Part 36

The right angle of the mouth was withdrawn slightly upward and outward, and lagged a little in active movements.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: