Part 31

A Russian private, 24, sustained shell-shock April 14, 1915. He was observed, when the shell burst, to crouch down, and then to fall to the ground, unconscious. The unconsciousness lasted about two days, after which he was found to be oriented, though slow and stammering of speech, hardly able to concentrate attention or sustain a conversation, and giving the impression of a man stunned. There was difficulty in the expression of thoughts, and a marked over-fatigueability. After adding and subtracting accurately two-digit figures for a time, the man quickly grew confused and said that trying to solve such a problem made him dizzy.

His imagination was filled with gunshots, shell-bursts, and the killing of comrades, and during any conversation the man frequently shuddered. Concerning the shell-shock, he remembered only that a number of shells had burst near him and that he came to in the hospital. He kept looking to one side and to a distance, as if listening, sometimes bending his head downwards. He would cry and sigh during conversation, and then be quite unable to explain why. He said there were loud noises in his ears, and that his head and the whole right side of his body felt hot. Pain was felt in the left side of the head. The right hand and the right foot were weak (on distraction, this hemiparesis remained unaltered). Tremors affected all the extremities. He had a sensation, possibly hallucinatory, of the creeping of insects on his skin. The hearing of the left ear was objectively diminished. There was palpitation of the heart and difficulty of breathing. Tendency to Romberg. There was a general hypalgesia, more marked on the left side of the body. Both conjunctival reflexes were diminished. Knee-jerks and Achilles jerks were exaggerated. All the reflexes on the right side were livelier than on the left. There was a moderate Babinski reaction on the right side. Mechanical over-excitability of muscles. Dermatographia. Both sides of the skull were sensitive on tapping, but especially the left side. Mannkopf sign on pressure of the left side of the cranium.

Hemorrhagic points without injury to the skin were noted on the skin of the left hand and foot. Speech was stammering. There was a marked digital tremor, sometimes spreading to the rest of the body during examination. The muscles of the face, eyelids, and tongue showed sharp fibrillary twitching. The pulse stood at 100 and frequently missed beats. Battle hallucinations, visual and auditory, sometimes occurred, the commands of superiors and the noise of guns, rifles, yelling, and groans; the man would see trenches or redoubts, or a field full of wounded soldiers or attacking columns of the enemy. He recognized the hallucinations as such. His sleep was troubled by nightmares of the same general description.

For eight months the man had been in action at the front, under heavy gun and rifle fire. He was a courageous man, who had never felt fear, regarding himself as used to battle and the bursting of shells. He had not been wounded. The entire situation seems to have developed after the single shell burst of April 14, 1915.

LOCALIZATION OF SHELL-SHOCK SYMPTOMS: Hemiparesis and hemianalgesia on side of body exposed to explosion; contralateral irritative symptoms of face and tongue.

=Case 256.= (OPPENHEIM, January, 1915.)

A soldier had a shell explode to his right, October 23, 1914. He declared that the concussion launched him through the air. When he recovered consciousness three hours later, he lay in a bog and was unable to move either leg. Gradual improvement followed. The symptoms were sensations of formication in the legs, pain in the back, blurred sight, hardness of hearing, disturbance of speech, headache, vertigo, weak memory. After a fortnight weakness in right arm.

He was admitted to hospital a week after the injury, unable to walk, restless, given to palpitation and attacks of anxiety. On attempts to walk, leg spasms and tachycardia.

Transferred to nerve hospital, December 2. Sleep poor, uneasy with dreams. Tic on left side of face. On opening the mouth, left-sided faciolingual spasm. Paresis of right arm. At first, right-sided ankle-clonus and paresis of leg. Knee-jerks increased. Speech hesitating. Right hemianalgesia. Concentric contraction of visual fields. Tachycardia (120). In walking the right arm failed to swing normally. Attacks of vertigo, with falling. Patient got up at night and pushed against objects in his room.

There was only slight improvement while under observation. He became psychically more frank and even talkative, and was moving more readily when transferred.

_Re_ Oppenheim’s conception of the strongly peripheral element in traumatic neurosis, he sums up by saying that a traumatism attacking the organism at its periphery is in line to produce a neurosis without any psychic mediation whatever. The rôle of the psychic process, in Oppenheim’s view, is contributory to the fixation of neuroses. Even when there is a free interval betwixt shell burst and neurosis, still there are physical effects of trauma upon neurones.

Shell-shock; unconsciousness; after improvement in symptoms (4 months) return to trenches; more symptoms after 5 days: Sensory disorders, especially on left side (the side more exposed to explosion); exaggerated reflexes on right side with slight clonus and with Babinski sign. Improvement.

=Case 257.= (GERVER, 1915.)

A Russian Captain, 45 (heredity good; non-alcoholic, non-syphilitic; always in good health) sustained shell-shock in a battle in southeastern Prussia, August 13, 1914, and was unconscious for two days. He was carried to one of the provisional field hospitals, and then evacuated to Petrograd, where during a period of four months, he was given electricity, suggestion, and baths. He was feeling so much better in December, 1914, that he went back to the front and headed his company in the trenches. He stood only five days of trench work, and was sent for mental examination December 29, 1914.

The captain was of middle height, well developed but poorly nourished, of a dejected and preoccupied appearance, looking to one side in conversation, and finding difficulty in the expression of his thoughts. He talked almost exclusively of his illness. He found difficulty in adding or subtracting 2-digit figures. He seemed to have amentia, frequently being mistaken as to the most important dates in his life. He complained of general weakness and inability to work. Any endeavor to concentrate caused vertigo, irritation, and pains in the head. Day and night he was troubled about his health, his future, and his family’s future. He was going to become an invalid and a burden. He was tormented with the idea that people thought him a simulator. He complained of lumbar pains. It seems that the explosion had affected the left side of the body more than the right and he complained more of pains upon that side. In the dark his gait was unsteady, and he often had marked tremors of feet and hands. In excitement the tremor would increase uncontrollably. The patient thought that his hearing was diminished, especially upon the left side, and that his left ear was weaker than the right. He slept poorly and had many nightmares; his appetite was poor, and he was constipated. There was difficulty in respiration; the pupils were slightly dilated and sluggish in their responses. There was a marked tendency to Rombergism; dermatographia marked; the skull and especially the lumbar spine was painful on tapping; hyperesthesia of the lumbar skin; paresis of left hand and left foot. The tendon reflexes were more marked on the right side than on the left, and there was even a slight ankle and patellar clonus. The Babinski sign was present on the right side. There were frequent fibrillary contractions of the muscles of the trunk and back.

Objectively the hearing was somewhat decreased in the left ear, and the vision of the left eye appeared to be somewhat impaired also. If the eyes had been held closed for a time, there was difficulty in opening them quickly. Aside from a somewhat elevated pulse and slight cardiac arrhythmia, there was no disorder of the internal organs.

This patient remarkably improved but was not absolutely well at the date of the report.

_Re_ organic signs in Shell-shock cases, Oppenheim warns practitioners and experts against undervaluing war neuroses. He does not like to have them set down in too offhand a way, as hysteria, wish-fulfilment, and simulation. Hysteria is not likely, according to Oppenheim, in cases with permanent cyanosis, disappearance of the radial pulse, trophic disturbances, hyperidrosis, alopecia, fibrillary tremors, myokymia, cramps, dilated and sluggish pupils, and weakening of tendon reflexes. Hyperthyroidism also has been found by Oppenheim.

Shell-shock, explosion on left side: Sensory disorders especially on left side; ecchymosis of right (uninjured) leg, possibly conditioned upon shock of left hemisphere.

=Case 258.= (GERVER, 1915.)

An artillery officer had had a shell burst to the left side of his horse, which veered to the right but did not fall. The officer’s left hand immediately became so numb and weak that he could not hold his reins with it; it shortly became more painful. The left foot showed a tendency to the same anesthesia and paresis.

Curiously enough, a number of punctate hemorrhages appeared on the right thigh and lower leg, upon the outer aspect. According to Gerver, these hemorrhages into the skin of the _right_ leg may have something to do with a disturbance of circulation related with effects wrought upon the _left_ hemisphere. During the course of the disease, pains occurred not only in the left arm and leg but also in the right leg.

_Re_ brain injuries produced by shell explosions without external wound, Roussy and Boisseau have not found a single clinical instance amongst 133 cases observed, which suggested cerebral softening, or even hemorrhage into the brain substance, the cord substance, or the meninges. These 133 cases were observed in army neurological centres and contained instances of (_a_) mental disease (confusion, delirium, amnesia), (_b_) nervous disease (astasia-abasia, tremors, paralyses, contracture), and (_c_) an intermediary group (either mental confusion with stupor, or hysterical deafmutism).

Shell-shock; unconsciousness: Hysterical deafness, speech-disorder, gait. Recovery by reëducation. Brief relapse to deaf-mutism at noise of drums. Improvement. Relapse to numerous and severe hysterical symptoms at small guns fired on King’s birthday. Improvement. Speech wholly regained in a quarrel. Recovery.

=Case 259.= (GAUPP, March, 1915.)

A musketeer, 22, had been blind for a time at 11 on account of some spinal cord disease.

He was a soldier up to Christmas eve, 1914, when he was hurled backward in a trench in the Argonne by an exploding hand grenade. He lay unconscious for several hours, though without sign of physical injury. Coming to his senses, he worked himself out of the trench and crawled to another, but again fell unconscious. When he awoke he was in a physician’s care in quarters, to which he had been taken by ambulance men. Thence to the field hospital, and then to a private hospital at B.

Upon admission, January 17, he was hard of hearing on both sides, and his speech was peculiar: choked off and retarded. His gait was heavy, on a broad base. He was subject to headaches.

Exercises gradually improved the speech and the walking disorder was quickly overcome. February 5 came a relapse through fright at the rolling of drums near by. Speech was completely lost, deafness set in, and the patient ran restlessly to and fro in tears. After a few hours speech returned with still some minor difficulty.

From time to time came fainting spells and attacks of disorder of consciousness, with loss of orientation and the idea of being in the trench or under cover. He would ask whether it were raining through. His mood herein was at times cheerful and excited. Speech further improved from the middle of February, as well as did the other symptoms.

On the King s birthday, February 25, occurred another relapse due to his hearing small guns fired: Apathetic stupor, clonic spasm, aphonia, abasia, severe deafness, poor sleep, refusal of food. The next day he was still mute, but the spasms had ceased. He lay apathetically in bed, taking a little liquid food. February 27 he was still mute, though more active, not deaf, getting up alone, walking unsteadily on a broad base, and playing cards at the table. March 2 the word _yes_ was again enunciated. March 3 he talked more freely and took a short walk. March 4 speech of a sudden came completely back on the occasion of getting excited in a quarrel among some other patients. The patient thereafter began to talk a great deal, was bright and cheerful, but still complained of a variety of nervous troubles. Speech was somewhat difficult, but he was free from any definite aphasia or paraphasia.

_Re_ Shell-shock deafness, Jones Phillipson states that concussion deafness is due to three contributory factors: (_a_) cerebral concussion, (_b_) fatigue (violent oscillation of the perilymph, continued noises, strain of organ of Corti), and (_c_) temporary or permanent disorganization of the conductive apparatus.

_Re_ concussion deafness, J. S. and S. Fraser found in four cases of actual explosion injury, a ruptured drumhead and hemorrhage into the fundus of the internal meatus in three cases. They did not find evidence of neuro-epithelial changes. Possibly the fundus hemorrhages, besides giving rise to deafness, may start up the tinnitus and giddiness that are sometimes found. In one case, there were changes in the delicate nerve endings of the auditory ampullae.

Shell-shock: Deafness

=Case 260.= (MARRIAGE, February, 1917.)

A shell burst behind an English lieutenant in 1914 without causing any wound but making him unconscious for an hour. During the hour the Germans passed by and stripped him of all articles of value. He came to and felt himself markedly deaf in both ears with an intense headache. There was no hemorrhage, no discharge, no tinnitus, no vertigo. Four days after the shell burst he could hear spoken words on each side at two feet, but could not hear a watch that could usually be heard from 3½ to 4 feet. With tuning fork C air and bone conduction proved much subnormal, though air conduction was better than bone conduction. With tuning fork C-5 air conduction was subnormal. Drums healthy. Improvement followed; hearing became normal eighteen days after explosion. The treatment was rest in bed with bromides early and strychnine later.

Marriage states that the psychical deafness due to shell-shock is usually bilateral and absolute. It is accompanied also, as a rule, by other nervous signs and symptoms, such as aphonia, tubular vision, paralyses, and anesthesias. Milligan and Westmacott state that the deafness is due to a functional suspension of neuronic impulses. They regard the brain as in a state of physical fatigue, and the mind as in a state of strain. There is no organic lesion. The neuronic impulses which are temporarily suspended are those which run from the higher cortical cells to the periphery.

Mine-explosion: Unconsciousness: Deaf-mutism. Recovery of speech after epistaxis and fever.

=Case 261.= (LIÉBAULT, October, 1916.)

A soldier, 24, teacher in civil life, was in a mine explosion November 27, 1914, at Vienne-le-Château. He was unconscious six weeks and remembered nothing of what had passed. They had told him that he had been blind for a month. After regaining consciousness he was a deaf-mute and for seven months he did not speak. His mutism did not bother him, as he thought he had always been mute. He had always been able to write. He could not remember what had interfered with his speech or tell whether he could think the words which he could not utter.

May 22, 1915, there was considerable nasal hemorrhage, with fever. Upon this day he began to speak, at first a few words, telegram style, and with aphonia. A week later his voice returned. He was very irritable during the period of mutism and had ideas of persecution and of suicide and complained of becoming easily fatigued and exhausted.

His voice, however, became completely normal again and his respiration better. On the spirometer he breathed four liters, but still got out of breath easily. His diaphragmatic respiration was still imperfect. His deafness remained at the time of report about as before, though he had now been hearing for some time a slight resonance of his own voice and could hear sounds emitted a few centimeters from his ear. At time of report there was still general fatigue with insomnia.

_Re_ war deafness, Castex states that not merely shell bursts and explosions are able to cause deafness, but the din of battle alone. There are two big groups of war deafness: one due to drum rupture, and the other due to labyrinthine shock. Labyrinthine shock--a much more serious matter--is produced when a big shell bursts. In these cases, the labyrinthine disorder is simply of the same general nature as _commotio cerebri_. The labyrinthine shock cases often need to be retired permanently from the front.

Shell-shock: Deaf-mutism.

=Case 262.= (MOTT, January, 1916.)

A deaf-mute, 24, not of a neurotic temperament or of a neuropathic predisposition, was admitted to the Fourth London General Hospital November 16, 1915.

He wrote, “I left England the 8th of March, and went to Gallipoli on the 26th of May, and about the middle of August, one of our monitors fired short. I felt something go in my head; then I went to the Canada Hospital. They said it was concussion.” He had seen the monitors firing. He came to in a dug-out about an hour afterward. He was quite deaf and his head felt as if it would burst.

He could see and speak a little but lost his speech completely when Barany’s tests were applied. The headache then passed away, leaving the deaf-mutism. The ears, on examination, proved normal. The patient was able to cough and whistle. He wrote his wife a letter, telling her how he killed a Turkish woman sniper, but he did not remember that he had written the letter. Although he said he did not dream, while asleep he would assume the attitude of shooting with a rifle, as if pulling a trigger, and then the attitude of using the bayonet: the right parry, the left parry, and the thrust. Sometimes while asleep he would jump as if a shell were coming, and he would catch his right elbow as if hit there. He would then open his eyes wide and look under the bed. Then he would wake up and begin to cry, but without sound. Just such habitual attitudes occur in soldiers under anesthesia. In hypnotic sleep, although he trembled at his trench experiences, he did not assume these defensive attitudes.

Mott states in his Lettsomian lectures that hearing is often absolutely lost, but that sometimes a man is absolutely deaf on one side alone, either from the ruptured drum or from the violence with which wax has been driven against the drum. Mott speaks of the frequency of auditory hallucinations, and of hyperacusis--part of the patient’s general hypersensitivity--which may increase the violence of the neurosis and especially aggravate the headache.

Shell-shock: Deaf-mutism; convulsions and dream.

=Case 263.= (MYERS, September, 1916.)

A private, 28, was seen by Lt. Col. Myers at a base hospital. This deaf-mute wrote, “I was standing and a shell bursted and that is all I can remember.” This might have happened six days previously. The patient wrote vaguely about a walk to “windy corner”; about being billeted in a dug-out, a train journey, and another hospital. He was deaf, deficient in sensibility throughout, especially in the left arm and left side of the face, and had severe headache. Two days later he started distinctly when hands were clapped while he was writing, but at the next hand-clapping there was no response.

After Lt. Col. Myers wrote down, “Imitate me,” and made consonant sounds, the patient succeeded imitating them. “You hear me a little now,” Lt. Col. Myers wrote. “Is this the first time you have spoken?” Patient replied, “I hope the Lord I can get my speech.” “But you did speak just now. Read this word. Say it.” Whereupon he was got to say his name and number.

The therapy was proceeding properly when suddenly he was seized with convulsions, limb movements chiefly clonic, back arched, eyes starting, later upturned. The patient pulled out a crucifix from a locker near the bed and regarded it ecstatically (pulse 85, corneal reflexes preserved). Three minutes later there was quieting down, and the patient was induced to talk. He began to talk about his wife. He had just been “seeing a farm and all the fighting.” A shell must have come in there. He had “seen the Lord Who saved him.” Intense headache and thirst followed. According to the patient the excitement was due to recovery of speech.

He later said, “It was just like a dream when I came to. I was sweating awful. I was seeing the Lord while I was in the farm by the Captain. I dreamed that I had the cross in my hand to meet him coming. I saw the trenches and the dug-outs and the wife.” In point of fact, the Captain at the farm had had his arm blown off, and he had found him lying on the straw unconscious. Under hypnosis it appeared that he had gone to a dugout from the farm and that at the clearing station he had been “raving, seeing things, shells, trenches, and things like that, sir.” A slow recovery was made after evacuation to England. Seven months later he returned to the front.

This case appears to belong to the B group of mutism cases, according to the classification of Myers, namely, to the group in which the effects are psychical rather than physical. According to Myers, whether mutism occurs as an apparent result of physicochemical or of mental causes--that is, as an A or a B case--it is _actually_ always the result of mental--that is, psycho-physiological shock. Mutism in the A cases of physical nature, where the shock must have been grosser and more profound, generally proves more severe than in the B cases. As to the appearance of unconsciousness, apparently confirmed by the patients’ statements that they “lost consciousness,” it is a question whether these cases are not really cases of deep stupor. According to Myers, the mutism is in nearly every instance closely dependent on some form of stupor, being generally the relic of such stupor after it has passed off. Let the loss of consciousness be a profound stupor due to the lifting or burial of the patient, then from this stage there will be a transition to a state of ordinary stupor in which intelligence is active but the patient is unresponsive to stimuli. The patient is in a condition called by Myers _excommunication_, in which the inhibitory process may be regarded as protecting the individual against further shock. As the stupor now passes away, it is natural that the inhibition should appear lost in the case of hearing and speech, which are two main channels of intercourse with others.

Dumbness is, by far, the commonest disorder of speech, occurring in about ten per cent of shock cases in the first thousand cases of shell-shock seen by Lt. Col. Myers. Stuttering and jerky speech have occurred in about three per cent. Loss of voice is rarer.

As against the view of Babinski, that mutism, being curable by suggestion, must have been produced by suggestion, Lt. Col. Myers argues that the stupor preceding mutism is the antithesis of suggestibility and is, in fact, a condition of extreme _autofixity_.

Naval gun-fire effects on seaman: Aphonia. Two recurrences.

=Case 264.= (BLÄSSIG, June, 1915.)