salesman in civil life, 36, as a non-commissioned officer took part in severe fighting in the East shortly after the outbreak of the war. He was under violent shell fire at one time for five hours at a stretch. In the middle of November, after a skirmish in the woods which had lasted for three days, he was found unconscious. According to his own story, he was awakened from this unconsciousness about a week later in a hospital. He described himself as quite unable to say anything about what had gone on during that week.

The medical report on the case stated that he arrived at the hospital, November 18, in a dormant state of mind. He had appeared markedly excited and kept incessantly talking about military matters, such as the placing of machine guns, the occupation of the edge of the woods by his company, addressing the nurse as “Captain,” and the sister as “Mrs. Captain,” making as it were an official report to them. He showed shyness, and always an extreme excitement. His hands and legs were in constant motion; he complained of headaches and itching finger-tips. Sleep could be achieved only by drugs. This mental state lasted till November 26, when he became oriented. Sleep improved, but he complained of pains in the back of the head.

Upon transfer to a convalescent home, December 5, he was still occasionally excited and sometimes sleepless. On December 30, the patient began to stammer; his speech had before this been somewhat difficult, but the stammering began suddenly; speech was indistinct and slow; syllables failed to follow one another at like intervals. The headache at this time radiated from the middle of the top of the head to the side of the neck. There was a complaint of vibrating pains on the two sides of the vertebral column, and a feeling of weakness and unsteadiness in walking. The patient would sway with eyes closed and turn sidewise. The heart action was tumultuous, the pulse irregular and uneven.

The patient was transferred back to the reserve hospital on January 2, 1915, whereupon the stammering became worse, sleep restless, and arms and legs subject to spasmodic pains and twitching. On January 25, he was removed to the Jena Hospital. He remarked that at the convalescent home he became very much excited at the Christmas celebration and had to cry, whereupon his speech became more and more difficult; he could not find the beginnings of words and had to stammer. Upon admission he also complained of sharp pains in the soles of the feet and in the finger-tips.

Neurologically, there was marked dermatographia, the deep reflexes were increased, abdominal reflexes were absent; there were points of pain on pressure in both supra-orbital regions, and there was a general hypalgesia with the exception of the head, the lower legs, the feet, the scrotum, the penis and the anal region. Pin-pricks were recognized on the right side only, when the patient was tested bilaterally. They could be recognized on both sides when the patient was examined on one side at a time. There was a static tremor on both sides (?). He could move his arms, but in dorsal decubitus he could move his legs only jerkily and uncertainly. His gait was waddling with dragging of toes.

There was a marked photophobia. The palatal and swallowing reflexes were in excess; speech was hesitant and stammering. The first letters of words, especially initial consonants, could be pronounced with difficulty, explosively with cheeks blown up, after several attempts. The consonant would be repeated several times before the vowel could be added. The patient’s name was Singer, and he would pronounce it: _S … S … S … Si … n … n … ger_; the last syllable (_ger_) being brought out with a strong accentuation. The whole process took five seconds. The word _Flanelllatten_ took 14 seconds. It seems that the patient had already suffered (in 1907) from nasal catarrh and disturbance of hearing from stoppage of the Eustachian tubes. Another attack in 1908 had been accompanied by an irritating cough, and there seems to have been catarrh on the right in 1913, as well as cerumen on the left side.

Treatment: The patient was isolated; in the next few days there was improvement in the headache. The patient complained of muscular twitchings, which would occur suddenly in different parts of the body. On February 1 there was a subjective feeling of happiness since all pains had disappeared.

The patient was given regular exercises in speaking and there was gradual improvement in speech. Body-weight increased, regular walks were taken, and the patient occupied himself with garden work.

By June, 1915, he had still further remarkably improved, working now all day long, partly in the garden, partly in the hospital office. Disturbance of speech was not noticed except for hesitation before the last syllables of long words during comparatively long conversations. All trace of difficulty in walking had disappeared. In this patient no hereditary taint could be proved. He appears to have been of normal development, serving in the army from 1901 to 1903. In his life as a traveling salesman, there was frequently catarrh of the throat, and in 1912 there was a marked swelling of the vocal cords with extreme hoarseness and inability to speak, which condition was cured after local treatment.

_Re_ hysterical speech and voice disorders, Binswanger has found them amongst the most obstinate conditions, often persisting when all other hysterical phenomena have dropped away. He states that apparently the cure of some of these cases must be postponed until the end of the war.

_Re_ general results of the therapeutic treatment of the war hysterias, Binswanger states that he has been able to send some cases back to the front that have successfully stayed there. He has had failures, however, even amongst men who have had no _mauvaise volonté_ and have themselves desired to be sent back to the front.

Gordon Wilson observed 250 cases of Shell-shock at the Ypres salient and on the Somme. Fifty of these cases complained of deafness, and 17 of the 50 were found to have actual nerve deafness. Wilson treated “fixed idea” cases by hypnotism, and sometimes by cold water run into the ear. He, in general, divides the cases in to (_a_) cases of nerve deafness, (_b_) fixed idea cases, and (_c_) malingerers.

Marage states that frequent exposure to the noise of shells for long periods may produce a permanent deafness, as has long been known in naval gun-makers and boiler-makers in peace times. He advocates obturators, a good form being plasticine wrapped in gauze moulded to the shape of the internal meatus. Celluloid plugs, sometimes used, have been known to be set afire by the flash of a shell. Cerumen sometimes protects against deafness, but Mott speaks of the driving of the wax into the tympanum as a dangerous effect in certain shock cases.

BURIAL by shell explosion: DEAFMUTISM. Treatment: phonetic reëducation.

=Case 580.= (LIÉBAULT, 1916.)

A machine gunner, 26, was buried at Rheims, January 5, 1915, by the explosion of a large shell bursting over the dugout. He was unconscious three days and deafmute on coming to, without amnesia but with a feeling of constriction in the throat.

After fifteen days in the ambulance he was sent for four months to the Maritime Hospital at Brest, and treated by hypnotism. Seven or eight sittings had no other result than to fatigue him. There were then three months of convalescence. Returned to Vannes, September 20, 1915, he was put into the auxiliaries. As he could not work much he was sent, December, 1915, to the Hôtel-Dieu at Nantes. Here electric vibratory massage was given, which secured a few hoarse sounds.

Phonetic reëducation was then undertaken at Prés-à-goutrière, May 10, and his respiratory capacity increased from 170 the first week to 250 and 300 the following weeks. His blowing strength was raised from 15 to 20 to 25 at the same time. In a few weeks he was much improved and June 27 passed on to his auditory reëducation. The respiratory capacity in this man was insufficient. He could not speak, but his respiratory movements were good and he learned again to speak in a voice as good as ever.

According to Liébault, it is a general principle that, if the respiratory capacity is increased, the voice will clear or become better; but, if the respiratory capacity remains stationary, the voice will not improve. It is the same with normal persons. A subject with a very subnormal respiratory capacity cannot speak loudly, but, if his respiratory capacity approaches normal, he can speak normally. According to Liébault, all cases of this sort have had some respiratory anomaly and each case must be systematically examined with the aid of anthropometric tables, including weight, height and chest capacity. The vocal disorder is proportionate to the degree of functioning of the phonating apparatus taken as a whole. It is not merely that the larynx should be examined, but the motor side of the apparatus, the respiratory muscles, the resonating apparatus, the lips, the mouth, the nasal fossæ and the pharynx.

_Re_ curability of different types of war deafmute, Roussy and Boisseau maintain that the type (_a_) that comes gesticulating, pointing to the ears, and desirous of writing, is the type that responds most rapidly to psychotherapy. There are two other types less responsive: (_b_) is an apathetic type, with impassive and stupid facies, lies immobile in bed, or sits in a chair in mental confusion; type (_c_) shows a facies of terror, looks haggard and anxious, confused, disoriented, and possibly delirious.

_Re_ general treatment of deaf cases, Zange suggests that emotion should not be aroused by intense auditory impressions, that he should not be reminded of his shock, and should be kept as cheerful as possible. Zange states that he found the static electric current of service, and got good results in hysterical deafness of sudden development by applying a strong faradic current.

A year’s service; leave: Hysterical aphonia developed at home. Respiratory gymnastics.

=Case 581.= (GAREL, April, 1916.)

A soldier, 35, went on leave August, 1915. Arriving at his farm, he had a violent feeling of moral perturbation and suddenly lost his voice. When he returned from leave he seemed stupid, spoke very few words and seemed to look about in a vague and undecided way. He was several months in this state and sent January, 1916, to Saint-Luc.

The vocal cords were there found of a normal color and without paralysis. “It was, therefore,” remarks Garel, “a nervous aphonia susceptible of instantaneous cure.” The patient was made to make a sound in the lowest tone possible. While he was making this attempt, sharp pressure was exerted upon the lower part of the sternum, to provoke expiratory reinforcement. The sound emitted was loud, to the great astonishment of the patient, who, thus aided by suggestion, shortly began to talk aloud.

In this particular patient a temporary return of voice was readily obtained, but not maintained. Special exercises had to be instituted, whereupon the patient immediately fell back into a complete aphonia. He was then made to scan words, syllable by syllable, executing with his arms classical movements of respiratory gymnastics, or sometimes with the utterance of every syllable the epigastrium was manually compressed or the shoulders suddenly lowered. The patient could now read a book in a jerky manner, and after a few lines he could read without his shoulders being pressed.

Another plan was to have the man read or talk while walking. As soon as he was stopped and accosted, however, he lost his voice again. Up to the time of report it was impossible to secure a definite return of voice, as the patient was not willing to associate words with peculiar movements. It might make him ridiculous. Accordingly, the nurses were requested not to fulfil requests unless they were made aloud. Recovery was to be hoped for from this measure.

Wounded: Recurrent stammering: Reëducation.

=Case 582.= (MACMAHON, August, 1917.)

A young English officer, previously cured of stammering while a boy, fell to stammering again after being twice wounded. The impediment was of the laryngeal type. When spoken to he was often quite speechless. In Shell-shock stammering, the chief difficulty according to MacMahon is in the production of voice consonants and vowel sounds. In mild cases the trouble is best left alone.

This officer was anxious to pass into the regular army from the reserve to which he was attached. The stammering prevented this. He was treated nine months and improved rapidly. He passed through the trying ordeal of the medical board successfully and went to his regiment.

In severe cases the patient is taught how to fill his lungs properly. He is taught to acquire an inferior lateral costal expansion in inspiration. During expiration the abdominal muscles are trained to contract slowly and strongly, pressing the diaphragm upwards and drawing the lower ribs downwards and inwards. This steady breathing produces a sensation of repose in the stammerer. He is not to raise the upper chest and not to tense the throat, tongue or jaws.

The main vowel sounds are now taught. The main vowel sounds are oo, oh, au, ah, a and ee. They combine in six ways, oh and oo in the word wound, ah and ee make the long i, au and ee in boy, oh and oo in road, a and ee in rain and fair, ee and oo in new and you. There are also words in which no main vowel or compound sounds appear, which may be placed either on the open ah position or the closed ee position. Such words as long, abbot, among, which are on the position of ah and such words as it, sister, minister which are in the position of ee. The voice consonants are b, d, g, j, l, m, n, r, v, w, y, z, w being oo sound and y the ee sound. The breathed consonants are c, f, h, k, p, q, s, t.

The treatment of stammering intensified by Shell-shock is more difficult than that of Shell-shock stammering de novo.

Wound of face: Speech disorder. Recovery by reëducation in two months.

=Case 583.= (MACMAHON, August, 1917.)

An officer was wounded under his left eye, October 7, 1916. His speech was affected only five days later in a casualty clearing station. Observed by MacMahon, November 5, he was found to speak with great difficulty and became exhausted after a few words. He was tensing all the muscles in attempting to speak. Breathing advice was given and counsel how to relax in the abnormal efforts.

November 12, the officer, who was at Number One London General Hospital, began to speak with more freedom. “I am getting a bit better. I feel I must keep quiet, and it comes after a bit. I think far quicker than I speak.” He said that the breathing exercises had helped him most.

November 15, he still spoke in a rather staccato way; but the words did not check as they had. In a week further there had been so much improvement that he was discharged with a prognosis of complete recovery.

January, 1917, he had recovered.

Shell wound and burial: Camptocormia (psychoelectric treatment successful in one séance) and lameness (long reëducative treatment successful).

=Case 584.= (ROUSSY and LHERMITTE, 1917.)

At a Neuropsychiatric Center, September 2, 1916, arrived a chasseur, 29, showing lameness of a pseudocoxalgic type on the left side, combined with an anterior camptocormia. The whole situation had lasted a year. The chasseur had been wounded by shell explosion on the left side and was buried on July 29, 1915. He lost consciousness and had respiratory trouble and mutism. His arched walk and lameness began August 20, 1915.

He had a number of terms in hospital and six months at the dépôt. He was sent back to the front, June 20, 1916, being proposed for auxiliary work. There was some mental weakness. After one séance of electric treatment, the improper attitude of the trunk was corrected. The lameness, however, persisted and required long daily reëducation.