Part 28

I went out to France on the 3/11/14 and I was two days at Le Havre and then we went on to our 1st Batt. When we arrived at our destination the regiment was in the trenches so we had to go in. It was snowing hard and I felt it very cold. This was at Givenchy. We were relieved the following night and we went back for a rest. The next place we went to was just opposite Neuve Chapelle on the La Bassée Road and it was awful, the trenches were up to the knees in mud and water. The first night was very quiet, but the following morning about 9 p.m. the Germans started shelling and continued all day; the next was the same, but about 1 o’clock the Germans were seen to be coming up in masses. They got to within a distance of about twenty-five yards, then they turned. They commenced shelling us again and they had another try about three o’clock but they did not get far. One of the men on my left had the half of his face blown away and we had about ninety-two killed and wounded. We got relieved after being in five days, then we went back for three days’ rest. The next place we went to was Rue de l’Epinette and we had an awful time there just before Christmas. We went into the trenches and we were up to our middle in water and in some places it would have taken you over the head. We were in these trenches for twenty-four hours. There was nothing unusual happened and we got relieved by the Royal North Lancs.; but we did not get far away; we had just got into our billets and were making some tea when the fall-in went and we were told that the Germans had broken through the North Lancs. We went away without any great-coats, and into the trenches we went for other seventy-two hours, and if the Germans had attacked again we could not have fired a shot as we were hardly able to stand for the cold and with the wet kilts on our legs it was awful. We got nothing to eat except three biscuits that some of the men went out and got. When we came out of the trenches on Christmas Eve we looked all like old men and a lot of them had to be carried. We went back for a rest to (Nervaille?) about thirty kilometers from the firing line for a month. When we came back again we went to La Bassée and had a pretty hot time there. The next place we were at was at that big fight at Neuve Chapelle when 472 guns bombarded the German trench for thirty-five minutes. At about 7 p.m. the word was passed along that we were to charge the German trench in front supported by the City of London Territorials. We got the trench all right and I got orders about 4 p.m. to go back to our own trench and bring along the belt-filling machine belonging to the machine gun. There was not a proper communication trench, there was a small dry ditch that ran out in the direction of the trench we had taken for a distance of 150 yards, the other 100 yards you had to come across the open. We got into our trench all right, and I got this box on my back and started back to the trench. I was just stepping out of the trench when a shell burst just over my head and I went down. When I came to my senses I was lying in our support trench where I had been carried by two of the men of the 4th Black Watch. One of them said something but I could not hear him and I tried to tell him so, then I discovered that I could not speak.

Shell-shock by windage: Hysterical crural monoplegia, of gradual development beginning four days after accident. Recovery by suggestion.

=Case 228.= (LÉRI, February, 1915.)

A number of chasseurs were doing the “tortoise-shell” under bombardment, when the last chasseur in the line was blown forward above his comrades by a shell bursting about a meter behind him. He was projected some four or five meters, got up, walked four or five kilometers, found an automobile, and was carried to Nancy. He passed, according to his story, red urine three or four times. He was six days at Nancy, where a slight abrasion of the side was treated. He began to feel heavy in his left leg on the fourth day. At Vendôme, the paralysis got worse, and by November 17 he had apparently a complete paralysis of the left lower extremity, called “spinal contusion.” He walked upon two canes, dragging left leg behind and had to be carried upstairs on a stretcher. The reflexes were normal except that there might have been a very slight excess of the left knee-jerk. There was a slight hypesthesia of the left leg, sharply limited above.

These phenomena were strikingly modified, at a single sitting, by verbal suggestion and faradism, but the man was one of those with _mauvaise volonté_. He did not want to get well so quickly, so that his complete cure was delayed a while.

NATURE OF SHELL-SHOCK: At the nerve clinic the patient presents, _e.g._, sundry CONTRACTURES, of such a nature that they may be caused to DISAPPEAR BY SUGGESTION, _e.g._, by mental influences during recovery from chloroform narcosis (note battle-dreams). PAINS and ANESTHESIAS disappear PARI PASSU with the contractures. The history is of shell explosion so near as to burn patient’s clothing, fall with nosebleed, eight hours unconsciousness, crural monoplegia with anesthesia (crawled 3 meters, however).

=Case 229.= (BINSWANGER, July, 1915.)

The treatment of a German private, 22, for contracture of the left leg and other phenomena, culminated in narcosis. Binswanger lays stress upon the mental influence to be exerted upon the patient at the conclusion of narcosis, at the moment in which the patient is particularly accessible to verbal suggestion. Treatment (see diagnostic details below) was carried out as follows:

After a few days of essentially suggestive treatment with continued attempts at passive movements of the contracted joints (knee, ankle, toe), with steady concentration of the patient’s attention upon the joints, a slight mobility in the toe joint on passive movement was obtained.

After a few more days, the ankle became passively mobile to some degree; the patient exerted a certain resistance to passive flexion of toes and ankle. A week later, reflex contractions of the toes could be evoked by deep pin-prick. There had been an analgesia of both lower thighs and of the soles of the feet, and this analgesia remained unchanged. At this point, the subjective complaints of the patient, namely, noises in the head, especially in the left ear, and other cephalic sensations, tended to disappear and the patient felt subjectively better; yet there was still an intolerable itching of the head and spine.

A month after the admission of the patient to the nerve hospital of the psychiatric clinic in Jena, there had been no essential change in the immobility and contracture in extension in the left leg. Accordingly, with the permission of the patient, he was placed in deep chloroform narcosis, and the knee-joint was bent at a right angle and fixed in approximately that position with a bandage. This experiment failed because, while the patient was waking out of his narcosis, the leg slipped back into extension, breaking the bandage. Accordingly, deeper narcosis was undertaken, and the leg fixed at a right angle in a plaster cast.

While the patient was coming out of narcosis, it was evident that he had been dreaming of battle scenes. In fact, Binswanger remarks that these dream pictures and the words spoken while going under and coming out of narcosis, are curiously demonstrative of “_sympathy with the enemy_,” for while waking out of narcosis, he cried: “Dost see, dost see the enemy there? Has he a father and mother? Has he a wife? I’ll not kill him.” At the same time, he cried hard and continually made trigger-movements with his right forefinger.[6] In point of fact, throughout his waking treatment, no one was able to learn what was going on in his mind, his sleep was good and deep, and his emotional state was entirely quiet and patient.

[6] Compare sentiments of a Russian in narcosis (Case 319, Arinstein.) See also Case 181 (Steiner).

As the patient was coming out of chloroform and regaining consciousness of his surroundings, he was repeatedly and persistently assured that the bending of his leg was now accomplished and the cramp removed. All that he would now have to do was to get back the strength of his leg.

During the next few days he complained of violent pains in his left knee-joint and in the ankle-joint, but he remained in good spirits and full of confidence. Accordingly, in five days the plaster was removed and the contracture in the knee-joint was found to be completely absent; the knee was easily movable. The ankle-joint was but slightly movable. He could accomplish slight active flexion of the knee-joint while lying in bed, and the toe-joint had already, before the narcosis, been both actively and passively mobile. After a few days, exercises in walking were begun. The patient had a little difficulty with his left knee-joint in walking, walking in fact as if with knock-knee. The foot was not well raised from the ground on account of the persistent stiffness of the ankle-joint. Walking, however, improved daily. He walked for three hours, resting at intervals.

A sensory examination showed that the upper limit of the analgesia had come down five centimeters from its former level, now occupying the left foot and leg up to the junction of the lower with the middle third. There was now a zone of anesthesia interposed between the normal skin of the upper thigh and the anesthetic-and-analgesic skin of the lower thigh and leg. Upon the posterior aspect of the leg, the analgesia and anesthesia had disappeared to a point at about the middle of the upper thigh.

About five weeks after the narcotic experiment, the extended left leg could be actively raised while lying in bed, up to the full extent, with slight tremors. The patient described himself as fatigued by the active movements of this leg. The ankle-joint remained less effective. There was still a trace of resistance to passive movements. Although the passive movements of the toes were normal, active movements of these were weak and hard to execute. There was still a trace of difficulty at the knee in walking and the gait was awkward, trepidant, precipitate. He could get about without a cane, however. If unobserved, his posture was more certain and free. If he exerted himself hard, severe parietal headache on the right side would develop.

It was then proposed to the patient that another narcosis would rid him of the stiffness in his ankle-joint. He feared narcosis and was told that regular and energetic voluntary movements would also rid him of the stiffness. These will exercises consisted in his directing his whole attention to his left ankle-joint until he felt it. Then he was given the command: “Let go the joint”--whereupon he would take his attention away from the ankle-joint at once. In this way, he was told, his will would make the ankle-joint mobile. Meantime he was given twice daily a gram of bromophenacetine for his parietal headache.

The result was a rapid recovery. There were still a few traces of difficulty at date of report. The zone of sensory loss had retreated to the ankle, with a cuff-like zone of hypalgesia above the definite zone of analgesia and anesthesia.

As to the previous nature of this case, although there was neuropathic heredity on the mother’s side, there had been no sign of any individual neuropathic disposition. He had been a volunteer since 1911 in a guard regiment of infantry. His military training had been well borne; in the war he had fought through 20 battles. On November 11, 1914, in a storming attack, he had had his breeches burned from the effects of a shell. He had fallen, unconscious; the unconsciousness lasted about eight hours. He found on awaking that he had had nosebleed. When he wanted to get up, he found that his left leg was completely paralyzed and insensible; in fact, he thought it had been cut away. He crawled for about three meters to a trench in which there were several wounded. In the evening he was taken by automobile to a field hospital, and on the 17th was removed to a reserve hospital at Erfurt. Thence he was transferred to the Jena Hospital, January 25, 1915.

A strongly built man, with many reflexes increased and a lively dermatographia. The reflexes of the left, or contractured, leg were lacking; the mastoid processes were painful, and the occiput and temples were painful to percussion. The spinous processes of the vertebral column in the lumbar region were painful. The other phenomena have been sufficiently indicated above. The head sensations were peculiar; there were no pains but a peculiar itching. Contraction of the fingers of the left hand was painful. There was a feeling as if there were lice under the skin in the left upper thigh. There was itching in the nose, which the patient described as due to the sulphur “out there,” meaning shell gases. Sleep and appetite were good. Memory was imperfect: he could no longer remember the names of the battles, and of late had had to count on his fingers to find out how much was 2 times 2. As to the curious parietal headache, contralateral to the contractured leg, Binswanger inquires whether we may not here have to do with localized vascular phenomena of the brain part which might conceivably be related with the innervation of the leg. Binswanger remarks that if the plaster cast be left on too long, it may happen that hysterical contracture will take place in the new position.

As to the will exercises used in the present case, Binswanger remarks that the patients must be intelligent and attentive, and naturally they must desire to get well. Fortunately, many of the war hysterics do want to get well, since the contrary experience is had in various industrial cases.

Wound of thigh: Pseudocoxalgic monoplegia with anesthesia. Cure of anesthesia by faradism at one sitting. Cure of lameness by reëducation and electricity in one month.

=Case 230.= (ROUSSY and LHERMITTE, 1917.)

An infantryman, observed at Villejuif, February 9, 1915, was suffering from a right-sided crural monoplegia of a pseudocoxalgic type, following a wound September 9, 1914. The wound had been a through-and-through one in the upper right thigh. Every active movement could be performed as well on the right side as on the left; but the strength of the movements was less on the right, especially that of leg-extension. The reflexes were normal, the lameness was slight, with toeing out; the sole came down flat upon the ground. There was an absolutely complete anesthesia of the entire right leg and side up to the umbilicus.

Energetic faradization of the skin caused the anesthesia to disappear the day the patient was brought to the hospital. The cure of the lameness required a month of reëducation and electricity.

According to Roussy and Lhermitte, crural monoplegia is less frequent than brachial monoplegia. The flaccid form is rare, and when it occurs, complete, though the patient always remains capable of executing some voluntary movements and can walk with crutches or cane. During the automatic movements of walking, some muscles may be observed to contract that remain immobile when the patient is being examined recumbent. Naturally such a difference in contractions standing and lying, would be very exceptional in a case of organic monoplegia.

Contusion of thigh: HYSTERICAL right crural MONOPLEGIA. An ORGANIC CRUTCH PARALYSIS develops in the right arm, unobserved by the patient whose main concern is his useless leg. Cure of leg by psychotherapy.

=Case 231.= (BABINSKI, 1917.)

A certain lieutenant, following contusion of the right thigh, developed a crural monoplegia of hysterical nature. In fact, although the paralysis had lasted several months, the tendon reflexes, the skin reflexes, and the electrical responses of the muscles, were absolutely normal. Moreover, the good effects of psychotherapy confirmed the hypothesis. But besides the hysterical crural monoplegia, there was a radial paralysis on the right side, clearly organic in nature, due to the nerve compression by the crutch which the patient had employed on account of the paralysis of his leg.

Babinski notes that this association of conditions was remarkable in that it demonstrated that hysteria and simulation should not be confounded with one another. To be sure, it is difficult to tell simulation from suggested phenomena, for there are no objective characters that demarcate the two. Babinski had himself said that hysteria was a demi-simulation; but a demi-simulation is not a simulation. The patient was in fact, sincere enough in his belief that he could not move his leg. To obviate this paralysis, he had in fact leaned so conscientiously upon his crutch that an organic paralysis had resulted. In fact the radial palsy had only been discovered incidentally, and the paradox appeared that a purely imaginary trouble occupied in the patient’s mind for a long time a much more important place than the genuine organic trouble which accompanied it.

Bombardment; war strain; gassing?; collapse; arthritis: Hysterical MONOPLEGIA and ANESTHESIA of leg, interpreted as a “PROTECTIVE” reaction. Later, monoplegia and anesthesia of arm.

=Case 232.= (MACCURDY, July, 1917.)

A corporal described as normal (“except for some shyness with the opposite sex”) adapted himself well to training and went to France in May, 1915, where he was at once thrown into 18 days of almost continuous bombardment. After some initial fright, he settled down to work well enough, but, when the weather got bad in September, 1915, grew tired of the situation. Bad dreams began (falling into a deep hole; being shelled). He thought of suicide, wanted a shell to incapacitate or kill him, began to have pains in the head, arms and legs, and was already groggy when a gas attack came. Whether he got a whiff of the gas or not, he at any rate felt giddy, got a swallow of water, and when the gas passed got out of his dugout in the open air. He was fatigued and much relieved when the company was ordered back. Now, however, he got shaky and fell in a collapse on a pile of straw, without, however, losing consciousness.

Apparently he had an attack of acute articular rheumatism. There was a sore throat and a pain in the head, radiating to left shoulder and to finger tips, with pain also in legs. The pain was worse in the right leg on moving the knee-joint. These pains lasted for a month in hospital. The leg had been like a log since the collapse on the pile of straw. Even after the pains left him a month later, the right leg was paralyzed and anesthetic. He walked with a crutch and developed a crutch palsy. After a month a hysterical paralysis of the right arm, with superficial anesthesia, supervened. During a period of eight months thereafter improvement was steady under reëducative measures.

According to MacCurdy’s analysis, the acute arthritis led to paralysis as a protective reaction. The paralyses are disabilities that would ensure absence from the front.

Lance-thrust in back, rapidly healed. Paralysis of right leg, disappearing with rest and exercises. Later, psychotic symptoms, with recovery.

=Case 233.= (BINSWANGER, July, 1915.)

N. H., 21, a laborer, industrious and sober (mother healthy, father insane and a suicide; patient somewhat sickly in childhood after pneumonia, a good scholar) volunteered at the outbreak of the war. Early in November he was on the Eastern front. November 17 to 22 he was in a number of small reconnoitring skirmishes almost daily, as a cavalryman. On the 22d, there was a clash with a Cossack patrol of far superior numbers. Eight German horsemen cut their way through, riding about 4 kilometers back to their squadron.

While dismounting, N. H. discovered that his back was wet. It occurred to him at once that he had been wounded. However, he successfully dismounted and then collapsed, feeling as if his right leg had fallen asleep. His companions found a wound in his back, which had come from a lance-thrust. The wound was bandaged. He was transported to Germany on a peasant’s wagon, the trip occupying six days, and on December 6 he came to the surgical clinic in Jena. The wound was insignificant and healed quickly.

The leg remained motionless, and on December 10 the patient was referred to the nerve hospital. He was a small, slenderly-built man, with poor nutrition, weighing 108 pounds. The scar, about 1 cm. long, alongside the thoracic vertebra, was still somewhat red and but slightly sensitive to pressure. Neurologically, the knee-jerks and Achilles jerks were greater on the right than on the left, and there was on the right side a distinct patella and ankle clonus. There was no Babinski reaction on either side.

The movements of the right leg were not of wide excursion, and flexion and extension of the knee and ankle-joints, while lying on the back, were slowly and hesitatingly performed, with an expression of pain, and with visible effort by the quadriceps muscles. Flexion and extension of the toes were likewise difficult, and when the toes were stretched there was a distinct contraction of the tibialis anticus. Electrically the muscles were normal. On passive motion, there was slight spastic tension in the musculature of the right leg, and the patient said he felt marked pain. In walking, the right leg was moved with a limp and with the evident design of sparing it. The knee was imperfectly bent and the sole of the foot was dragged along the ground. There were short out-throwing movements of the lower leg.

Pain sense was normal, or possibly slightly in excess. There were painful points on pressure on the lower part of the os sacrum and coccyx and over the right sciatic and tibial nerves. Intelligence examination showed school knowledge to be extremely poor and calculation ability poor. Critical judgment and reasoning power were deficient. Memory and perception were without marked disturbance. The patient was dull and without interest in his surroundings. He complained that his right leg was as if dead and that he felt great pain in any attempt to move it. He also complained of pains at night in the region of the right shoulder and neck. His nerves, he said, had been very weak since his trip back from the front, during which trip he had been very cold and poorly cared for.

Treatment consisted of rest in bed, application of moist packs to the right leg, active and passive exercises of the right leg. After ten days he made his first independent attempts to walk, and active movements of the right leg in dorsal decubitus became unrestricted and painless. He remained somewhat unsteady in station, showing bilateral twitchings and movements of the right leg muscles. In walking the right leg was dragged behind in a spastic-paretic fashion. Appetite improved; spasms decreased; but at the end of December foot clonus was still persistent.

Upon January 10 there was an odd mental change. He became seclusive and suspicious. January 15 he expressed ideas of poisoning; his sister, he said, wanted to poison him, and others were watching him suspiciously; his room-mates were talking about him; in fact, he thought one comrade was an Englishman. Sleep was poor. At the end of January, after a short period of improvement, he again had ideas of being poisoned, and had dream-like, unclear thoughts. His actions became incoherent: he would undress suddenly in the daytime and go to bed, getting up five minutes later and dressing. Senseless postcards were written.