and then, in October, put into the reserve of an active regiment
and sent to the front. He reached the first line trenches in the
night, greatly affected by ruins he saw on the road. He slept poorly
and had nightmares. At daybreak he woke up to see a pile of corpses
near by, and felt an indescribable terror on account of the corpses
and the noise of bullets, machine guns, and shells. By superhuman
efforts--according to the man--he mastered his emotions and took his
turn at the observation post. Another sleepless night. Next day he got
such tremors that his sergeant sent him to the hospital where he was
at first thought to be suffering from a fever. But his temperature was
found normal, and he was sent back to the trenches.
He passed another night without sleep, and next day he could not hold
his gun for trembling. The Captain sent him back to be a kitchen man in
the rear, and here he remained six weeks--restless, trembling, eating
very little. He would have anxious spells. In the morning, as he was
carrying coffee to the men in his company, on seeing a pile of corpses,
he dropped his pot and ran back to the kitchen declaring that _whoever
wanted to carry coffee might_, but he would not go back. He spilled a
pot of soup on his left foot. The Captain had him evacuated, saying:
“Go! when you come back, I hope the war will be over!”
He was sent back to a hospital near Paris, where he was all right
for a few days, happy as a prince. The burn got well, and as the
time approached when he would probably have to go back to the
front, the terror returned. He had visions of corpses, and imagined
bullets whistling, machine guns popping, and shells bursting. He
wept, lost appetite, hid in corners, made three suicidal attempts
by poisoning,--though the sincerity of these attempts was doubtful
(zinc oxide ointment; rose laurel leaves; verdigris). Sent back to a
dépôt before getting leave, he had crises of tremor with anxiety, and
was then sent to Val-de-Grâce on the mental service, and finally to
Ville-Évrard. He unhesitatingly confessed his terror, becoming more
and more anxious and tremulous, and almost _losing his pulse_ while
describing his experiences. He said he would commit suicide rather
than return to the front. He stayed at the Hospital, working in the
garden rather calmly, but when it was a question of leaving, even on
convalescence, his terror and anxiety returned. Every time he was
examined there was an emotional explosion, with expressions of anguish,
generalized tremors and crises of clonic convulsions with respiratory
disturbance even of threatening suffocation, depression of pulse. It is
this latter which is the most important element in the proof that such
a case is not a case of simulation.
_Re_ war cases, Bennati remarks upon the great number that do not fall
into known categories. There is, he thinks, an anaphylactic group
in which the trauma acts as the secondary toxic agent; and there is
another group in which exhaustion works after the manner suggested by
Edinger: that is, by a physiological overwork of certain structures.
Martial misfit, dwelling on horrors of war at home; exposure; shell
fire: Mental exhaustion with depression, emotionality, tachycardia.
=Case 303.= (BENNATI, October, 1916.)
An Italian corporal, in civil life a writer (mother very nervous;
patient himself rickety, unmarried; relatives well off), was in front
line trenches for some fifty days. He was repeatedly excused from
service on account of fatigue, distress, poor appetite, insomnia,
depression and even confusion (aimless shots fired off in the night).
It turned out that he had been in just this state of mind when he left
home and family and that the very thought of war had seemed dreadful to
him. He did not at all enjoy leaves at night, as he stumbled and fell
about in the darkness and had shells burst near by. He lived immersed
in mud. He reacted unfavorably to antityphoid injection.
The very day he went on winter furlough he greatly improved, but then
suddenly relapsed into depression, emotionality, inattentiveness,
sluggishness of mind, and exhaustion. The tendon reflexes were lively,
the abdominal reflexes sluggish. There was tachycardia (120), the
Mannkopf-Thomayer tests were positive at 76 and 80, oculocardiac
reflexes 84 and vagotonic. Stellwag and v. Graefe symptoms.
Hereditary instability.
=Case 304.= (WOLFSOHN, 1918.)
An English soldier, 23, had been ten months on active service in
France, when he was buried by a shell December 19, 1915. He became
unconscious and later suffered from nervousness and stuttering,
depression, insomnia, frightful dreams, and tremor. Improvement was
such, under treatment, that he was again returned to the front. A shell
burst near him once more and again he grew dazed, trembled, had lapses
of memory and fell into a state of general nervousness. He improved
again in hospital.
On returning to the front in a few days he saw a bomb burst some
distance away. He began to stammer and to wander about aimlessly.
Insomnia, tremor of legs, arms and head, fatiguability, feeling of
lassitude, occipital and vertical headache, fear of aircraft and
crowds, frightful dreams, absences and aimless wanderings appeared.
There was one attack of deafmutism. Whenever the patient saw aircraft
he ran. He was easily startled by noises.
He was the son of an excitable, alcoholic father and of a nervous and
bad tempered mother. A sister had had nervous prostration. The man
himself had always been more or less moody and a nail-biter. According
to Wolfsohn, 74 per cent of the war neuroses have a family history
of neurotic or psychotic stigmata, including insanity, epilepsy,
alcoholism and nervousness; 72 per cent show previous neuropathy.
According to Wolfsohn, wounded soldiers do not show war neuroses
except in rare instances. In the wounded soldiers studied by him no
neuropathic or psychopathic stigmata occurred in the family history and
previous neuropathic tendencies in the patients themselves were found
in about 10%.
A soldier that is excessively fatigued or has been under undue mental
anxiety, expecting to be blown to pieces, may go into psychoneurosis
more easily than one without such emotional strain.
Genealogical tree of a shoemaker.
=Case 305.= (WOLFSOHN, 1918.)
An English private, shoemaker, 37, was partially buried in a shell
explosion and came to, stupid, shaky, weak and fearful of the dark.
Twice, in a dazed state, he attempted to murder companions and was
afterwards amnestic. He had always been of a violent temper and his
outbursts had been followed by petit mal. He had also always been
afraid of the dark. One of his children had fits; three were hysterical
and had temper fits. The man’s father was in an insane hospital. Sundry
other facts are shown in the genealogical tree presented herewith.
M violent temper Pedigree
| prison record
| Note the stigmata all on
+-m insane paternal side.
| +-f prostitute
| +-f imbecile (The chart reads from left
| +-f imbecile to right.)
+-f ment. def.
|
+--------------M violent outbursts
| f | (died as result of one)
| +-m imbecile |
+-m temper +--f-+-+-m
| | f m
F | insane
|
+-m crook
| +-m crook
| f insane criminal
+-----------------M violent temper
| f | sexual maniac
| +-m St Vitus |
| | dance +-m fits
M | +-f | mental degen.
| | +-f +-m emotional
+-f +-m crook, rebel | enuresis
| | prison record +-m violent
+--------------F | outbursts
| +-m violent
+-m | outbursts PATIENT
| +----------------M petit-mal
+-m sexual maniac | | violent temper
| +-f nervous |
F +-f nervous +-m fits of
+-f nervous | temper
+-f violent |
| outbursts +-f hysterical
M | restraint |
| | |
+-----F nervous +-f hysterical
| breakdown |
F follows | nervous
husb^{s} +-m clever musician
outbursts | & in studies
M |
| |
+-----F
|
F
Fall from horse in battle; fear of being crushed: Hysterical crises.
Case offered as showing TRAUMATIC HYSTERIA in a young physician WITHOUT
HEREDITARY OR ACQUIRED PSYCHOPATHIC TENDENCY.
=Case 306.= (DONATH, 1915.)
A physician of twenty went into the war as a volunteer Hussar. During
an attack, he fell from his horse without losing consciousness, though
he was at the time much afraid of being crushed. The attack ceased and
he returned to the lines on horseback.
Immediately there developed an emotional crisis, and thereafter he
broke into weeping on the slightest occasion. He was afraid he was
going to lose his reason; that some spiritual power was going to
suppress his ego and madden him. He wept as he was going under narcosis
to be operated upon for an intercurrent appendicitis. He became so
sensitive to noise that he wanted to choke the offender. One day he bit
himself on the arm in his excitement. Sensory tests could not be executed
on account of his fear of the brush. Reflexes were normal.
It took four hypnotic seances to get him in proper rapport with his
physician for psychotherapy.
This case is cited by Donath as one in which traumatic hysteria has been
proven to exist in a man without any sign of neuropathic or psychopathic
taint, either in his previous history or in his relatives.
A perfect soldier type. Mine explosion; burial; superficial wounds: War
neurosis.
=Case 307.= (MACCURDY, July, 1917.)
A lieutenant, 29, had been a regular soldier for eight years before
the war and was made a non-commissioned officer almost at once after
enlisting. He went out as a sergeant with the original expeditionary
force and got through the retreat from Mons and the first battle of
Ypres intact. He enjoyed the fighting hugely and even got indifferent
to the burial work. The death of chums saddened him, but he carried on
and soon forgot about the incidents. He might be regarded as a perfect
soldier.
In August, 1915, there was a slight touch of rheumatism. Two or three
months later the Germans exploded a mine immediately in front of the
trench where he was. He went pale for the first time in his life, but
kept his men “standing to.” Thereafter he began to think for the first
time about danger. Mining was hereabouts the chief form of attack, and
he frequently heard Germans digging beneath a dug-out. He slept well in
billets, but was too restless for sleep on active duty.
He got more and more on edge during the next weeks. Six weeks after
the mine explosion he was buried in a dug-out. Though he did not
lose consciousness, he was dazed and had to lie down for two hours.
Nervousness, chronic headache and insomnia, even in billets, followed.
His imagination played upon the blowing out of dug-outs and the bowling
over of men by shells. He had become company sergeant-major and the
responsibility made him grow worse and worse. At times he tended to
jump when the shells came, but was outwardly perfectly calm. He began
to take morphia, though with little result. He had suicidal thoughts.
After two months of these symptoms he was sent to England. He began
to sleep fairly well and three months later applied for light duty;
was greatly bored by the company accountant work given him; got a
commission and was sent back to the front nine months later, January,
1917. He got on with the active fighting very well, sleeping four or
five hours a night. In April he was sent to Arras. He had had a dream
that he was going to be bowled over, buried and wounded in the neck.
Sleep got poorer. In April he led his men in an advance and actually
was bowled over, buried and hit in the neck as well as in the knee and
the hand, though all the wounds were superficial. He was carried back,
dazed, to hospital, where he grew fairly comfortable in ten days and
even undertook a journey down to the base.
He arrived in collapse, remained in camp at the base three weeks,
getting steadily worse. Something, he could not tell what, was going to
happen and kill him. He could not concentrate, even to read. He thought
of suicide. He slept practically not at all, waking from a doze with a
start, feeling that something had hit him. He had dreams of being taken
prisoner and on waking would in fancy start a fight to escape from
imagined imprisonment back to the British lines. After two weeks in
various hospitals he spent ten days in a hospital for nervous cases and
grew better. Riding on trains he was terrorized in every tunnel lest he
should be crushed.
According to MacCurdy, an anxiety neurosis would have developed had
not his superiors sent the lieutenant back to hospital after the final
burial in April. As this perfect soldier said: “_There is no man on
earth who can stick this thing forever_.”
Shell-shock; thrown against a wall: Tremors--TREMOPHOBIA.
=Case 308.= (MEIGE, February, 1916.)
Meige has studied shell-shock tremors, especially those occurring
without external wound.
A corporal was with his squad on the Nouvron Plateau, January 13, 1915,
when he was thrown against the wall by a bursting shell, which killed
or wounded several comrades but did not wound the corporal. Whether
he lost consciousness is unknown, but he lay on the ground for some
time, until he could be moved through a communication trench. After
the explosion he began to tremble, and was still trembling on his trip
back. Constantly trembling, he lived on at the front for a fortnight,
but without eating; and, although he had been a good rifleman, he had
lost all his former skill with a gun.
There was a delay of a month before evacuation, but the trembling did
not cease, and he was passed through various units, to the neurological
center at Villers-Cotterets, where he remained for two months,--April
13 to June 15, 1915,--with a diagnosis of hysterical chorea. He was
examined by Guillain, who found, besides the generalized tremors,
lively knee-jerks and Achilles jerks, an excessive emotionality,
particularly marked when the guns were going or bombs bursting. Lumbar
puncture yielded a perfectly normal fluid.
June 19 the corporal went to the Salpêtrière under P. Marie. July 14 he
was evacuated to the civil hospital of Arcueil, where he remained till
September 24, when he was sent home to convalesce, from October 26 to
December 15.
He returned to the Salpêtrière December 15, 1915. Throughout these
various movements from hospital to hospital, his status was unchanged.
At the time of report about a year after shell-shock, he was still
constantly and uniformly trembling. All four limbs were affected,
perhaps the right arm and the left leg more markedly. There was no
tremor during sleep, but there was a tremor when the patient lay awake
in dorsal decubitus just as when he was sitting or standing. The tremor
was worse in the evening than in the morning, and the patient could
get to sleep only very late. There was slight tremor of the head; the
eyelids and the tongue showed a few tremors, which were not synchronous
with those of the limbs. Nystagmus was absent. To diminish the effect
of the trembling, the patient held his forearms flexed and kept his
elbows close to his body. If the trembling of the legs got intense, the
patient would rise and walk a few steps. Any movement, such as carrying
a spoon or a glass to the mouth, led to an exaggeration of the tremors;
and there was at this time a suggestion of the intention tremor of
multiple sclerosis. The tremor was increased when the eyes were closed.
Any sudden noise or sharp command, or recalling to mind of trench
service, would bring about extraordinary motor crises, in which there
was an intense and generalized tremor, so the patient would lose his
balance. Any attempt at eliciting reflexes would produce generalized
violent tremor. Sensations were normal; tendency to hyperidrosis; pulse
in repose, 60, rising to 120 if one struck the table sharply.
Meige remarks that a number of examples of tremors suggestive of
Parkinson’s disease were observed in the War of 1870. Might the
explosion have caused properly situated lesions in the encephalon of
such a nature as to produce a Parkinsonian tremor? The tremors were
stationary, and if due to some lesion, the lesion remains now exactly
what it was at the beginning. There was no digital tremor such as is
characteristic of Parkinson’s disease. Moreover, the intention tremor
of such a patient, rather than Parkinson’s disease, suggests multiple
sclerosis, of which latter disease, however, there is no other sign.
Nor does there seem any evidence that these tremors were of cerebellar,
paretic, goitrous, or of any definite toxic origin. On the whole, Meige
regards it as a neuropathic manifestation resembling what is found in
traumatic neurosis. He believes that there is not sufficient evidence
that it is the consequence of any structural change in the nervous
system.
Meige remarks that the analysis of any case of tremor must take the
mental state into account. This patient, perfectly conscious of his
tremors and their critical exacerbations, was much chagrined thereby.
He suffered mentally from his impotence, especially when bystanders
would intentionally bring about his paroxysms. He looked like one
shuddering from fear, and it is actually probable that he was afraid
of his own tremors and shuddering. He was, besides subject to tremor,
also a victim of tremophobia,--a kind of phobia described some years
since by Meige, somewhat resembling ereutophobia, or fear of blushing,
described by Pitres and Régis.
Four hours in a freezing bog: Hysterical glossolabial hemispasm twelve
hours after rescue. No sensory disorder of face or tongue; sensory
disorder of arm, but no motor disorder.
=Case 309.= (BINSWANGER, July, 1915.)
A man, 27, in good health, called on the second day of the
mobilization, got into the line two weeks from mobilization, first in
the West, and then, from mid-September, in the East. He was in the
artillery and stood shell fire in a big battle very well.
However, December 27, 1914, while engaged in transport service, on
the way back with his horse, he fell into a bog and gradually sank to
his neck. Attempts to get the man and his horse out failed. All that
saved him from drowning was the freezing of the bog surface. After
four hours he was freed by his comrades, apparently frozen stiff, but
with consciousness completely preserved. On the next day, at about
five o’clock,--twelve hours after his release from the frozen bog,--he
had a seizure. It began with headache on the left side and loss of
consciousness that lasted 24 hours. The right leg was paralyzed and
very painful. He passed through various hospitals and finally arrived
at the Jena Nerve Hospital, January 25, 1915.
He was a tall, powerful man, with a slow regular pulse, accelerated
heart sounds, lively dermatographia, increased muscular excitability,
general increase of knee and Achilles reflexes (left greater than
right), slight patellar and ankle clonus present on the left side,
Babinski reaction absent, plantar reflex more lively on the left than
on the right, but abdominal reflex more lively right than left. Head
painful to percussion in the left temporal region. Touch and pain sense
segmentally absent in both right extremities. Arm movements free;
tremors absent. Active movements almost impossible in the right leg;
on passive movement marked pain. Slight muscular tension about knee-,
hip-, and ankle-joints. The patient got about with a cane, trailing
the left leg. Romberg sign.
The right angle of the mouth was withdrawn slightly upward and outward,
and lagged a little in active movements. The protruded tongue deviated
completely into the right angle of the mouth and there remained, but
without tremor. The uvula deviated to the right, and the right palate
was held higher than the left. Lively palatal reflex. Speech intact.
The patient’s chief complaint was attacks of coughing, which increased
his headache to the point of intolerability. A harmless drug caused
the coughing and headache to disappear. The patient was a quiet,
willing man, who industriously went through his exercises, and on the
Kaiser’s birthday was already walking in the marketplace. His tongue
contractions gradually improved. His body-weight increased.
In the course of two months the glossolabial and palatal contractions
had largely disappeared. The walking movements of the right leg had
improved, although there was still a distinct paresis, and a stiffness
in the right knee and ankle joints. Climbing stairs was impossible
on account of difficulty at the hip. March 30, 1915, the sensory
improvement was marked. There was a feeling as though the last three
fingers of the hand were asleep; walking was improved; he could walk
one or two hours a day. The walk was still slightly spastic-paretic,
May 28, when he was discharged.
It is remarkable that the hysterical attack had such a long incubation
period in this case: twelve hours after his removal from the marsh.
There were doubtless physical factors of refrigeration, on the one
hand, and on the other, psychic factors of fear of sinking alive in
the marsh, at the bottom of the phenomenon. The most marked feature,
of course, was the glossolabial hemispasm. In the presence of this
hemispasm, it is remarkable that there should have been no anesthesia
or analgesia of the face, cheek, or tongue; and moreover the paresis of
the right mouth and tongue was far less marked than the contracture.
It is also striking that the right upper extremity, although it had
sensory disorder, failed to show motor disorder.
Slight bruise by horse: Apparently invincible complaints of pain. Cure
by single-handed capture of many Russians.
=Case 310.= (LOEWY, April, 1915.)
An infantryman was standing below an embankment when a horse fell upon
him, bruising him slightly on the left hip. This infantryman later
continually complained of pains in the opposite hip though there had
never been a contusion there, nor anything felt there. These complaints
could not be influenced by exhortation, by diversion, or by drugs. If
they were purposely ignored, the patient reacted complainingly and in a
way to suggest delusions of persecution.
Nevertheless, this querulous man soon proved an effective soldier in
a storming attack in which the whole battalion distinguished itself,
putting himself forward particularly. In fact, by himself he captured a
whole group of Russians!
Thereupon all the pains in the hip ceased, nor did they recur so long
as he was under observation. Morose and complaining before, he now
became cheerful.
Kick in abdomen by horse: General spasticity; tremors; eye symptoms
(_e.g._ monocular diplopia); convulsions. Improvement.
=Case 311.= (OPPENHEIM, July, 1915.)
A cuirassier was kicked by a horse on left side of abdomen, November
24, and lost consciousness. A month later, in hospital, hardness and
tenderness to pressure of abdominal wall, _spastic muscles_ everywhere,
pseudospastic tremor of legs, and complaints of double vision were
noted. He also had attacks of convulsions, in which he became
unconscious, twitchings appeared, but the tongue was not bitten. Urine
was often involuntarily passed in these attacks, but he was not always
continent outside attacks, as, for instance, in coughing.
On admission to nerve hospital: Right-sided monocular diplopia;
mild ptosis; ocular movements free. Rapid tremor on shaking hands.
Stood with straddling legs affected by vibrating tremor. Knee-jerks
considerably increased. In the dorsal position movements of the left
leg were accompanied by marked tremor. He even could not go to sleep
easily on account of twitching of the left leg.
His comrades observed that he had convulsions at night, and often
spoke in his sleep. Inoculation against typhoid fever was made early
in December. Later, permanent rise of temperature to 37.8. Several
attacks, lasting about ten minutes, came under observation of the
physician.
In January, progressive improvement in the motor sphere and also
psychically. The urinary disturbance likewise disappeared, but the
spasms persisted.
Windage from a shell; fear; fall, unconscious: Homonymous hemianopsia
(organic? functional?) with blinking and vasomotor excitability.
=Case 312.= (STEINER, October, 1915.)
A volunteer, 19 (never ill; no nervous disease in the family) after a
period of training went into the field October 3, 1914. November 5 a
shell struck near his trench, but failed to explode. Up to that time
everything had been quiet. The soldier had been looking out of the
loop-hole, surveying the landscape. He felt a great fear, felt a blow
in the neck, and fell down unconscious. How long he was unconscious is
unknown. Sometime later he walked back with his comrades.
About an hour later, this volunteer--who was a very intelligent young
man, possessing some knowledge of biology, including the nature of
visual fields--noticed a black spot in the field of vision, which
came and went, but after a few hours remained continually without
disappearing. Otherwise there was no complaint except a feeling of
dizziness when stooping.
Upon examination there could be found no disorder of the internal
organs. Neurologically there was blinking, vasomotor excitability,
slight reddening of the face, and dermatographia. An expert in
ophthalmology confirmed the existence of a homonymous defect in the
fields of vision. This defect could not be influenced by suggestion or
by any other treatment, nor did any other change whatever occur in the
condition.
Steiner inquires whether this hemianopsia is to be taken as organic
or functional. The air-pressure of the shell hissing past might have
produced a concussion, or the falling unconscious might have produced
a _commotio cerebri_ or a slight hemorrhage. The tic-like blinking and
vasomotor excitability, however, suggest functionality.
Shell-shock PSORIASIS. Post-traumatic eczema.
=Case 313.= (GAUCHER AND KLEIN, May, 1916.)
A soldier, 28, came to the Saint-Louis skin clinic, May 15, 1916, for
leg lesions three months old. These lesions were cicatricial, squamous,
irregular-contoured, and had developed following a wound. The lesions
were eczematous.
On the trunk, arms and elbow were lesions of psoriasis. These lesions
had appeared after shell-shock. The man had been bowled over June
16, 1915, by a _marmite_. The psoriatic lesions appeared shortly
afterwards. The patient had never seen anything of the sort before.
In this case the trauma provoked eczema; the emotion, psoriasis.
Gaucher and Klein say that they have been struck by the recrudescence
of psoriasis since the outbreak of the war, and remark, also, that
there has been a relative increase of new cases since July, 1914.
There are cases of psoriasis following nervous shock, emotion and
trauma. Sometimes the psoriatic lesion develops upon the scar of a
wound. In the above case, as in the case of a woman of 25, a refugee
from the Arras bombardment, the psoriasis began _de novo_ and slowly
developed immediately after the catastrophe of the Jena. Five, possibly
six, out of eight cases totaled, appear, unlike the case sketched
above, to have developed in cases either tuberculous or of tuberculous
stock.
_Re_ psoriasis, Vignolo-Nutati remarks that this is a relatively
frequent skin disease amongst Italian soldiers. He states that many
of these cases are due to nervous shock. Some are related to wounds
appearing near the scars. In all cases an emotional disturbance is the
chief cause. Vignolo-Nutati had 86 cases of psoriasis in six months, 52
of the men coming from the front. Eighteen of the men said that they
had not previously suffered from the disease.
A sergeant gets the CROIX DE GUERRE and SHELL-SHOCK together: Transient
deafness; later pseudohallucinatory electric bell ringing, reminiscent
of civilian work; stereotyped movements, reminiscent of war experience.
=Case 314.= (LAIGNEL-LAVASTINE AND COURBON, May, 1916.)
A sergeant, 24, had worked about Parisian hotels from the age of
thirteen and a half. He won the _croix de guerre_ and was evacuated for
his wounds April 24, 1915.
It seems that he carried the remains of his company, which had been
decimated the night before by a mine explosion, on to the enemy trench,
getting there first and facing three Germans, whom he beat down. At
this time, gas shells began to rain about. Making a number of violent
expiratory movements to get rid of the gas, he found himself unable to
progress on account of the fall of the shells, and sat motionless with
his hands before his face. He was cast to the earth by an explosion,
which at the same time blew off a revolver which the wounded lieutenant
had passed to him. He sat up, and, observing that the soldiers had
gotten the trench, went back to the lines, where he told his story.
He then found that he was deaf, and wounded in the left leg. The wounds
rapidly healed, but sundry other symptoms developed. He had a peculiar
sensation back of the forehead. He could not think, read or write and
was very weary. He got better in a few months, but disorders kept
returning.
His deafness had left him in about a fortnight, but when his hearing
came back spontaneously, there were peculiar sensations. He constantly
heard an electric bell, intense and continuous, like that of a French
cinema advertising its films. The sounds seemed to begin in the ear
and to run out as a sort of whistling. This sensation was preceded by
buzzing and associated with noises like those of a musical triangle
or a steam whistle. The noise kept up during waking hours, but was
often forgotten while he was at work. In sleep he heard nothing, except
sometimes battle noises. August 20, 1915, he was given the diagnosis:
labyrinthine shock--hearing returned.
About ten weeks after evacuation, when the headaches and thought
blocking began to disappear, a generalized tremor, especially of
the head, set in, which the patient called St. Vitus’ dance. Then a
peculiar gait began, which lasted several weeks and then transiently
reappeared. Every few steps his legs would bend, and he could only walk
forward in the attitude of a man who is concealing his height. After
resting a few minutes he began to walk regularly again and the cycle
began over again. He had to walk with two canes. If he felt some sudden
emotion, or sometimes without any obvious reason, he would stop short
and look straight ahead, with body bent, and arms before his face. This
would last but a moment, whereupon he would walk again normally.
When this anomalous walking disappeared, curious face movements and
gestures began. If a strange person arrived, the forehead and eyebrows
would contract, the eyelids would stand wide, which gave him an
expression of surprise lasting a few seconds. At the same time the
mouth would open and remain so for some moments. A forced expiration
would be executed, suggesting a fish out of water. He would then
imperatively strike the table with his fist, or the ground with his
foot.
Laignel-Lavastine and Courbon explain the anomalous movements as
stereotypies due to secondary automatism. They are not convulsive, are
not preceded by emotion or followed by a sense of relief, and are not
tics. They are gestures and postures without present significance,
but adapted to certain former circumstances. The electric bell effect
is a sort of pseudohallucination, differing from true hallucinations
in little except the absence of the externalizing feature. The
stereotypical movements are reproductions of things done in the battle,
and the pseudohallucinations relate to the former hotel work of the
soldier.
Cinema worker, two days after being waked up by a shell, develops a
nystagmiform tremor of eyes and tachycardia. Graves’ disease? Tic
(“occupational virtuosity”)?
=Case 315.= (TINEL, April, 1915.)
A soldier was waked up with a start Sept. 22, 1914, by a shell burst.
The man was not wounded or shocked, and merely felt a good deal moved.
The next day but one he felt a little movement of his eyes, which was
at first intermittent but in three or four days became continuous and
troublesome. These movements were those of nystagmus, almost transverse
and very rapid, and suggestive rather of a vibratory trembling than
of a true nystagmus of the eye or of labyrinthine disease. When the
patient fixed an object, the nystagmus would stop for a few seconds and
then immediately reappear. There had never been any vertigo, nausea,
vomiting, deafness, ocular disorder, or disorder of equilibration.
During the tests for nystagmus, the morbid nystagmus would stop and
be replaced by the normal nystagmus which was obviously slower and
more regular. The condition had persisted from September, 1914, to the
meeting of the Neurological Society, April 15, 1915. The patient said
he had become very emotional and got palpitations on the slightest
occasion, such as a fast walk, going upstairs, or hearing a loud noise.
There was also a slight vibratory trembling of the fingers and a
permanent tachycardia (120-140 beats). Tinel regards the case as one of
neurosis, due to a neuromuscular hyperexcitability comparable in some
ways with that found in Graves’ disease.
Meige, in discussion, called attention to the fact that not every
nystagmus is of organic origin and that there is a rare form of tic
of nystagmiform nature. The victim in this case was an employee in a
moving picture house, and very possibly his occupation had permitted
him to utilize what Meige speaks of as a “occupational virtuosity” of
the eye muscles.
Synesthesialgia: FOOT pain on rubbing dry HANDS, following bullet wound
of leg.
=Case 316.= (LORTAT-JACOB AND SÉZARY, November, 1915.)
A foot chasseur was wounded, September 15, 1914, low in the right
thigh, a bullet entering outside the biceps tendon and emerging on the
inner aspect of the leg, 4 cm. below the knee joint. He at once began
to feel pains in the right foot, which grew swollen and red. The leg
began to flex upon the thigh and, after straightening under anesthesia,
was placed in plaster. An arteriovenous aneurysm developed in the
popliteal space; operation, October 22nd, followed November 1, by
ligature. The pains in the foot grew better after this operation; but
as soon as the wound was cicatrized they came back again as before.
For seven months the foot pains remained sharp and continuous, such
that the man could not leave his bed. If a bright light struck his
eyes, the pains grew much more marked, especially in the morning on
awakening. The patient found that when his _hands_ were _dry_ he could
not use them because of the violent _pains_ which rubbing them would
cause in the _right foot_. Accordingly he kept putting his hands to his
mouth to moisten them. Finally he kept a wet rag by him which he could
pass from one hand to the other.
The pain was what made walking difficult. Foot movements were only a
bit less ample on the affected side than on the normal side. There was
a general muscular atrophy of the lower extremity (30.5: 34 about calf,
and 40: 49 about thigh). Right knee-jerk more lively than left. Right
Achilles jerk absent. Negligible disorders of electrical excitability
in the territory of the right sciatic nerve. The skin of the foot was
a little thin and pale; the temperature was low; and the nails had
transverse striations. The pains grew gradually a little less marked,
but if the room temperature was increased or lowered or if the foot
became cold, the pains became extreme. Pressure on the popliteal space
produced pain on the external border of the foot; likewise pressure
on the calf. Lasègue’s sign could not be tested for on account of the
contracture of the flexors of leg on thigh. Due to the direct action of
the bullet, there was an objective hyperesthesia of the dorsum and sole
of the foot. The toes were anesthetic. A cold foot bath increased the
pains, and a warm foot bath diminished them (contrary to experience in
analgesias).
This was a case of synesthesialgia in the right foot, brought about by
rubbing dry hands, exactly as if there were a direct contact with the
foot. Milder painful reactions were brought about by bright lights and
loud noises; but on the whole, these other effects were insignificant.
It must be remembered that the man was wounded and plainly had also
organic nervous disorder. He sometimes complained of radiations of
the pain up to the left hypochondrium, and sometimes he showed the
classical sensation of “esophageal globus” (lump in the throat). In
short, there was in him a special excitability of the nervous system
which may partly explain the synesthesialgia.
Shell-shock; burial: Clonic spasms; later, stupor with amnesia.
=Case 317.= (GAUPP, March, 1915.)
A reservist, 28 (laborer in civil life, of a nervous family; even
before mobilization had attacks of weakness at his work or in the
company of others) January 3 or 4, 1915, fainted in the trench while
shells were striking around him. On January 5 he was brought to
hospital in deep stupor. He went to the reserve hospital at N. by
hospital train, January 8, and arrived at the Tübingen clinic January
18.
A slip of paper stated that after burial in the trench he had been
brought from the field unconscious. Clonic spasms of the upper part
of the body are said to have occurred. At the reserve hospital in N.,
January 10, he was still unconscious, at times twitching his face and
the upper part of his body, and once at night excited and delirious.
At first in the clinic he was apathetic, speaking not a word, looking
vacantly into the air as if lost in a dream. He went to the section
passively, and lay passively in bed.
In the examining room, he stood speechless with unemotional face,
sometimes looking up to the ceiling, slowly scratching his head,
failing to answer questions, although fixing his eyes upon the
physician. He could not be communicated with in writing, playing
uncomprehendingly with the pencil or scratching his head with it. He
would start with fright at a sudden noise or an unexpected touch.
Sometimes he would heave a deep sigh, grasp his head in his hands, or
lay hold of his hair with a hopeless expression of face and shake his
head to and fro.
Next day, January 19, he made a few slow, low answers. He was found
to be entirely disoriented and with associations impeded, although he
could get out his name and residence with difficulty. Some of his color
identifications were correct, such as red and green; some impossible,
as yellow, brown, violet. A comrade who was called in and could speak
the Cologne dialect, was talked with at first with difficulty, later
more easily. Although the patient was visibly freer, he remained
without apparent emotion, retaining a rigid and dreamlike expression of
face. It was hard to find words, although objects were named correctly,
and there was no paraphasia or agnosia. Vision and hearing were normal;
walking, manual movements, eating were all undisturbed though slow. The
patient had to be led to the toilet. It seemed as if all intellectual
life was at rest, and that in the absence of impulses from without,
there would have been complete apathy. It was made out that the patient
thought he was still in the trenches.
Next day, the stupor had decreased and the patient spoke, getting his
bearings for a time. There was a complete amnesia as to the cause and
duration of his condition. During the next period, up to the beginning
of February, 1915, consciousness cleared and the apathy was replaced
with anxiety, weariness, and a dull headache.
During February, the patient gradually returned to his senses, and
remained in a state of general nervous exhaustion. Amnesia was complete
for at least two weeks of his life and recollections were fragmentary
for the first three days of his stay in the clinic. He worked willingly
in the garden with the other patients. On February 26, the patient was
cured and went back to the reserve battalion in a much strengthened
condition.
Battles (including liquid fire); eventually shell-shock: Hallucinatory
delirium, mutism, asthenia--after a few days puerilism (history of
convulsive crisis in adolescence) with regression of personality to
late childhood.
=Case 318.= (CHARON AND HALBERSTADT, November, 1916.)
Puerilism (Dupré) appeared in a soldier, 21 (uncle and cousin insane;
patient had difficulty in studies at fourteen and nervous spells for
two years, with loss of consciousness, fall and convulsions probably
at rare intervals; a student at eighteen) after he had taken part in
a number of battles with the Chasseurs Alpins. He was exposed once
to liquid fire July 21, 1916. He entered the military psychiatric
center at Amiens. Mental troubles had followed the bursting of a
shell near him. He said a few words, such as, “Alsace; fire; blood;
snow; it hurts.” These phrases, spoken in a low tone, with an anxious
appearance, eyes fixed, suggested hallucination. He seemed to be
listening. Aside from the isolated words above mentioned he showed
complete mutism. There was physical weakness, difficulty in walking
without support, exaggeration of patellar reflexes, pains in the head
and limbs. After several days, he said, “Milk; bread.” After this the
anxiety and the slow and difficult walking disappeared, whereupon the
puerilism appeared.
Now the soldier began to run instead of walking. He galloped and
gamboled like a child imitating a horse, or he would sit on a board
seeming to paddle. He would skip along the halls. The puerilistic
phases were rather brief and for the most part he lay in bed. There was
still a certain asthenia. He made little paper boats in bed, keeping
them in a small metal box along with bits of bread, looking glass and
the like. If a gesture was made to take them away, he would protest and
press the box to his breast, looking childish and anxious, and if the
box were taken he would weep hot tears. Sometimes he would stick out
his tongue at the attendants. His mother came to see him and afterwards
he would say, “Mamma told me to be good, to eat well, to get well and
to go home.” He would use childish grammar,--“Me eat much.” Asked why
he had hollowed out a small hole in the wall of the room, he answered,
“I did it for fun, but I will not do it any more. Mother doesn’t want
me to.” The patient was unwilling to answer a question correctly; would
sometimes answer incorrectly at first and correctly afterward.
It appears that the man had adopted the language, occupations and
attitude of a child, showing a regression of personality ten to twelve
years backwards. There was a neurotic basis in the convulsive crises
of adolescence. On the basis of this predisposition following shock
there appeared an attack of confusion, upon which, several days later,
supervened ecmnesic phenomena of hysterical nature assuming all the
features of puerilism.
Bomb-dropping from airplane; unconsciousness: Battle dreams. Leaves of
absence failed to relieve. Episodes of dizziness and fugue.
=Case 319.= (LATTES AND GORIA, March, 1917.)
M. Alessandro, Class ’79, baker (father a drunkard; brother an idiot,
in asylum), had typhus in youth, and as a boy had periods of intense
“pavor nocturnus,” but no convulsions. He enjoyed good health in the
army before the following event:
On July 13, 1915, a bomb, dropped by an airplane, fell near an Italian
soldier, killing many comrades, and throwing the man to the ground
unconscious. He awoke several hours later at a hospital in a stunned
condition. During the night, under the influence of terrifying dreams,
he would leave his bed to look for enemies who, it seemed to him, were
throwing stones and firing. He managed to grasp a rifle and fire at the
images he saw. He was given a 60 days’ leave of absence during which
he did not improve; and then again 90 days’ furlough, which he spent
at his home, where terrifying dreams, tremor of limbs and asthenia
continued.
He came under observation February 10, after his second leave.
Nutrition fair. Insomnia. Constant terrifying dreams. Coated tongue.
Tremor of hands, head, body, ceasing during voluntary movements.
Episodically he had spells of dizziness followed by absent-mindedness,
whereupon he wandered aimlessly about, of a sudden becoming aware of
being in a place, but not knowing how he came there.
Special senses intact. Several points of cutaneous hyperesthesia,
particularly mammary and pseudo-ovarian on the left, pressure whereon
provoked a lively emotional reaction with acceleration of pulse,
redness, lacrimation. Knee reflexes lively, cutaneous reflexes normal,
except the plantar which were very lively. Restless, hyperemotional, he
wept for insignificant reasons and wanted to leave hospital for fear of
dying there. He was discharged unimproved after a fortnight.
Nostalgic temperament; depression on entering service; rheumatism. A
box falls from an airplane near by: Fear and tears; later depression,
nostalgia, dreams, hyperthyroidism.
=Case 320.= (BENNATI, October, 1916.)
An Italian private in the infantry was recalled to military service. He
was a small farmer, and being disposed to homesickness, grew depressed
from the day he left for service. His sleep was disturbed, he was
greatly affected by the wet and damp of the trenches, and was in a
state of continual fear. Finally, pains, hypersensitiveness, and fever
developed.
As an enemy airplane passed over one day, a box fell at the man’s
feet and threw him into a profound fear with tears. He was conducted
to a tent to rest; his regiment was shortly sent to the rear, and he
remained on active service for a few days despite the fever and pains.
Finally the swelling of his leg compelled him to take to bed. (Fatigue
in antebellum life had always shown itself in aches of the legs.) He
had now been in active service about a month and his homesickness
overcame him. He was in a state of deep physical and mental depression.
It was not his own troubles so much as those of his family which
preoccupied him. His knees hurt him so that he had to weep; or if
Sardinia was mentioned, he cried, and said, “Oh, how I love Sardinia!”
He grew fatigued very easily. He had many dreams about Sardinia, his
father, and the war, especially dreaming about being wounded in the
legs (question of being stimulated by the joint aches). The reflexes
were normal, though slight tremors set up in the legs after testing.
The thyroid gland was somewhat swollen, and it appears that the patient
had noticed this five days before entering hospital. The patient was
rather vagotonic; pulse-rate stood at 56; oculocardiac-reflex, 56-84;
Mannkopf negative; Thomayer and Erben marked (56-88 and 88-60); von
Graefe marked; Stellwag present.
A shell pitches without bursting: Unconsciousness; stupor; MAMA MIA!;
oniric delirium; amnesia. Recovery in five weeks.
=Case 321.= (LATTES AND GORIA, March, 1917.)
An Italian soldier of the Class of ’95, a mechanic (mother cardiac; as
a boy, pains in joints and heart; since boyhood, no illness), had a
big Austrian shell pitch near him, July 23, 1915. The shell failed to
explode and injured no one. The patient, however, fell to the ground,
unconscious, and remained in the camp hospital for two days, quite
immobile. This event followed an advance by his company under very
fatiguing circumstances without sleep for a period of four days.
July 26, the patient was observed in profound stupor, non-reactive,
constantly and monotonously repeating the phrase, _Mama mia!_, with
fixed gaze and smiling as if at visions. He swallowed food. The pupils
reacted poorly to light, and the cornea and nasal mucosa seemed
anesthetic. The tendon and skin reflexes were lively. The muscles were
hypotonic; bradycardia, 56; no control over feces or urine.
July 27-28, restlessness at night, gasping movements, and poses of
terror.
July 29, he called for his mother, who had been dead for several years.
He was still stuporous and insensible.
From August 1 to 10, he improved slowly and became able to carry bread
to his mouth after it had been put in his hands. He still did not speak
and made signs when he wished to urinate or defecate. Pulse 50-60.
August 12, the patient began to react to intense light and to pain
stimuli, as well as to pressure. He ate voraciously.
August 15, visual stimuli were responded to, the pulse had risen to 80,
the skin reflexes were no less lively. There began to be terrifying
dreams at night, with motor reactions.
August 17, the patient looked about more alertly, promptly seeing bread
when placed in the center of the field of vision and saying words to
the man who might try to remove the bread. He did not yet react to
acoustic stimuli, nor was there any other change up to August 21.
August 22 a notable improvement set in. The hearing was now slightly
diminished, questions were answered after a brief refractory period.
After a few questions, however, a state of exhaustion would ensue,
which would disappear only after a short rest. There was amnesia for
the entire period following the day of his departure for the front,
May, 1915. At this time, instead of eating voraciously, he showed
anorexia. The skin and tendon reflexes, instead of being lively, were
now dull. There still were battle dreams of enemies trying to kill him.
August 25, there was an area of hypesthesia on the inner aspect of the
right thigh, but otherwise no disorder of sensation. The pulse stood at
80 and there were no other neurological phenomena.
August 31, the patch of hypesthesia of the thigh and the retrograde
amnesia disappeared. There was still a slight diminution of hearing.
The accident of the non-exploding bomb could now be recalled, but there
was a memory gap for all facts up to the latter part of August.
September 2, dreamless sleep; no signs of abnormality except a slight
diminution of hearing. Discharged, well.
Jostled carrying explosives; no explosion; unconsciousness: Deafmutism
and foggy vision. Gradual recovery from these symptoms. Then, on rising
from bed, camptocormia.
=Case 322.= (LATTES AND GORIA, March, 1917.)
An Italian of the Class of 1891 (convulsions and pains in the spine,
with rigidity, as a child; typhoid fever at 18; brother sickly,
neuropathic; mother subject to periodic convulsions; father alcoholic
and nervous), on the night of November 26, 1915, was carrying a number
of tubes of explosives. A comrade stumbled and fell over the soldier,
who fell to the ground unconscious. None of the glycerine tubes
exploded, and none of the soldiers round about were hurt.
The man regained consciousness at the camp hospital, but remained
deafmute and also impaired as to vision. It was as if a screen of fog
lay between him and objects seen.
During fifteen days of observation at the camp hospital, he had
terrible war nightmares. The mutism, the visual disorder, and the
deafness then gradually disappeared without special treatment.
However, when the patient rose from bed, it was found that his lumbar
vertebral column was stiff. He walked bent forward and was unable
to bend or straighten the back. There was a hyperesthesia along the
vertebrae, especially on pressure. X-ray examination showed no bone
lesion. The larynx and cornea were sensitive, and the plantar reflexes
were absent. The abdominal reflexes were present. The pupils reacted
to light and accommodation. There were two areas of analgesia in the
nipple regions. The expression of the patient’s face was relaxed and
drooping.
A heavy cannon slides and grazes a man: Unconsciousness; stupor;
amnesia (anterograde amnesia persistent). Complete recovery in less
than seven weeks.
=Case 323.= (LATTES AND GORIA, March, 1917.)
An Italian soldier of the Class of 1895, a peasant (family healthy;
non-alcoholic; good scholar) was, July 19, 1915, helping drag a heavy
cannon up hill. The big gun slid, hit several men, and grazed the
patient, making a slight abrasion on his leg. He immediately lost
consciousness, and arrived at the camp hospital in a stupor, which
lasted so long that catheterization was necessary.
A week later he was observed in hospital, immobile and non-reactive,
with a swollen abdomen and fecal impaction. The pupils were widely
dilated and reacted poorly to light. The corneal reflexes were absent,
and the nasal mucosa was anesthetic. Pulse 50. The patient failed
to eat. Next day there was no change in his condition. He was quiet
throughout the night.
On the morning of July 29, a number of answers were obtained to
questions put in a loud voice, though he was unaware of much more than
his name, being ignorant of the name of his country, his age, his
division, where he had come from, what had happened to him, or where he
was. He had now begun to eat spontaneously.
During the following days, up to August 4, the amnesia gradually
dissolved for the facts before the trauma. He remembered having been
greatly frightened at the time of the accident but could not remember
the accident itself, and the gap for subsequent events was still
complete. The pharyngeal reflex was still poor. August 5, he began
to remember the details concerning the accident. About the middle of
August there was no longer any diminution of hearing and ideation
became more free and rapid.
September 4, he was discharged, well.
Shell explosions SEEN: Emotion; insomnia. Artillery HEARD twelve days
later: “finished off.”
=Case 324.= (WILTSHIRE, June, 1916.)
A lance-corporal, 36, had had a nervous debility four or five years
before the war, caused by an overstudy of music. He had not stopped
work at that time, but suffered from depression, anorexia, and
insomnia, lasting for some weeks.
The lance-corporal got on well at the front for 11 weeks, until finally
eight shells pitched near him. Although he was unhurt, he began to
suffer from anorexia, insomnia, and depression. While in billets 12
days later, some English artillery became heavily engaged, whereupon
“The noise promptly finished me off.” The insomnia, depression, and
anorexia became more marked, and the patient could not sleep unless
heavily drugged.
Shell-shock: Emotion. More shells: Insomnia; war dreams. Head tremor
and tic, two weeks after initial shock.
=Case 325.= (WILTSHIRE, June, 1916.)
The psychic trauma is, according to Wiltshire, more important than
physical trauma in the following case of a sergeant of infantry, 28,
a man without neuropathic taint. This man had been nine months at the
front and through Mons, but had been quite well until three weeks
before coming to hospital.
“Twenty-three days ago, I was issuing rations when they got the range
of us--and killed the other chaps. I got blown away and knocked over.
I saw everything--fellows in pieces. Then a second shell came. I got
lifted and knocked about ten yards.” Then he began to shake but carried
on.
Two days later, “Shells dropped on the dug-out and killed the other
chaps. I have not slept properly since this. If I go to sleep, I wake
up seeing people killed, shells dropping, and all kinds of horrid
dreams about war.” One or two of the men killed had been pals.
A fortnight after the first incident, while in a base hospital,
head-shaking began. The patient would jump at the least sound. There
were spasmodic tic movements with the extension of the head, protrusion
of lower jaw, and contraction of occipitofrontalis muscle. Sometimes
the left shoulder girdle was affected in the same way. There was a
slight fine tremor of hands and eyelids and difficulty in keeping the
eyes fixed on an object.
Hyperthyroidism, hemiplegia, irritative symptoms after exhaustion (by
heat?).
=Case 326.= (OPPENHEIM, February, 1915.)
A man (not previously nervous, no faulty heredity, heatstroke August
21) suddenly fell down in a great heat, after a fatiguing march,
and remained unconscious for several hours, waking with vertigo,
headache, paralysis of left side, vomiting, and twitching of the
face. On September 23, admitted to reserve hospital. Knee phenomenon
increased. Urinary retention; catheter used. Speech disturbance,
facial twitching. Vomiting had stopped September 10. Catheterization
could be avoided through warm sitz-baths. October 30, on sitting up,
occipital pain and vertigo. November 15, urinary symptoms improved.
Also improvement otherwise. December 1, gait vacillating and uncertain.
Headache. Admission to nerve hospital, December 3. Here complained of
twitchings in the frontals and corrugators. Wide palpebral gaps. Rare,
or absent, movements of lids. The extended hands showed active, rapid
tremor. Tendon phenomena increased in the arms and especially in the
legs. Abdominal reflexes increased. Active tremor in the legs. Gluteal
tremor. Very pronounced Graves’ symptoms. Syndactylism very pronounced
in the feet, between second and third toes. Later on, improvement under
half-baths, etc. Worse after ten days’ leave of absence, especially
marked increase of tremor (rest tremor), augmented on movement.
_Re_ heat stroke, Wollenberg has called attention to the effect of the
heat of the summer months upon German soldiers. Cases of heat stroke
have not been rare in the German army. About half the cases have
convulsions or epileptoid seizures, as well as tremors and nystagmus.
About a quarter of the cases have shown confusion and delusions, with
anxiety and mania. A degree of mental impairment has followed a number
of these heat strokes, together with sundry signs of organic disorder,
such as reflex changes, pupillary changes, and difficulty in speech.
Forced marches; skirmishes; rheumatism: Generalized TREMORS. On the
road to recovery in six months.
=Case 327.= (BINSWANGER, July, 1915.)
A German letter carrier, 27, entered the war at the outset, made forced
marches in great heat, was in a number of skirmishes and in the capture
of Namur, and fell ill early in September, with swollen and painful
right foot and rheumatic pains in knees and shoulders. He was put on
garrison duty; but the rheumatic pains in the joints increased toward
the end of September, and he was treated in hospital for rheumatism.
He became able to walk only in the second half of December, marked
tremors affecting the whole body. His bodily condition had been good.
He slept well, and while at rest in bed he felt entirely well; but upon
every attempt to get up and put his feet down, these violent trembling
motions would always reappear. Treatment by hydro- and electrotherapy
remained entirely unsuccessful. February 8 he was transferred to a
nerve hospital.
He had been in the postal service from 1903. He was of normal bodily
and mental development and had had no previous illnesses. His military
service had been executed from 1909 to 1911. He had always been a
passionate smoker but had not abused alcohol. His mother is said to
have been for some time paralyzed, following a fright.
Physically, the patient was a slender but strongly-built and fairly
well-nourished soldier. The first sound at the apex of the heart was
rough and impure, and the heart was somewhat enlarged to the left.
The pulse was irregular, 106. The arteries were somewhat stiff.
Neurologically, there was a marked dermatographia of comparatively long
duration. The periosteal reflexes were increased; the deep reflexes
could not be properly examined. The whole leg trembled and heaved
unsuccessfully on attempts to raise it voluntarily. After even a
slight stroke on the patellar tendon, the trembling became excessive
and irregular, and the leg passed into a heaving spasm which would
outlast the percussion for some time. The patellar clonus could be
obtained with the knee extended. The shaking movements were somewhat
more marked on the right than on the left side. Similar phenomena
occurred when the Achilles reflexes were being examined. The triceps
reflexes on both sides were increased but there was no tremor or spasm
of the arms. The plantar reflexes were very lively, and following these
reflexes appeared tremors of the legs. When the spinous processes
of the vertebral column were percussed, a general shaking spasm
appeared. Tactile sense was everywhere normal, but the pain sense
was increased. Upon slight pin-pricks in the skin of the legs, there
would occur a marked shaking spasm of the leg, passing directly to the
other leg. These phenomena were more marked on the right side than
on the left. When sitting upon a chair with back supported, a slight
tremor would appear when the hands were raised and stretched out, more
markedly on the right side than on the left. Movements of the arms
were normal. However, the hand-grasps were: right, 105; left, 80. In
dorsal decubitus the movements of the leg were performed comparatively
well at first, but after a few repetitions, the shaking spasm would
occur on both sides, and the movements would become very awkward. The
heel-to-knee test would then fail. If the patient were put on his feet,
he would immediately fall into spasms, first in the right leg, then in
the left. The trunk would now be involved, and soon the arms, whereupon
the whole body, with the exception of the head, would be seen trembling
and shaking, and the patient would fall forward, trying to get support
by leaning against a wall, seizing a chair, or sinking down slowly.
The spasms disappeared at once in dorsal decubitus and in sitting with
supported back. Outward irritation by the acoustic, optic or tactile
avenues would bring out spasms in the legs, always more markedly on the
right side than on the left. Psychic irritations would cause spasms.
The muscles of the limbs were held in great tension, the flexors and
extensors being alternately affected. When the patient was moving
along a wall with a difficult, swaying gait, his efforts reminded the
examiner of the attempts of a heavily intoxicated man to walk. Upon
attempts to create passive movements of the lower limbs, severe shaking
and trembling movements set in, followed by a general spastic tension
of the leg musculature such that it could not be further flexed or
extended.
The patient was put in the psychiatric section, as too seriously ill
for the nerve hospital. He improved after a few days, being then able
to walk without much support although still with some shaking and
tremor. If his attention was diverted, passive movement of the leg
could be carried out without developing spasm. He was treated in a
room by himself with removal of all outward irritation. His legs were
treated for an hour, three times daily, by means of moist packs. On
account of complaints of insomnia he was given small doses of hypnotics.
The main thing here, according to Binswanger, is the psychotherapy. The
patient was told almost daily in the course of conversation, first,
that the illness was being cured; secondly, that upon recovery he would
be employed in the future only on the postal service. He was told that
he would have to avoid marked physical exertion, of course, but that he
still would be fit for office work and could serve the fatherland in
this way. Still he could not be transferred back to the hospital, he
was told, unless he became entirely well, so that he could move with
perfect freedom.
February 23 the patient was performing daily exercises in walking and
standing; the spasm became very slight on standing, and often would
entirely cease, but it remained still plainly present in the legs; the
trunk and arms were free. External irritations were now less prone to
excite spasm. Sleep became quiet and dreamless. He was transferred to
the nerve hospital, able to move about freely in house and garden and
only tremulous after long walks and considerable bodily and mental
fatigue. He was given a week’s furlough home. He wished very much to
get into the postal service; at the time of the report he had not
attained this goal. He had renewed attacks of trembling upon exertion,
and was transferred at the end of June to a convalescent home.
Shell-shock; emotion: Hyperkinesis, fear, dreams.
=Case 328.= (MOTT, January, 1916.)
A private, 21, was with 30 men carrying sandbags in the daylight, under
shell fire. He was thrown into a deep hole by an explosion, climbed
out, and saw all his mates dead.
He was admitted to the Fourth London General Hospital, June 20, 1915,
having been at Boulogne for a fortnight. He was lying in bed on his
back, making continuous jerky lateral movements of head, and movements
of arms, especially of the left arm. He was groaning slightly, now and
then raising his eyelids with a staring expression of bewilderment
and terror. He was able to mutter answers to questions. He would
occasionally raise his right hand to his forehead. If he was observed,
these movements became exaggerated. They ceased in sleep. He muttered
even when unobserved. He continually said, “You won’t let me back.”
Asked as to dreams, he replied, “Guns.” Voluntary movements were made,
which prevented obtaining reflexes. When his pupils were to be examined
by a man in uniform, he showed a marked facies of terror; his pupils
were dilated; the eyes opened wide, the brows were furrowed, and there
was an anxious scowl. The flash of an electric light produced the same
effect.
June 24 the patient was much better. He said the explosion which had
killed his friends after he had been only a few weeks at the front,
was the first serious event in his service. He kept seeing it again,
with bright lights and bursting shells. Sometimes he would hear the men
shouting. In dreams he both saw and heard shells and men. There was
pain in the back and right side of the head.
June 26 he was improved but still had pain in the back of the head,
especially when trying to remember, and a slight tremor of the hands.
He had been given hot baths at Boulogne on account of being very cold
and shivering. He had always felt sick at the sight of blood. He was
boarded for Home Service six months after admission.
Shell fire and barbed-wire work: Tremors, anesthesias, temperature and
pain hallucinations.
=Case 329.= (MYERS, March, 1916.)
A corporal, 39, had been working under shell fire at barbed-wire
entanglements. The man was big and robust, but much depressed,
complaining of noises in the head, pricking pains, unsteady legs,
fatigue, irritability, loss of confidence. He showed tremors of arms
and legs on movement, and stood unsteadily with eyes closed. He said:
“My legs have been very unsteady, especially when some one is looking
at me. They must have thought me drunk at times.”
The head and tongue were tremulous, the knee-jerks exaggerated, the
soles insensitive to touch and pain; but sensibility to deep pressure
was retained. There was a gradual return of right answers on further
trials, aided by comparison with effects of stimuli applied to the
dorsum of the foot. Though he gave correct replies on heat and cold
tests over the arms, he gave wrong answers over the dorsum of the feet,
less often over legs, sometimes over thighs.
Later during examination, the feet became tremulous. He felt a “silly
childish fear,” and his hands began to feel cold and clammy; whereupon
he began to reply _hot_ or _cold_ when the tubes were not applied
at all (temperature hallucinations). There were apparently pain
hallucinations in the soles and errors in response to the compasses.
_Re_ the temperature hallucinations noted by Myers, these are to be
distinguished from true vasomotor disorders. Babinski believes that he
has definitely established that, though hysteria may cause a slight
thermo-asymmetry, yet never a definite vasomotor or thermic disorder.
_Re_ hysterical pains, the most frequent are probably those of
hysterical pseudo sciatica, in which true signs of sciatica are absent,
namely, (1) loss of Achilles jerk, (2) scoliosis, (3) Lasègue’s sign
(pain on thigh flexion with leg extension), (4) Neri’s sign (with trunk
bent forward, affected knee flexed), and (5) Bonnet’s sign (pain on
thigh adduction).
Shell-shock: Emotional crises; twice recurrent mutism; amnesia. A
comrade in the same explosion gets off with transient phenomena.
=Case 330.= (MAIRET, PIÉRON AND BOUZANSKY, June, 1915.)
December 15, sitting back of a wall were three minor officers and
an _homme de liaison_, when a 105 shell punctured the wall and
burst, killing one and wounding another severely. One of these, _a
sous-lieutenant_, lost consciousness for a quarter of an hour and had
some severe headaches for a few days, but nothing more. The other, the
_homme de liaison_, was found standing, bewildered, looking at the
dead. When his name was called, he jumped and started off, weeping and
crying out.
When caught, he was still somewhat clear, recognized his superior
officer, answered yes and no, but kept asking, “Where is the other?”
Next day he kept weeping and said not a word.
He was evacuated through a series of hospitals and was sent to
convalesce with his sister at Montpellier, having now got back his
speech. He had a seizure of fear in the street and was picked up by
the police and was carried to a general hospital January 21. Here he
could not speak, could hardly write, being unable to find his words.
He walked slowly, bent over, eyes abnormally wide open, with a look
of terror. The lighting of a match made him start off weeping. The
symptom picture included tinnitus, vertigo, deafness, some reduction
of the visual field (especially on the left side), hypesthesia and
hypalgesia on the left side, hyperalgesia on the right, painful points
(epigastric, inguinal, supra and infra mammary left), reflex, muscular
and tendon, hyperexcitability on right side, jactitation, impairment
of recollective memory, complete memory gap for the accident and
everything thereafter, retentive memory reduced, imagination impaired,
nightmares (awaking with a start).
A few days later he was able to pronounce his name with difficulty
and to say yes and no. February 4 there was an appendicular crisis,
whereupon mutism became absolute again and lasted into May, despite
suggestive therapy.
May 10, improvement in memory for things before the accident grew
better, nightmares had become less frequent, the jactitation had
continued.
There was no neuropathic predisposition in this case except infantile
convulsions in two sisters, followed by nervous crises in one.
_Re_ appendicular crisis, which was the occasion of a relapse in
mutism, see remarks under relapses under Case 292.
_Re_ mutism, Babinski counts mutism, hysteria major, and rhythmic
chorea as so characteristically hysterical that no nervous disturbance
of an organic nature can resemble them. The description of hysterical
mutism is due to Charcot. According to Babinski, mutism is just as
curable as hysterical deafness, and perhaps more curable. Yet mutism
persists unchanged for many months unless it is treated properly
by some form of suggestion. “It may be almost said that a subject
suffering from speech defect, who nevertheless succeeds in making
other people understand by all sorts of varied and expressive gestures
the circumstances of his condition, is a hysterical mute and not an
aphasic.” According to Babinski, no true case of hysterical aphasia has
been published since the beginning of the war; all the cases have been
cases of mutism.
Shell explosion; fainting: Hysterical crises of emotion; fright at a
frog in the garden. Hereditary and acquired neuropathic taint.
=Case 331.= (CLAUDE, DIDE AND LEJONNE, April, 1916.)
A lieutenant, 28 (mother nervous; father had nervous spells at fifteen;
patient himself nervous as a child), was under a great moral strain at
the outbreak of war, and was utterly exhausted in a hard battle that
lasted more than twenty-four hours.
A shell burst near him September 25 at the Somme, whereupon he
fainted. He was evacuated to Amiens for three weeks; kept his bed;
somnambulistic; subject to nervous crises.
He passed to the hospital of Ferté-Bernard for a month, the crises
becoming more frequent. He was sent to a convalescent dépôt for three
days, thence for three months to La Plisse; got better; lived at home,
but went to a show where they played the _Marseillaise_, was profoundly
moved thereby, and had more crises; accordingly went back under medical
care and finally to his dépôt, where, upon seeing his old comrades, he
had more crises, and was finally evacuated to the neurological center
of the Eighth Region.
He there seemed mistrustful when asked to tell his story. There was
a noise of cannon, whereupon he got up, ran in all directions in the
garden, bumping into trees in the greatest terror, yelling, “There they
are!”; gesticulating, soliloquizing: “Bomb! Shell! Bayonet!” His pulse
was rapid. After he was calmed down, he began to talk again in a very
clear, distinct, somewhat tremulous voice. A metallic sound made him
shudder and cry out, “The drums!” and another scene of rushing about
followed.
In the consulting office he wept. Battle dreams and nightmares,
soliloquies and terror, seminal losses, occurred during the next few
days.
August 4, while alone in the garden, he heard a noise, went toward it
and spied a frog, whereupon he had another crisis of fear and emotion.
He got another lieutenant, and both returned, sticks in hand. Pointing
to a hole in the earth, Lieutenant A. said, “Trenches! There they
are!” “What? Who?” said Lieutenant B. “The Boches!” said Lieutenant A.
Whereupon Lieutenant B also saw them and cried out bravely, “Go away!”
However, the second lieutenant immediately saw that he had been the
subject of suggestive hallucination.
Fifteen days of calm followed, during which the lieutenant became more
sociable and grew better having no more crises.
Four other cases of “hysteroemotive nature” are reported by Claude, all
of them showing a special constitutional basis before the war. In the
differential diagnosis, alcoholism, cyclothymia, obsessive psychosis
and occasionally systematized delusional psychosis may be considered.
There were occasional stereotypical features in the cases, but of a
very fugitive nature. Dementia praecox is hardly to be considered.
_Re_ “hysteroemotive” cases, Babinski holds that the claim of emotion
as a single factor capable of causing hysteria by itself, is a false
claim. To be sure, the patients themselves may give accounts which lead
to the idea of an emotional hysteria. Dide, one of the authors of the
above case, states that functional disorders occur only in subjects
whose emotional tone has been relaxed. The heaviest bombardments are
not in line to produce these disorders when the morale of the troops
is good. The bloodiest affairs may leave no single case of nervous
disorder when the morale is good. Dide found in a whole year’s work
but a single functional case,--an oniric delirium, following a trench
mortar explosion. Roselle and Oberthür also state on the basis of
intensive experience, that large projectiles do not cause any intensive
emotional reactions. Clunet’s observations upon the shipwrecked _La
Provence II_, quoted by Babinski, run in the same direction. It will
be noted that the five cases called “hysteroemotive” showed a special
constitutional basis antebellum.
War strain; slight wound; burials; shell-shock: Neurosis with anxiety;
war dreams; apparent recovery. Relapse with depression.
=Case 332.= (MACCURDY, July, 1917.)
A man, 27 (normal mischievous boy, successful in work, unmarried, shy
with women), enlisted October, 1914; adapted himself well to training;
at first enjoyed his work, though later bored with routine; and in
February, 1915, went to the firing line in France. The first shell-fire
experience made him break into a cold sweat with fear and slowed him
down for a time. However, he enjoyed the active operations until, after
eight months in the trenches, he was invalided home with nephritis.
After four months’ convalescence he was recommended for a commission,
obtained after two months’ training. After two further months in the
regimental dépôt, he went back to France as lieutenant in June, 1916,
plunging into four months of heavy fighting on the Somme, in which he
was wounded slightly once and was one day buried three times by earth
from shell explosion. The last time he was buried he was unconscious
for ten minutes and was relieved for three days. He got frequently
knocked out for short periods by shell concussion.
At the end of October, 1916, he was sent to the Ypres section, where
he worked with a pioneer battalion that buried many dead. After a
month of this pioneer work he became mildly depressed; fatigue set in,
and now for the first time he began to jump nervously when the shells
came over. To counteract this nervousness he began to drink and in a
fortnight developed insomnia. The Somme front scenes kept constantly
in mind as he tried to sleep. He felt as if he had to go up to the
trenches next day and that he did not want to go. There were hypnagogic
hallucinations of trenches and shells, recognized as imaginary and
productive of no fear. Week by week he became more nervous, became
unable to locate shell falls, and felt as if they were all coming at
him. Early in 1917 he had taken heavily to drink and grew greatly
fatigued in the struggle to prevent betraying his fear to his men. The
horror at bloodshed, to which he had long since become accustomed,
reappeared. He actually wished that he might be killed.
He carried on until March, when one day on a raid seven men were killed
around him and he was immediately thereafter buried. He reported sick
and was found to be somewhat febrile. He carried on for two more days;
had to report sick again; was sent to hospital and for two or three
weeks had bad headaches back of the eyes and a sleep interrupted by
sudden wakings with a start. Nightmares now began for the first time.
They dealt with the Somme front, merciless shelling coming nearer and
nearer. Finally, he would wake with a shriek when a shell landed on
top of him. In the day time any noise would be interpreted as a shell.
Hypnagogic hallucinations of Germans entering the room appeared. After
a little over a week in French hospitals he was transferred to London;
grew better; was sent to a hospital in the country where outdoor
exercise and recreation helped him.
Two weeks later the death of one of his best friends depressed him
a good deal. He failed in an attempt to sing at a concert, and then
grew much worse, with the old dreams every night and hypochondriacal
complaints of sweats and loss of weight. He was convinced that he was
physically and nervously a permanent wreck.
According to MacCurdy, this case is a typical case of war neurosis of
the anxiety type, except that a relapse with depression is somewhat
atypical.
_Re_ anxiety, Lépine counts trauma as one of the most important
factors. The reduction of morale in physically injured cases may at
times require their rapid withdrawal to a safety zone. The delirium of
the physically injured sometimes takes on a melancholic tinge. Fatigue,
loss of sleep, and cold are other factors of a physical nature. Among
the moral factors, Lépine thinks responsibility (for certain _âmes
scrupuleuses_) is hardly less important than the factor of felt danger.
The contacts of highly cultivated men with the rougher soldier element,
may also count, as well as the separation from home and friends, and
the factor of despair concerning the ending of the war.
_Re_ sexual influences, the factor of sexual continence, though it
may have some importance in producing morbid anxiety, seems to have
less importance under war conditions, when self-preservation is more
in the eye than the sexual life. On the whole, the pre-existent
emotional constitution (Dupré) is of greater importance. A previous
wound may cause a man to acquire such a constitution. Amongst physical
states, hypotensives are candidates for depression; tuberculosis is
particularly important.
_Re_ MacCurdy’s case, the factor of alcoholism was mentioned. The
importance of alcoholism, Lépine has particularly stressed. He
particularly emphasizes the number of men who have taken to drink to
get over their emotions and to forget. Visual hallucinations, angry
excitability, sudden persecutory ideas, nocturnal occurrence of the
symptoms, flushing of the face, suggest alcoholism. Some of the cases
of encephalitis which are supposed to be due to some unknown bacterium,
may really be alcoholic in origin. A third of Lépine’s cases were
alcoholic; perhaps two-thirds really alcoholic if one took into account
the factor of sensitization.
Bombardment from airplanes: Fear; suicidal thoughts; oniric delirium
(“moving picture in the head.”)
=Case 333.= (HOVEN, May, 1917.)
A soldier (born at seven months, somewhat feebleminded, given to
depression, early victim of convulsions, talking only at five years,
with a history of once leaving his father’s house with suicidal ideas
after being scolded, already invalided in peace times) on enlistment
remained with the regiment but a few days and was then sent to a
workers’ company of blacksmiths.
Toward the end of February, 1916, his cantonment was bombarded by an
airplane escadrille. The patient was much frightened, ran away and hid
in a ditch, felt sick, stopped eating, wanted to kill himself and had
to be evacuated to Calais and then to Chateaugiron.
He was there found to be well oriented, but depressed and bewildered.
There was an emotional tachycardia. At night he would fall into a
delirium like the oniric delirium of Régis, always dreaming of the same
bombardment scene, saying it was like a _moving picture in his head_.
The delirium affected him so that he actually tried to make away with
himself.
The dream delirium did not last long but recurred several times on very
slight emotional occasions. It was possible to excite his hallucinatory
dreams experimentally by showing him battle pictures.
Some cases of such delirium develop, according to Hoven, after moving
picture shows of battle scenes.
_Re_ oniric delirium, Chavigny states that mental confusion and oniric
delirium are the two forms of mental disorder that come most frequently
after explosions. He believes that at least 95 per cent of these cases
are rapidly curable; and, in fact, found amongst 60 cases observed in
his army service that only two were so severe as to require being sent
to the interior: all the others were cured in six days at the outside.
These cases, according to Chavigny, ought to be treated in special
wards at the front (bed, quiet, purgation, baths). Chavigny prearranges
slight emotional shock for these cases by talking with them about their
families. Their apparent apathy vanishes in a trice.
Régis, who has named the state “oniric delirium,” states that the
condition never lasts more than a fortnight, is caused by emotional
shock, and occurs in all cases with mental disorder following battle;
but similar hallucinatory conditions have begun to appear also amongst
alcoholics, in garrison or at home. There is emotional constitution in
most of these cases. There is not so much evidence of heredity. Out
of 50 of Régis’ cases, 22 had been wounded, and 28 not. Régis states
that the psychoses are rather more apt to affect men in the reserve,
and are severest in officers. These cases should not be committed to
institutions, but ought to be treated in special military psychiatric
wards containing separate rooms. Very fine-spun diagnosis may be
necessary now and again on account of the occurrence of infectious
deliria and phenomena of the banal psychoses that may closely resemble
oniric deliria.
Shell-shock; emotion (best friend mangled): Stupor with amnesia.
=Case 334.= (GAUPP, March, 1915.)
A soldier, 23 (in civil life a turner, of Polish descent, and of a
somewhat nervous and easily excitable disposition), early in August
went from Strassburg into the Vosges and Lorraine. August 26 a number
of shells exploded near him. The troop was excited and took refuge in
a cellar. His best friend was torn to pieces by a shell. When the body
was removed, the man felt sick and lost consciousness. He arrived at
the clinic in Tübingen in a stuporous condition, by hospital train,
August 31, 1914. He walked weakly to his bed, supported by two men, and
lay in the bed, apathetic and reacting to questions only with a stare.
Things put in his mouth were swallowed. He remained motionless.
Next evening he answered a low _Yes_ to a nurse’s question about
eating. A little afterwards, he said he supposed he was a prisoner in
the enemy’s country. A while later he got properly oriented but still
did not know how he had come. September 2, however, he was much clearer
and said he had awakened out of a long dream. There was a complete
amnesia, however, from the moment when he went to help remove the torn
body of his friend up to September 1. Memories became clearer for the
period before the shell explosion. The patient became very lively,
talking vividly of war experiences, imitating the hiss of shells with
an expression of intense anxiety, getting accustomed to the battle
scenes, saying that he was now seeing everything again as if real. He
remained anxious for some days, complaining of weight on his chest and
of feelings of inner restlessness and tension.
Amnesia for the period August 26 to September 1 remained; all that he
could say was that he had been thrown sidewise for some distance by the
air pressure of the shell.
From September 6 onwards, he grew calmer but he was still very labile,
given to lively imaginings and emotion. By mid September he could be
discharged for garrison duty.
Emotional shock; shooting a comrade: Horror, sweat, stammer, recurrent
nightmare. Improvement on “tracing back.” Brief recrudescence on death
of child.
=Case 335.= (ROWS, April, 1916.)
A man after a charge was placed on outpost duty. It was dark, and he
was in a state of considerable tension. He heard a noise which he
thought came from somewhere in front of him. Suddenly the space around
him was illuminated by a flare of light, and he saw a man crawling
over the bank. Without challenging, he fired and killed the man.
Next morning, he found to his horror that he had killed a wounded
Englishman, who had advanced beyond his comrades and was crawling back.
A physical expression of horror, together with an intense sweating and
a very marked stammer, persisted for months. At the same time, he was
tormented with a fearful nightmare, and in his sleep he was heard to
say, “It was an accidental shot, sir; yes, Major, it was not my fault.”
In the day time, also, his attention was concentrated on the memory of
the incident, so that “I cannot forget it no matter how I skylark.”
Carrying his story back to this trying time led to his recounting
his terrible secret, and a marked improvement followed. The physical
signs of the intense emotion gradually disappeared. The vividness of
the dreams diminished, and his attention was less concentrated on
the one subject. It is interesting to note that the production of a
marked emotional state by the death of one of his children led to a
recrudescence of his former symptoms: an expression of “horror and the
stammer.” But they disappeared again in a short time.
Emotional shock: Phobias.
=Case 336.= (BENNATI, October, 1916.)
An Italian corporal in the infantry, a robust man of a well-to-do
family, took a good deal of pleasure in the war life. One day a
comrade was injured by a missile of some sort, and died almost
immediately. This comrade, after being hurt, had thrown himself
against the corporal, who was asleep at the time. He woke up sharply
and immediately felt sick. His status was one of great terror,
lacrimation, lack of spontaneity, and insomnia. He would wake up from
sleep and start from a terrible dream. He had a number of phobias and
was especially interested in other persons who had the same sort of
mental state as himself. He was in a state noted by Bennati as one
of “emotional anaphylaxis” to various events around him. There was a
horizontal nystagmus, the Mannkopf sign was positive (87-72), Thomayer
90-114, Erben 114-90. There was a slight tendency to dizziness when the
Erben movements were made.
Shell-shock; fright: loss of consciousness next day: Generalized
tremors; “somebody above with a mallet.”
=Case 337.= (WILTSHIRE, June, 1916.)
A sapper of 19, with a nervous mother, had had an attack two years
before his war neurosis, of a somewhat similar nature. This former
attack had been caused by overwork; there had been no accident or
fright, but the man had been unable to work for five months.
At the front, he had been well up to ten days before observation. In
a dugout a shell had pitched on top of the bank, followed by another
shell bursting in front. There was a slight falling in of the dugout
but no special damage.
The patient carried on that night but reported sick next morning,
feeling queer and shaking slightly above the waist. He remembered
getting half-way down the road to see the M. O., but nothing more until
he came to in the dressing station (perhaps 2½ hours later). After two
days in hospital, he was transferred to a convalescent camp, and then
admitted to another hospital. He complained of twitching and slight
frontal headache; funny feelings at night prevented his going to sleep.
Thus: “A man was over my head with a mallet, going to hit me.” There
was a dream of “somebody above me all the time.” Both arms, head,
and tongue were in a state of constant tremor, and there were jerky
movements of the legs. There was some spasm of the right leg. Both legs
went into violent tremor on examination, and during examination there
was free perspiration.
_Re_ tremors, all sorts of tremors of unknown nature are apt to get
the designation _hysterical_. Meige believes that the Shell-shock
tremors, which are apt to be very persistent, are very possibly due to
changes in the nervous system. Ballet has noted how the tremors, as
in the above case, are often associated with expressions of fear. Now
and then there is an obsessive disorder dubbed tremophobia by Meige,
which produces a vicious circle. Tremors lead to obsessions, and the
obsessions in turn exaggerate the tremors. These Shell-shock tremors
are apparently not related to (though they may need differential
diagnosis from) such conditions as paralysis agitans, multiple
sclerosis, hyperthyroidism, cerebellar disease, neurosyphilis, and
alcoholic or other intoxication.
Roussy and Lhermitte distinguish the tremors into (_a_) atypical ones;
that is, disorderly, irregular movements seemingly determined by the
subject’s caprice; and (_b_) typical tremors, such as those found in
the well-known nervous diseases and presumably imitated in hysteria
from these well-known diseases. Generalized atypical tremors are, as a
rule, combined with a variety of other Shell-shock symptoms, and often
exhibit a sort of mimicry of fear.
Shell-shock; burial-work: Amnesia. Shell whistling conditions idea of
something nasty.
=Case 338.= (WILTSHIRE, June, 1916.)
A private, 19, in the R. A. M. C., was sent in with a field ambulance
note as follows:
“Private ---- was close to a shell which burst among a company
standing in the road, killing 20 and wounding 20 others. He
worked well in assisting the wounded, and then proceeded to
clear up the fragments of the killed. Whilst doing this, he
suddenly lost his mental balance and has been in his present
state nearly 24 hours. He has been given bromides.”
An M. O. attached to the same ambulance wrote: “This man is
suffering from mental shock caused by having to clear away
the remains of a number of men killed by a shell. He does not
recognize his friends, and at frequent intervals has periods
of terror, exclaiming, ‘Cover it up.’ He is sleepless (without
drugs); he takes food badly. He is possibly suicidal or may
become so.”
According to the patient himself, he had been quite well for four
months at the front. He was on the La Bassée Road with the troops after
a day or two of heavy work under shell fire. “And I remember the flash
of some shot and a shell burst I think, and I can’t remember anything
more. I awoke in the morning, in the train” (48 hours later). “I can
only remember men calling out.” He complained of a feeling in the
head, as if expecting something. “Something seems to be coming,--as
if something was going to happen,--something nasty, whenever I hear
anything like the whistling of a shell coming towards me.” This patient
was without tremor and was physically normal. So far as the patient’s
own story went, the case might well be regarded as one due to physical
concussion, but the notes of the medical officers give evidence of a
psychic element.
Depression with suicidal thoughts after witnessing death of comrade.
=Case 339.= (STEINER, October, 1915.)
A farmer, 52, volunteered and was put in charge of a drinking-water
still. He had never been ill nor was there any nervous or mental
disease in his family. From the end of August he was frequently under
shell fire, but the only effect thereof was a somewhat poorer sleep
than normal.
December 14, 1914, a young comrade, a volunteer, wanted to clean his
dirty kettle at the drinking-water still. The farmer later described
this volunteer as a young fellow “like milk and blood” (as we might
say, “like peaches and cream”) and as the handsomest young man he had
ever seen in the war. The rules forbade such use of the still, and
young “milk-and-blood” was told to go down to the brook, and then come
back and get the distilled water. The young man complied, but while at
the brook he was shot and killed in full sight of the farmer.
The farmer grew much excited and trembled all over. Thereafter he could
not eat or sleep; he reproached himself, although he knew he had acted
quite correctly; wished he had been in the place of this comrade;
and had suicidal thoughts. He was deeply depressed, wept easily,
and showed manual tremor. Steiner terms the farmer’s account of the
person of the deceased “reactive idealization.” After a week there was
considerable improvement. B. was sent back to work, which he felt would
be beneficial. He was put in less dangerous surroundings, and this also
had a good effect.
Marching and battles: Neurasthenia?
=Case 340.= (BONHOEFFER, January, 1915.)
A subaltern had been treated before the war for nervousness, dizziness,
and “mattigkeit” (convulsions in infancy), but proved himself a good
soldier, having gotten his rank after the first period of practice.
He was in three battles in Belgium, but on the march one day suddenly
had a spell of weakness and is said to have had convulsions. There was,
however, no biting of the tongue, and no enuresis. After a week in the
field hospital, he was sent back to Berlin where he had some somatic
feelings of anxiety without subjective disturbance or any disorders of
consciousness except a certain amount of inhibition; he was sleepless
and hypersensitive, cried easily, and was apprehensive on being
touched; he winked violently on examination of his eyes, and while
being tested for reflexes made violent contractions of a semi-voluntary
nature.
After four days in bed, which was a prescription hard to carry out
at first on account of the anxiety sensations, these sensations
disappeared, and at the same time the fears. Weight began to increase;
memories returned, except that even upon recovery he could not remember
that he had ever had any true subjective feelings of fear. He was
discharged 19 days later, desirous of going back into the field.
The peculiar absence of subjective feelings of fear in this case is
something like what Awtokratow reported from the Russo-Japanese War,
terming them neurasthenic psychoses.
_Re_ neurasthenia, Babinski believes that, by means of his logical
dismembering of the old hysteria concept, he has shown that the
exhaustion phenomena at the bottom of neurasthenia are precisely these
that cannot be cured by suggestion. There are numerous cases in which
hysteria and neurasthenia are combined. From these combined cases,
suggestion causes the hysterical or pithiatic symptoms to be removed.
English schoolmaster’s account of his war dreams.
=Case 341.= (MOTT, February, 1918.)
A sergeant, who had been a schoolmaster, was asked to write down his
dreams by Captain W. Brown, who had sometimes charge of Mott’s cases at
the Maudsley Hospital. The first dream was as follows:
“I appeared to be resting on the roadside when a woman
(unknown) called me to see her husband’s (a comrade) body which
was about to be buried. I went to a field in which was a pit,
and near the edge four or five dead bodies. In a hand-cart
nearby was a _legless body_, the head of which was hidden from
sight by a slab of stone. [He had seen a _legless body_, which
was covered with a mackintosh sheet, which he removed.] On
moving the stone I found the body alive, and the head spoke to
me, imploring me to see that it was not buried. Burial party
arrived, and I was myself about to be buried with legless body
when I awoke.”
The second dream was as follows:
“After spending an evening with a brother (dead 11 years
ago) I was making my way home when a violent storm compelled
me to take shelter in a kind of culvert, which later turned
into a quarry, situated between two houses. Men were doing
blasting operations in the quarry, and whilst watching them I
saw great upheavals of rock, and eventually the building all
around collapsed (explosion of a mine). Amongst the débris
were several mutilated bodies, the most prominent of which was
_legless_. I tried to proceed to the body, but found that I was
myself pinned down by masonry which had fallen on top of me.
As I struggled to get free the whole scene appeared to change
to a huge fire, everything being enveloped in flames, and
through the flames I could still see the _legless body_ which
now bore the _head of my wife_, who was calling for me. I was
struggling to get free when my _mother_ seemed to be coming to
my assistance, and I awoke to find the nurses and orderlies
standing over me.”
It appears that the patient had been shouting in his sleep, beginning
in a low voice and gradually becoming louder until at last he was
shrieking. The _legless body_ occurred in all his dreams; the sight of
this had evidently produced a profound emotional shock. He had worried
a great deal about his wife, who was much younger than himself, so that
we have this incongruous association of the _legless body_ and the
_head_ of his wife calling him; finally, what more natural than the
_mother_ to come to his help. The emotional complex is not incongruous
in this dream, for fear is linked up with the tender emotion.
_Re_ war dreams, see remarks under Case 333 concerning oniric delirium.
Roussy and Lhermitte say that emotion and concussion are the causal
factors; but in a case like 341 we have persistent war dreams of the
same general nature. Such a case as Mott’s would not be regarded as one
of oniric delirium, for the patient is not living throughout the day in
a dream, but merely has certain set dreams. The true oniric delirium
cases may lead to fugues of medicolegal importance. Mott’s conception
is that the terrifying experiences that come to light in the dreams are
repressed by the conscious activity of the mind in the waking state.
For this process, the phrase _psychic trauma_ might be used. Rows
speaks of a prolongation of mental disorder through memories which get
revived in dreams. The memories of past and recent events pile up on
one another. Elliot Smith remarks on the number of cases in which the
dreams show a coalescence and blending of episodes alien to the war.
_Re_ such combinations, see Case 342 of Rows, below.
Trench experience: War dreams, shifting to sex dreams. Recovery on
giving the patient an insight into the nature of his dreams.
=Case 342.= (ROWS, April, 1916.)
A patient broke out of a hospital after being refused permission
to leave the grounds. He grew much depressed and said he had been
disgraced and would commit suicide rather than bring disgrace on his
family. Investigation into this emotional outburst showed that his
father had deserted the family, that he had gotten into prison, and
“tainted me.” The patient was worried also about an idea of loss of
sex power, gathered from a book by a quack doctor, read years ago.
It appeared also that this doctor had advertised a special bread and
special medicine which would preserve the nervous system, and that for
years the patient had fed himself and his family with the bread and
medicine. When the true state of affairs was shown to the patient, his
restlessness at night disappeared. The mental condition of this man in
fact became practically normal, and the marked tic of facial muscles
and the general tremulousness of the man disappeared.
It is of note that this man’s dreams began with a terrible incident in
the trenches and then shifted to sex acts. He woke to find the clothes
disturbed.
This is an example of hallucinations dispelled by tracing them to their
source, and giving the patient a clear insight into their nature.
According to Ballet and de Fursac, after the acute phase of stupor
and excitement with hallucinations and delirium passes, the patient
remains a depressed and psychasthenic subject. In this psychasthenia
we find inhibitory phenomena, hyperemotionalism, and over-imagination.
Amongst the inhibitory phenomena are many of the hysterical effects.
The hyperemotionalism yields anxiety, worry, tremors, respiratory
and vasomotor disorder, dizziness, convulsions. The third main
disorder of the psychasthenic state into which the patient relapses
is over-imagination, whereunder we find bad dreams (bombardments,
drum-beating, corpses, attacks), somnambulistic hallucinatory episodes.
It is these hyperemotional and hyperfantastic features that distinguish
the Shell-shock syndrome from ordinary psychasthenic states.
_Re_ the sex element in this case, see remarks under preceding case
(341) and also Lépine on the sex factor (Case 332). Rows believes that
those cases which do not recover after a short period of rest and quiet
in hospital are cases in which there is some emotional state based upon
the constant intrusion of the memory of some past event. The physical
expression of the emotion of fear or terror may persist for a long time
quite unchanged and be proved to be due to this old factor.
Emotional shock: Recurrent dreams of war and peace incidents. Recovery
followed tracing the dreams to their origin.
=Case 343.= (ROWS, April, 1916.)
A soldier and a comrade were carrying a pail of water to the trenches.
It was very cold and they set down the pail in order to warm their
hands. The comrade placed his hand against the man’s cheek and said,
“That hand is cold.” At that moment he was shot dead.
This incident was involved not only in dreams at night, but in the
daytime too, if he were quiet and closed his eyes, he could feel the
cold hand against his face.
He was troubled at the same time by another dream, in which he ran
down a narrow lane at the bottom of which there was a well. He dipped
his hands into the water, but on withdrawing them, he was horrified
to find they were covered with blood. This dream was connected with a
love affair, in which a good friend interfered and angered him so much
that he attacked him when next they met. He left him on the ground so
injured that it was necessary to take him to a hospital. The patient
became anxious as to what the result might be and left the district. He
traveled, but never heard whether his victim had died.
When these two dreams were traced back to their origin they
disappeared: the patient made a rapid recovery and was able afterwards
to bear a severe trial satisfactorily.
See remarks under Case 342.
War dreams, including hunger and thirst.
=Case 344.= (MOTT, February, 1918.)
(_Recorded Dream of a Second Lieutenant._)
“During the five days spent in the village of Roeux I was continually
under our own shell fire and also continually liable to be discovered
by the enemy, who was also occupying the village. Each night I
attempted to get through his lines without being observed, but failed.
On the fourth day my sergeant was killed at my side by a shell. On the
fifth day I was rescued by our troops while I was unconscious. During
this time I had had nothing to drink or eat, with the exception of
about a pint of water.
“At the present time I am subject to dreams in which I hear these
shells bursting and whistling through the air. I also continually see
my sergeant, both alive and dead, and also my attempts to return are
vividly pictured. I sometimes have in my dreams that feeling of intense
hunger and thirst which I had in the village. When I awaken I feel as
though all strength had left me and am in a cold sweat.
“For a time after awaking I fail to realize where I am and the
surroundings take on the form of the ruins in which I remained hidden
for so long.
“Sometimes I do not think that I thoroughly awaken, as I seem to doze
off, and there are the conflicting ideas that I am in the hospital, and
again that I am in France.
“During the day, if I sit doing nothing in particular and I find myself
dozing, my mind seems to immediately begin to fly back to France.
“A dream that keeps on coming up in my mind is one that brings back
a motor accident I had about six years ago, which gave me a severe
nervous shock. I had, of course, entirely forgotten about it, except
when in a motor, when I always thought of it.
“Of the fifth day I have absolutely no recollections.”
This is the one instance in which a man has dreamt the experience of
hunger and thirst in addition to battle experience.
Olfactory dreams: Hysterical vomiting.
=Case 345.= (WILTSHIRE, June, 1916.)
A lieutenant in the infantry (mother, of a nervous disposition) had
been at the front for 3½ months when he started vomiting everything he
ate.
He was transferred a fortnight later to a base hospital as “gastritis.”
Physical examination proved negative, but the man complained of his
nerves. He slept badly owing to trench-life dreams, from which he would
wake in a sweat. He was quite unwilling to refer to these dreams.
In point of fact he had had to supervise the burial of many decomposing
bodies, after which he had been haunted “by that awful smell of the
dead.” Then developed states of abstraction, in which he went over and
over the burying experience. He cried by himself.
It seems that the vomiting was secondary to hysterical hallucinations.
_Re_ affections of smell and taste, Roussy and Lhermitte remark that
they are rare following shock or trauma in war. Medical suggestion may
produce a hemiageusia or a hemianosmia. Mott’s case above (344) showed
unusual dreams with hunger and thirst. For another olfactory case, see
Case 510 (Rivers) in the Treatment Section of the book, a case in which
Rivers was able to find no redeeming feature upon which to ground his
re-educative suggestions.
_Re_ vomiting, Roussy and Lhermitte state that this relatively common
condition is diagnosticated readily enough but that pyloric ulcer and
other organic causes must be eliminated. They remark that there is
no tendency to spontaneous cure of neuropathic vomiting, and commend
strict dietetic régime and psychotherapy. They ally the condition in
its nature and genesis with so-called false or hysterical incontinence
of urine in soldiers. Wiltshire’s case early received the diagnosis
“gastritis.” It is remarkable how little emaciation need follow such
vomiting.
Shell-shock: Amnesia; dreams of falling. POST-ONIRIC
suggestion--surprise produced fear of falling.
=Case 346.= (DUPRAT, October, 1917.)
A man was subjected to shell-shock August 11, 1916, at the Somme. He
lost consciousness for five hours and was picked up stuporous with
verbal amnesia, which soon passed leaving only a difficulty in getting
the right word promptly. He began to have frightful dreams of falling
into a hole and of exertions to avoid falling, whereupon he would awake
with a feeling of anxiety that would last some time. Treatment caused
the dreams to disappear.
There remained, however, a powerful _post-oniric_ suggestion. Any
slight surprise would cause the fear of falling to reappear. There was
a sort of derived phobia, against any military act that would need to
be performed upon sudden order. He developed a blind anger against any
commanding officer who gave a brusque order. After the crisis of anger
he would fall into tears and a feeling of profound depression coupled
with precordial anxiety. There was also a chronic aortitis physically
determined. The man himself had a vague idea of the relationship of his
fear of surprise to the old nightmares.
_Re_ persistence of fear and its relationship to nightmares, see
remarks under Case 342 (ROWS).
Four months’ SERVICE IN THE REAR: Depression; war HALLUCINATIONS (not
based upon actual experiences); psychasthenic symptoms.
=Case 347.= (GERVER, 1915.)
A Russian lieutenant, 32, arrived at the front in November, 1914, but
never served on the front line, or had occasion to visit the line or
the trenches. Toward the close of February, mental symptoms appeared,
which caused the man’s evacuation to the interior.
He was a tall, well-built, well-nourished man, who was physically
normal except for sharp twitching movements of the tongue, eyelids, and
face; tremors of extended hands, occasionally spreading to the whole
body; well-defined dermatographia (in places, stereodermatographia);
exaggerated tendon reflexes; tenderness of skull and spine;
hyperesthesia of chest; pulse 120.
Mentally, the patient was markedly depressed, irritable, at times
lacrimose. His complaints were of a psychasthenic tinge. He feared
incurable disease. He feared to go to the front, and was terrified at
what he might do there. He feared crowds of soldiers; he was afraid
of forests and mountains; the Germans were going to break through and
capture him; shells were about to burst over his head. He was also
disturbed about his family, regarding his wife and son as helpless,
sometimes even as dead. Suicidal thoughts at times.
At night, though he had never been at the front, he had hallucinations
of shots and the voices of soldiers, as well as those of his wife
and son. He smelt an unpleasant corpse-like odor. He was unable to
distinguish these hallucinations in any respect from reality. He
complained of general weakness, headaches, palpitation of the heart,
vertigo, and insomnia, and of a variety of pains.
He was non-alcoholic and non-syphilitic, and had been in perfect health
before the war.
_Re_ war hallucinations with service back of the line, compare remarks
of Régis (see under Case 333).
A case of hysterical astasia-abasia develops “big belly”
(“catiemophrenosis”), perhaps by hetero-suggestion from a ward neighbor.
=Case 348.= (ROUSSY, BOISSEAU and CORNIL, May, 1917.)
A farmer, 22, of the foot chasseurs, who had been in various hospitals
with a variety of diseases before his injury, was evacuated June 2,
1916, for “contusion of back,” to the temporary hospital at Bussant,
from which he was evacuated to Pontarlier for “contusion of back and
cerebellar shock” and thence, July 21, to Besançon for “internal
contusion and cerebellar shock”; thence to four other hospitals from
July 31 to February 17, 1917; finally to the Hospital at Veilpicard
with “functional disorders, paraplegia, trepidant astasia-abasia.”
It seems that he had lost consciousness for fifteen days and had
thereafter been paraplegic with retention of urine. The abdomen
had then increased in size in such wise as to be termed a nervous
pregnancy, _grossesse nerveuse_. The evolution of this pseudotympanites
was probably related to the presence of the same so-called “big belly”
of a patient who had been in a neighboring bed from May, 1916, onwards.
The feet were in equine position with toes flexed, suggestive in all
ways of hysterical paraplegia. The abdomen looked like that of a woman
six months pregnant and measured 78 centimeters in a plane passing
through the anterosuperior iliac spines and the umbilicus. The abdomen
was hard, tense, swollen, and on palpation, gave out a low, tympanic
note. When the diaphragm was mobilized progressively and slowly, the
tympanites could be made to disappear. Slow pressure on the abdomen
with flat hands effaced the swelling for the time being; but upon
release of the hands the abdomen would swell up again as before.
Pressure on the abdomen produced a contracture of the recti. Forced
flexion of thighs on pelvis (as suggested by Denéchau and Matrais) also
caused the swelling to go down. Faradization of the phrenic nerves
in the neck caused respiratory movements with a slight diminution
in the volume of the abdomen. There was an obstinate constipation
requiring daily lavage. Respiratory movements were short and rapid and
of the thoracic type. Abdominal compression caused the respiration to
assume almost a normal rhythm. X-ray examination of the abdomen, after
50 grams of bismuth carbonate had been taken in three spaced doses
the evening before, showed the intestine to be distended by gas in
such wise that the lower border of the liver became clearly visible,
as after insufflation of the stomach. The bismuth was found in the
large intestine. The splenic angle filled with bismuth was low. On
compression the splenic angle was raised with the diaphragm.
The main features of this disease are the large abdomen, simulating
what has hitherto been found chiefly in females under the name of
nervous pregnancy, but also suggesting a tuberculous peritonitis (one
patient was actually evacuated to a hospital for tuberculosis with this
disease); gastro-intestinal disorder with aerophagy, aerocoly, and
obstinate constipation (one case also showed almost daily vomiting).
The genesis of the condition appears to be a contracture of the
diaphragm in a low position of forced inspiration. The condition may be
termed a diaphragmatic neurosis.
Psychotherapy was applied, the patient was requested to walk, and
the movements made in walking required such an intense respiration
that the diaphragm was forced to function, whereupon the “big belly”
disappeared. The digestive disorders then rapidly disappeared. These
authors suggest the name of _catiemophrenosis_.
War stress; collapse going over the top: Neurasthenia (hereditary
taint; alcoholism).
=Case 349.= (JOLLY, January, 1916.)
A German soldier, 35, of a nervous make-up (his mother was nervous, and
he had been nervous and tremulous and easily excitable, and alcoholic
to the extent of at least 5 glasses of beer every night), was called
to the colors in September, 1914. He got through his training well;
in May, 1915, was on very strenuous duty in a very exposed position,
had frequently to stand up under heavy shelling, had a number of
frightful experiences, was surrounded by corpses and mutilated bodies,
and frequently took part in storming attacks. His nervousness came
to a head with some suddenness; just as he was about to “go over the
top,” he had no strength for the effort and collapsed. Thereafter he
could no longer stand shelling, could not speak, and was inattentive to
surroundings. When he was examined by a physician he fell asleep in his
presence, although sleep had latterly been almost impossible on account
of the shelling. He was immediately put on the hospital train and taken
to the reserve hospital in Nuremberg, where he presented an appearance
of extreme exhaustion, wept, seemed much fatigued, and trembled all
over whenever he started to do anything. He was very easily excited and
especially sensitive to noise. There was a fine tremor of the whole
body and especially of the head; the knee-jerks were increased; there
was a moderate vasomotor reddening of the skin after stroking; his
tongue was heavily coated; but there was no other evidence of internal
disorder. His pulse was strong and not rapid.
The patient got well gradually, complained at first of bad dreams, and
was given to weeping. The tremors slowly improved. The patient grew
better in a hospital at home.
As to the diagnosis of this case, Jolly regards it as one of nervous
exhaustion. The remarkable feature is the tardiness with which the
symptoms developed under the stress of war. Such a patient would
probably never develop a neurasthenia under normal peace conditions.
After recovery these patients may be sent back for garrison duty or
for other work not directly connected with the firing line. As for the
tendency to desire a pension, this wish, according to Jolly, must be
strenuously opposed, both in the interest of the state and that of the
patient. If there is no will to get well, some of these patients are
found vibrating from garrison service to furlough and to hospital.
The above case is one of the simplest observed; yet there is evidence
both of hereditary taint and of alcoholism. According to Jolly, the
majority of the severe exhaustion states of a neurasthenic nature
have been, in his experience, distinctly nervous before the war, and
frequently show hereditary taint as well.
_Re_ neurasthenia, see views of Babinski relative to differentiation
from hysteria (under Case 340).
Series of battles: Sudden mania followed by confusion with fixation of
mind upon war experiences, possibly hallucinatory; general analgesia.
=Case 350.= (GERVER, 1915.)
A Russian private, looking much older than his years (35), had been
in a number of battles without mental disorder. Where he was posted,
however, there was a heavy artillery fire in the last of the battles.
Suddenly the man became excited and leaped upon his comrades’ shoulders
crying, “The devil is here! This is hell and murder, and here are
the devil’s imps!” The commanding officer accordingly ordered him to
the rear. His regiment had suffered severe losses in a succession of
attacks upon a certain strategic height.
Upon evacuation to the field hospital and thence to the interior, his
excitement did not lessen. He went about with a lost look, trembling,
talking a great deal and gesticulating. His talk was incoherent and
pointless. After every few phrases, he would repeat, “Don’t ride there!
That’s hell! Murder is being done. Devils and unholy powers are beating
and killing people.” As he said this, he would tremble, and hands and
feet would stiffen with a suggestion of catalepsy. There was general
anesthesia to pain; no response was made to deep pin-pricks. The pupils
were dilated and failed to react, either to light or to pain. The
tendon reflexes were exaggerated. No contraction of visual fields. The
man was disoriented for time and place and much confused. No paralysis.
No wound or contusion.
_Re_ analgesia, we may only say that hysterical anesthesia appears in
a variety of forms; sometimes (_a_) in the form of a classical stigma
of hemi-anesthesia; (_b_) in a segmentary form; again (_c_) in isolated
patches; (_d_) in a very rough way approximating the peripheral nerve
distributions. Babinski gives an unpublished note by Lasègue, in which
he states that hysterical patients not enlightened by the doctor’s
investigations do not make mention of anesthesia. But in case 350 a
psychotic factor may have entered.
Ten months of military service (several battles) without reaction;
then, hot machine gun battle: Mania with disorientation and war
hallucinations.
=Case 351.= (GERVER, 1915.)
A Russian private, 24, in a scout company, entered the war on
mobilization and took part in several battles without reaction. May
11, 1915, he was sent with the scout party into a hot encounter, hand
to hand with machine-guns. After the battle, the man began to yell
incoherent phrases at the men around him, started to climb over the
top, and shot off his gun without permission. He was accordingly sent
to hospital, where he was under observation for a week, during which
he had occasional flashes of excitement, jumping out of bed and making
movements of cutting or shooting, and then in a few minutes subsiding
into inactivity.