Part 37

On July 13, 1915, a bomb, dropped by an airplane, fell near an Italian soldier, killing many comrades, and throwing the man to the ground unconscious. He awoke several hours later at a hospital in a stunned condition. During the night, under the influence of terrifying dreams, he would leave his bed to look for enemies who, it seemed to him, were throwing stones and firing. He managed to grasp a rifle and fire at the images he saw. He was given a 60 days’ leave of absence during which he did not improve; and then again 90 days’ furlough, which he spent at his home, where terrifying dreams, tremor of limbs and asthenia continued.

He came under observation February 10, after his second leave. Nutrition fair. Insomnia. Constant terrifying dreams. Coated tongue. Tremor of hands, head, body, ceasing during voluntary movements. Episodically he had spells of dizziness followed by absent-mindedness, whereupon he wandered aimlessly about, of a sudden becoming aware of being in a place, but not knowing how he came there.

Special senses intact. Several points of cutaneous hyperesthesia, particularly mammary and pseudo-ovarian on the left, pressure whereon provoked a lively emotional reaction with acceleration of pulse, redness, lacrimation. Knee reflexes lively, cutaneous reflexes normal, except the plantar which were very lively. Restless, hyperemotional, he wept for insignificant reasons and wanted to leave hospital for fear of dying there. He was discharged unimproved after a fortnight.

Nostalgic temperament; depression on entering service; rheumatism. A box falls from an airplane near by: Fear and tears; later depression, nostalgia, dreams, hyperthyroidism.

=Case 320.= (BENNATI, October, 1916.)

An Italian private in the infantry was recalled to military service. He was a small farmer, and being disposed to homesickness, grew depressed from the day he left for service. His sleep was disturbed, he was greatly affected by the wet and damp of the trenches, and was in a state of continual fear. Finally, pains, hypersensitiveness, and fever developed.

As an enemy airplane passed over one day, a box fell at the man’s feet and threw him into a profound fear with tears. He was conducted to a tent to rest; his regiment was shortly sent to the rear, and he remained on active service for a few days despite the fever and pains. Finally the swelling of his leg compelled him to take to bed. (Fatigue in antebellum life had always shown itself in aches of the legs.) He had now been in active service about a month and his homesickness overcame him. He was in a state of deep physical and mental depression. It was not his own troubles so much as those of his family which preoccupied him. His knees hurt him so that he had to weep; or if Sardinia was mentioned, he cried, and said, “Oh, how I love Sardinia!” He grew fatigued very easily. He had many dreams about Sardinia, his father, and the war, especially dreaming about being wounded in the legs (question of being stimulated by the joint aches). The reflexes were normal, though slight tremors set up in the legs after testing. The thyroid gland was somewhat swollen, and it appears that the patient had noticed this five days before entering hospital. The patient was rather vagotonic; pulse-rate stood at 56; oculocardiac-reflex, 56-84; Mannkopf negative; Thomayer and Erben marked (56-88 and 88-60); von Graefe marked; Stellwag present.

A shell pitches without bursting: Unconsciousness; stupor; MAMA MIA!; oniric delirium; amnesia. Recovery in five weeks.

=Case 321.= (LATTES AND GORIA, March, 1917.)

An Italian soldier of the Class of ’95, a mechanic (mother cardiac; as a boy, pains in joints and heart; since boyhood, no illness), had a big Austrian shell pitch near him, July 23, 1915. The shell failed to explode and injured no one. The patient, however, fell to the ground, unconscious, and remained in the camp hospital for two days, quite immobile. This event followed an advance by his company under very fatiguing circumstances without sleep for a period of four days.

July 26, the patient was observed in profound stupor, non-reactive, constantly and monotonously repeating the phrase, _Mama mia!_, with fixed gaze and smiling as if at visions. He swallowed food. The pupils reacted poorly to light, and the cornea and nasal mucosa seemed anesthetic. The tendon and skin reflexes were lively. The muscles were hypotonic; bradycardia, 56; no control over feces or urine.

July 27-28, restlessness at night, gasping movements, and poses of terror.

July 29, he called for his mother, who had been dead for several years. He was still stuporous and insensible.

From August 1 to 10, he improved slowly and became able to carry bread to his mouth after it had been put in his hands. He still did not speak and made signs when he wished to urinate or defecate. Pulse 50-60.

August 12, the patient began to react to intense light and to pain stimuli, as well as to pressure. He ate voraciously.

August 15, visual stimuli were responded to, the pulse had risen to 80, the skin reflexes were no less lively. There began to be terrifying dreams at night, with motor reactions.

August 17, the patient looked about more alertly, promptly seeing bread when placed in the center of the field of vision and saying words to the man who might try to remove the bread. He did not yet react to acoustic stimuli, nor was there any other change up to August 21.

August 22 a notable improvement set in. The hearing was now slightly diminished, questions were answered after a brief refractory period. After a few questions, however, a state of exhaustion would ensue, which would disappear only after a short rest. There was amnesia for the entire period following the day of his departure for the front, May, 1915. At this time, instead of eating voraciously, he showed anorexia. The skin and tendon reflexes, instead of being lively, were now dull. There still were battle dreams of enemies trying to kill him.

August 25, there was an area of hypesthesia on the inner aspect of the right thigh, but otherwise no disorder of sensation. The pulse stood at 80 and there were no other neurological phenomena.

August 31, the patch of hypesthesia of the thigh and the retrograde amnesia disappeared. There was still a slight diminution of hearing. The accident of the non-exploding bomb could now be recalled, but there was a memory gap for all facts up to the latter part of August.

September 2, dreamless sleep; no signs of abnormality except a slight diminution of hearing. Discharged, well.

Jostled carrying explosives; no explosion; unconsciousness: Deafmutism and foggy vision. Gradual recovery from these symptoms. Then, on rising from bed, camptocormia.

=Case 322.= (LATTES AND GORIA, March, 1917.)

An Italian of the Class of 1891 (convulsions and pains in the spine, with rigidity, as a child; typhoid fever at 18; brother sickly, neuropathic; mother subject to periodic convulsions; father alcoholic and nervous), on the night of November 26, 1915, was carrying a number of tubes of explosives. A comrade stumbled and fell over the soldier, who fell to the ground unconscious. None of the glycerine tubes exploded, and none of the soldiers round about were hurt.

The man regained consciousness at the camp hospital, but remained deafmute and also impaired as to vision. It was as if a screen of fog lay between him and objects seen.

During fifteen days of observation at the camp hospital, he had terrible war nightmares. The mutism, the visual disorder, and the deafness then gradually disappeared without special treatment.

However, when the patient rose from bed, it was found that his lumbar vertebral column was stiff. He walked bent forward and was unable to bend or straighten the back. There was a hyperesthesia along the vertebrae, especially on pressure. X-ray examination showed no bone lesion. The larynx and cornea were sensitive, and the plantar reflexes were absent. The abdominal reflexes were present. The pupils reacted to light and accommodation. There were two areas of analgesia in the nipple regions. The expression of the patient’s face was relaxed and drooping.

A heavy cannon slides and grazes a man: Unconsciousness; stupor; amnesia (anterograde amnesia persistent). Complete recovery in less than seven weeks.

=Case 323.= (LATTES AND GORIA, March, 1917.)

An Italian soldier of the Class of 1895, a peasant (family healthy; non-alcoholic; good scholar) was, July 19, 1915, helping drag a heavy cannon up hill. The big gun slid, hit several men, and grazed the patient, making a slight abrasion on his leg. He immediately lost consciousness, and arrived at the camp hospital in a stupor, which lasted so long that catheterization was necessary.

A week later he was observed in hospital, immobile and non-reactive, with a swollen abdomen and fecal impaction. The pupils were widely dilated and reacted poorly to light. The corneal reflexes were absent, and the nasal mucosa was anesthetic. Pulse 50. The patient failed to eat. Next day there was no change in his condition. He was quiet throughout the night.

On the morning of July 29, a number of answers were obtained to questions put in a loud voice, though he was unaware of much more than his name, being ignorant of the name of his country, his age, his division, where he had come from, what had happened to him, or where he was. He had now begun to eat spontaneously.

During the following days, up to August 4, the amnesia gradually dissolved for the facts before the trauma. He remembered having been greatly frightened at the time of the accident but could not remember the accident itself, and the gap for subsequent events was still complete. The pharyngeal reflex was still poor. August 5, he began to remember the details concerning the accident. About the middle of August there was no longer any diminution of hearing and ideation became more free and rapid.

September 4, he was discharged, well.

Shell explosions SEEN: Emotion; insomnia. Artillery HEARD twelve days later: “finished off.”

=Case 324.= (WILTSHIRE, June, 1916.)

A lance-corporal, 36, had had a nervous debility four or five years before the war, caused by an overstudy of music. He had not stopped work at that time, but suffered from depression, anorexia, and insomnia, lasting for some weeks.

The lance-corporal got on well at the front for 11 weeks, until finally eight shells pitched near him. Although he was unhurt, he began to suffer from anorexia, insomnia, and depression. While in billets 12 days later, some English artillery became heavily engaged, whereupon “The noise promptly finished me off.” The insomnia, depression, and anorexia became more marked, and the patient could not sleep unless heavily drugged.

Shell-shock: Emotion. More shells: Insomnia; war dreams. Head tremor and tic, two weeks after initial shock.

=Case 325.= (WILTSHIRE, June, 1916.)

The psychic trauma is, according to Wiltshire, more important than physical trauma in the following case of a sergeant of infantry, 28, a man without neuropathic taint. This man had been nine months at the front and through Mons, but had been quite well until three weeks before coming to hospital.

“Twenty-three days ago, I was issuing rations when they got the range of us--and killed the other chaps. I got blown away and knocked over. I saw everything--fellows in pieces. Then a second shell came. I got lifted and knocked about ten yards.” Then he began to shake but carried on.

Two days later, “Shells dropped on the dug-out and killed the other chaps. I have not slept properly since this. If I go to sleep, I wake up seeing people killed, shells dropping, and all kinds of horrid dreams about war.” One or two of the men killed had been pals.

A fortnight after the first incident, while in a base hospital, head-shaking began. The patient would jump at the least sound. There were spasmodic tic movements with the extension of the head, protrusion of lower jaw, and contraction of occipitofrontalis muscle. Sometimes the left shoulder girdle was affected in the same way. There was a slight fine tremor of hands and eyelids and difficulty in keeping the eyes fixed on an object.

Hyperthyroidism, hemiplegia, irritative symptoms after exhaustion (by heat?).

=Case 326.= (OPPENHEIM, February, 1915.)

A man (not previously nervous, no faulty heredity, heatstroke August 21) suddenly fell down in a great heat, after a fatiguing march, and remained unconscious for several hours, waking with vertigo, headache, paralysis of left side, vomiting, and twitching of the face. On September 23, admitted to reserve hospital. Knee phenomenon increased. Urinary retention; catheter used. Speech disturbance, facial twitching. Vomiting had stopped September 10. Catheterization could be avoided through warm sitz-baths. October 30, on sitting up, occipital pain and vertigo. November 15, urinary symptoms improved. Also improvement otherwise. December 1, gait vacillating and uncertain. Headache. Admission to nerve hospital, December 3. Here complained of twitchings in the frontals and corrugators. Wide palpebral gaps. Rare, or absent, movements of lids. The extended hands showed active, rapid tremor. Tendon phenomena increased in the arms and especially in the legs. Abdominal reflexes increased. Active tremor in the legs. Gluteal tremor. Very pronounced Graves’ symptoms. Syndactylism very pronounced in the feet, between second and third toes. Later on, improvement under half-baths, etc. Worse after ten days’ leave of absence, especially marked increase of tremor (rest tremor), augmented on movement.

_Re_ heat stroke, Wollenberg has called attention to the effect of the heat of the summer months upon German soldiers. Cases of heat stroke have not been rare in the German army. About half the cases have convulsions or epileptoid seizures, as well as tremors and nystagmus. About a quarter of the cases have shown confusion and delusions, with anxiety and mania. A degree of mental impairment has followed a number of these heat strokes, together with sundry signs of organic disorder, such as reflex changes, pupillary changes, and difficulty in speech.

Forced marches; skirmishes; rheumatism: Generalized TREMORS. On the road to recovery in six months.

=Case 327.= (BINSWANGER, July, 1915.)

A German letter carrier, 27, entered the war at the outset, made forced marches in great heat, was in a number of skirmishes and in the capture of Namur, and fell ill early in September, with swollen and painful right foot and rheumatic pains in knees and shoulders. He was put on garrison duty; but the rheumatic pains in the joints increased toward the end of September, and he was treated in hospital for rheumatism.

He became able to walk only in the second half of December, marked tremors affecting the whole body. His bodily condition had been good. He slept well, and while at rest in bed he felt entirely well; but upon every attempt to get up and put his feet down, these violent trembling motions would always reappear. Treatment by hydro- and electrotherapy remained entirely unsuccessful. February 8 he was transferred to a nerve hospital.

He had been in the postal service from 1903. He was of normal bodily and mental development and had had no previous illnesses. His military service had been executed from 1909 to 1911. He had always been a passionate smoker but had not abused alcohol. His mother is said to have been for some time paralyzed, following a fright.

Physically, the patient was a slender but strongly-built and fairly well-nourished soldier. The first sound at the apex of the heart was rough and impure, and the heart was somewhat enlarged to the left. The pulse was irregular, 106. The arteries were somewhat stiff. Neurologically, there was a marked dermatographia of comparatively long duration. The periosteal reflexes were increased; the deep reflexes could not be properly examined. The whole leg trembled and heaved unsuccessfully on attempts to raise it voluntarily. After even a slight stroke on the patellar tendon, the trembling became excessive and irregular, and the leg passed into a heaving spasm which would outlast the percussion for some time. The patellar clonus could be obtained with the knee extended. The shaking movements were somewhat more marked on the right than on the left side. Similar phenomena occurred when the Achilles reflexes were being examined. The triceps reflexes on both sides were increased but there was no tremor or spasm of the arms. The plantar reflexes were very lively, and following these reflexes appeared tremors of the legs. When the spinous processes of the vertebral column were percussed, a general shaking spasm appeared. Tactile sense was everywhere normal, but the pain sense was increased. Upon slight pin-pricks in the skin of the legs, there would occur a marked shaking spasm of the leg, passing directly to the other leg. These phenomena were more marked on the right side than on the left. When sitting upon a chair with back supported, a slight tremor would appear when the hands were raised and stretched out, more markedly on the right side than on the left. Movements of the arms were normal. However, the hand-grasps were: right, 105; left, 80. In dorsal decubitus the movements of the leg were performed comparatively well at first, but after a few repetitions, the shaking spasm would occur on both sides, and the movements would become very awkward. The heel-to-knee test would then fail. If the patient were put on his feet, he would immediately fall into spasms, first in the right leg, then in the left. The trunk would now be involved, and soon the arms, whereupon the whole body, with the exception of the head, would be seen trembling and shaking, and the patient would fall forward, trying to get support by leaning against a wall, seizing a chair, or sinking down slowly. The spasms disappeared at once in dorsal decubitus and in sitting with supported back. Outward irritation by the acoustic, optic or tactile avenues would bring out spasms in the legs, always more markedly on the right side than on the left. Psychic irritations would cause spasms. The muscles of the limbs were held in great tension, the flexors and extensors being alternately affected. When the patient was moving along a wall with a difficult, swaying gait, his efforts reminded the examiner of the attempts of a heavily intoxicated man to walk. Upon attempts to create passive movements of the lower limbs, severe shaking and trembling movements set in, followed by a general spastic tension of the leg musculature such that it could not be further flexed or extended.

The patient was put in the psychiatric section, as too seriously ill for the nerve hospital. He improved after a few days, being then able to walk without much support although still with some shaking and tremor. If his attention was diverted, passive movement of the leg could be carried out without developing spasm. He was treated in a room by himself with removal of all outward irritation. His legs were treated for an hour, three times daily, by means of moist packs. On account of complaints of insomnia he was given small doses of hypnotics.

The main thing here, according to Binswanger, is the psychotherapy. The patient was told almost daily in the course of conversation, first, that the illness was being cured; secondly, that upon recovery he would be employed in the future only on the postal service. He was told that he would have to avoid marked physical exertion, of course, but that he still would be fit for office work and could serve the fatherland in this way. Still he could not be transferred back to the hospital, he was told, unless he became entirely well, so that he could move with perfect freedom.

February 23 the patient was performing daily exercises in walking and standing; the spasm became very slight on standing, and often would entirely cease, but it remained still plainly present in the legs; the trunk and arms were free. External irritations were now less prone to excite spasm. Sleep became quiet and dreamless. He was transferred to the nerve hospital, able to move about freely in house and garden and only tremulous after long walks and considerable bodily and mental fatigue. He was given a week’s furlough home. He wished very much to get into the postal service; at the time of the report he had not attained this goal. He had renewed attacks of trembling upon exertion, and was transferred at the end of June to a convalescent home.

Shell-shock; emotion: Hyperkinesis, fear, dreams.

=Case 328.= (MOTT, January, 1916.)

A private, 21, was with 30 men carrying sandbags in the daylight, under shell fire. He was thrown into a deep hole by an explosion, climbed out, and saw all his mates dead.

He was admitted to the Fourth London General Hospital, June 20, 1915, having been at Boulogne for a fortnight. He was lying in bed on his back, making continuous jerky lateral movements of head, and movements of arms, especially of the left arm. He was groaning slightly, now and then raising his eyelids with a staring expression of bewilderment and terror. He was able to mutter answers to questions. He would occasionally raise his right hand to his forehead. If he was observed, these movements became exaggerated. They ceased in sleep. He muttered even when unobserved. He continually said, “You won’t let me back.” Asked as to dreams, he replied, “Guns.” Voluntary movements were made, which prevented obtaining reflexes. When his pupils were to be examined by a man in uniform, he showed a marked facies of terror; his pupils were dilated; the eyes opened wide, the brows were furrowed, and there was an anxious scowl. The flash of an electric light produced the same effect.

June 24 the patient was much better. He said the explosion which had killed his friends after he had been only a few weeks at the front, was the first serious event in his service. He kept seeing it again, with bright lights and bursting shells. Sometimes he would hear the men shouting. In dreams he both saw and heard shells and men. There was pain in the back and right side of the head.

June 26 he was improved but still had pain in the back of the head, especially when trying to remember, and a slight tremor of the hands. He had been given hot baths at Boulogne on account of being very cold and shivering. He had always felt sick at the sight of blood. He was boarded for Home Service six months after admission.

Shell fire and barbed-wire work: Tremors, anesthesias, temperature and pain hallucinations.

=Case 329.= (MYERS, March, 1916.)

A corporal, 39, had been working under shell fire at barbed-wire entanglements. The man was big and robust, but much depressed, complaining of noises in the head, pricking pains, unsteady legs, fatigue, irritability, loss of confidence. He showed tremors of arms and legs on movement, and stood unsteadily with eyes closed. He said: “My legs have been very unsteady, especially when some one is looking at me. They must have thought me drunk at times.”

The head and tongue were tremulous, the knee-jerks exaggerated, the soles insensitive to touch and pain; but sensibility to deep pressure was retained. There was a gradual return of right answers on further trials, aided by comparison with effects of stimuli applied to the dorsum of the foot. Though he gave correct replies on heat and cold tests over the arms, he gave wrong answers over the dorsum of the feet, less often over legs, sometimes over thighs.

Later during examination, the feet became tremulous. He felt a “silly childish fear,” and his hands began to feel cold and clammy; whereupon he began to reply _hot_ or _cold_ when the tubes were not applied at all (temperature hallucinations). There were apparently pain hallucinations in the soles and errors in response to the compasses.