Part 35

Dupuoy speaks of the reason for the hysterical “choice” of this disease, since his mother had had a probably organic hemichorea, also on the right side, with which she died at thirty years in a stroke. The boy was at that time thirteen years old and had had a rhythmic chorea six weeks, limited to the extensors of the hand on the forearm, treated in hospital.

This new hemichorea was quickly and completely cured by psychotherapy.

Hallucinations and delusions in a soldier, of antebellum origin. Treatment by explanation of causes.

=Case 301.= (ROWS, March, 1916.)

A private, 31,--a case of Capt. W. Brown,--was admitted to hospital suffering from hallucinations of hearing and delusions of supervision by his family and friends; he heard his relatives telling him what to do and what not to do. He thought they belonged to a secret police entrusted with the task of supervising his actions and seeing that he did not again transgress as he had done. An inquiry into his past revealed the following facts:

He had been a bank clerk before the war and once because of a nervous breakdown as a result of drinking and smoking had been given a three months’ vacation. On this occasion he went with a prostitute--his first and only offence in sex matters. He later thought the behavior of his family indicated that they knew of his misdeed. He heard the voices of members of his family, became rapidly worse and more depressed, and attempted suicide.

He went to a private asylum. Later, he emigrated to Canada, but he was still pursued by the voices and he returned to England. He enlisted at the outbreak of the war and went to France. He was soon invalided and sent to Maghull.

The cause of his condition, according to Rows, was his affair with the prostitute and his previous drinking. This was explained to him as the basis of his strong feeling of self-reproach. The hallucinations and idea of suicide had developed therefrom. Recovery “to a large extent.”

A poor risk (hereditary and acquired); emotionality: Tremors and convulsive crises with lowering of pulse.

=Case 302.= (ROGUES DE FURSAC, July, 1915.)

A man, 36 (boat painter to 30 and thereafter a wine seller; paternal grandmother insane, father alcoholic and suicide; gonorrhea, 20; two attacks of lead colic, 25 to 30; purulent pleurisy, 31; phlegmon of mouth, 34; also a chronic alcoholic), at the time of examination showed arteriosclerosis and slightly hypertrophic liver; unequal pupils, slightly contracted and sluggish to light. He complained of frequent headaches, possibly due to a combination of plumbism and alcoholism. He was not in any respect demented, and had an excellent memory. He had always been emotional, being unable to go to a funeral without many tears, or remain in a house where there was a corpse without threatening to faint. He was always overcome if he saw a fight going on; and even in his wine shop he would escape when there was a fight and get a neighbor to bring the police.

He was mobilized on the fifth day, sent first to a territorial regiment 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.