Part 39

“Private ---- was close to a shell which burst among a company standing in the road, killing 20 and wounding 20 others. He worked well in assisting the wounded, and then proceeded to clear up the fragments of the killed. Whilst doing this, he suddenly lost his mental balance and has been in his present state nearly 24 hours. He has been given bromides.”

An M. O. attached to the same ambulance wrote: “This man is suffering from mental shock caused by having to clear away the remains of a number of men killed by a shell. He does not recognize his friends, and at frequent intervals has periods of terror, exclaiming, ‘Cover it up.’ He is sleepless (without drugs); he takes food badly. He is possibly suicidal or may become so.”

According to the patient himself, he had been quite well for four months at the front. He was on the La Bassée Road with the troops after a day or two of heavy work under shell fire. “And I remember the flash of some shot and a shell burst I think, and I can’t remember anything more. I awoke in the morning, in the train” (48 hours later). “I can only remember men calling out.” He complained of a feeling in the head, as if expecting something. “Something seems to be coming,--as if something was going to happen,--something nasty, whenever I hear anything like the whistling of a shell coming towards me.” This patient was without tremor and was physically normal. So far as the patient’s own story went, the case might well be regarded as one due to physical concussion, but the notes of the medical officers give evidence of a psychic element.

Depression with suicidal thoughts after witnessing death of comrade.

=Case 339.= (STEINER, October, 1915.)

A farmer, 52, volunteered and was put in charge of a drinking-water still. He had never been ill nor was there any nervous or mental disease in his family. From the end of August he was frequently under shell fire, but the only effect thereof was a somewhat poorer sleep than normal.

December 14, 1914, a young comrade, a volunteer, wanted to clean his dirty kettle at the drinking-water still. The farmer later described this volunteer as a young fellow “like milk and blood” (as we might say, “like peaches and cream”) and as the handsomest young man he had ever seen in the war. The rules forbade such use of the still, and young “milk-and-blood” was told to go down to the brook, and then come back and get the distilled water. The young man complied, but while at the brook he was shot and killed in full sight of the farmer.

The farmer grew much excited and trembled all over. Thereafter he could not eat or sleep; he reproached himself, although he knew he had acted quite correctly; wished he had been in the place of this comrade; and had suicidal thoughts. He was deeply depressed, wept easily, and showed manual tremor. Steiner terms the farmer’s account of the person of the deceased “reactive idealization.” After a week there was considerable improvement. B. was sent back to work, which he felt would be beneficial. He was put in less dangerous surroundings, and this also had a good effect.

Marching and battles: Neurasthenia?

=Case 340.= (BONHOEFFER, January, 1915.)

A subaltern had been treated before the war for nervousness, dizziness, and “mattigkeit” (convulsions in infancy), but proved himself a good soldier, having gotten his rank after the first period of practice.

He was in three battles in Belgium, but on the march one day suddenly had a spell of weakness and is said to have had convulsions. There was, however, no biting of the tongue, and no enuresis. After a week in the field hospital, he was sent back to Berlin where he had some somatic feelings of anxiety without subjective disturbance or any disorders of consciousness except a certain amount of inhibition; he was sleepless and hypersensitive, cried easily, and was apprehensive on being touched; he winked violently on examination of his eyes, and while being tested for reflexes made violent contractions of a semi-voluntary nature.

After four days in bed, which was a prescription hard to carry out at first on account of the anxiety sensations, these sensations disappeared, and at the same time the fears. Weight began to increase; memories returned, except that even upon recovery he could not remember that he had ever had any true subjective feelings of fear. He was discharged 19 days later, desirous of going back into the field.

The peculiar absence of subjective feelings of fear in this case is something like what Awtokratow reported from the Russo-Japanese War, terming them neurasthenic psychoses.

_Re_ neurasthenia, Babinski believes that, by means of his logical dismembering of the old hysteria concept, he has shown that the exhaustion phenomena at the bottom of neurasthenia are precisely these that cannot be cured by suggestion. There are numerous cases in which hysteria and neurasthenia are combined. From these combined cases, suggestion causes the hysterical or pithiatic symptoms to be removed.

English schoolmaster’s account of his war dreams.

=Case 341.= (MOTT, February, 1918.)

A sergeant, who had been a schoolmaster, was asked to write down his dreams by Captain W. Brown, who had sometimes charge of Mott’s cases at the Maudsley Hospital. The first dream was as follows:

“I appeared to be resting on the roadside when a woman (unknown) called me to see her husband’s (a comrade) body which was about to be buried. I went to a field in which was a pit, and near the edge four or five dead bodies. In a hand-cart nearby was a _legless body_, the head of which was hidden from sight by a slab of stone. [He had seen a _legless body_, which was covered with a mackintosh sheet, which he removed.] On moving the stone I found the body alive, and the head spoke to me, imploring me to see that it was not buried. Burial party arrived, and I was myself about to be buried with legless body when I awoke.”

The second dream was as follows:

“After spending an evening with a brother (dead 11 years ago) I was making my way home when a violent storm compelled me to take shelter in a kind of culvert, which later turned into a quarry, situated between two houses. Men were doing blasting operations in the quarry, and whilst watching them I saw great upheavals of rock, and eventually the building all around collapsed (explosion of a mine). Amongst the débris were several mutilated bodies, the most prominent of which was _legless_. I tried to proceed to the body, but found that I was myself pinned down by masonry which had fallen on top of me. As I struggled to get free the whole scene appeared to change to a huge fire, everything being enveloped in flames, and through the flames I could still see the _legless body_ which now bore the _head of my wife_, who was calling for me. I was struggling to get free when my _mother_ seemed to be coming to my assistance, and I awoke to find the nurses and orderlies standing over me.”

It appears that the patient had been shouting in his sleep, beginning in a low voice and gradually becoming louder until at last he was shrieking. The _legless body_ occurred in all his dreams; the sight of this had evidently produced a profound emotional shock. He had worried a great deal about his wife, who was much younger than himself, so that we have this incongruous association of the _legless body_ and the _head_ of his wife calling him; finally, what more natural than the _mother_ to come to his help. The emotional complex is not incongruous in this dream, for fear is linked up with the tender emotion.

_Re_ war dreams, see remarks under Case 333 concerning oniric delirium. Roussy and Lhermitte say that emotion and concussion are the causal factors; but in a case like 341 we have persistent war dreams of the same general nature. Such a case as Mott’s would not be regarded as one of oniric delirium, for the patient is not living throughout the day in a dream, but merely has certain set dreams. The true oniric delirium cases may lead to fugues of medicolegal importance. Mott’s conception is that the terrifying experiences that come to light in the dreams are repressed by the conscious activity of the mind in the waking state. For this process, the phrase _psychic trauma_ might be used. Rows speaks of a prolongation of mental disorder through memories which get revived in dreams. The memories of past and recent events pile up on one another. Elliot Smith remarks on the number of cases in which the dreams show a coalescence and blending of episodes alien to the war. _Re_ such combinations, see Case 342 of Rows, below.

Trench experience: War dreams, shifting to sex dreams. Recovery on giving the patient an insight into the nature of his dreams.

=Case 342.= (ROWS, April, 1916.)

A patient broke out of a hospital after being refused permission to leave the grounds. He grew much depressed and said he had been disgraced and would commit suicide rather than bring disgrace on his family. Investigation into this emotional outburst showed that his father had deserted the family, that he had gotten into prison, and “tainted me.” The patient was worried also about an idea of loss of sex power, gathered from a book by a quack doctor, read years ago. It appeared also that this doctor had advertised a special bread and special medicine which would preserve the nervous system, and that for years the patient had fed himself and his family with the bread and medicine. When the true state of affairs was shown to the patient, his restlessness at night disappeared. The mental condition of this man in fact became practically normal, and the marked tic of facial muscles and the general tremulousness of the man disappeared.

It is of note that this man’s dreams began with a terrible incident in the trenches and then shifted to sex acts. He woke to find the clothes disturbed.

This is an example of hallucinations dispelled by tracing them to their source, and giving the patient a clear insight into their nature.

According to Ballet and de Fursac, after the acute phase of stupor and excitement with hallucinations and delirium passes, the patient remains a depressed and psychasthenic subject. In this psychasthenia we find inhibitory phenomena, hyperemotionalism, and over-imagination. Amongst the inhibitory phenomena are many of the hysterical effects. The hyperemotionalism yields anxiety, worry, tremors, respiratory and vasomotor disorder, dizziness, convulsions. The third main disorder of the psychasthenic state into which the patient relapses is over-imagination, whereunder we find bad dreams (bombardments, drum-beating, corpses, attacks), somnambulistic hallucinatory episodes. It is these hyperemotional and hyperfantastic features that distinguish the Shell-shock syndrome from ordinary psychasthenic states.

_Re_ the sex element in this case, see remarks under preceding case (341) and also Lépine on the sex factor (Case 332). Rows believes that those cases which do not recover after a short period of rest and quiet in hospital are cases in which there is some emotional state based upon the constant intrusion of the memory of some past event. The physical expression of the emotion of fear or terror may persist for a long time quite unchanged and be proved to be due to this old factor.

Emotional shock: Recurrent dreams of war and peace incidents. Recovery followed tracing the dreams to their origin.

=Case 343.= (ROWS, April, 1916.)

A soldier and a comrade were carrying a pail of water to the trenches. It was very cold and they set down the pail in order to warm their hands. The comrade placed his hand against the man’s cheek and said, “That hand is cold.” At that moment he was shot dead.

This incident was involved not only in dreams at night, but in the daytime too, if he were quiet and closed his eyes, he could feel the cold hand against his face.

He was troubled at the same time by another dream, in which he ran down a narrow lane at the bottom of which there was a well. He dipped his hands into the water, but on withdrawing them, he was horrified to find they were covered with blood. This dream was connected with a love affair, in which a good friend interfered and angered him so much that he attacked him when next they met. He left him on the ground so injured that it was necessary to take him to a hospital. The patient became anxious as to what the result might be and left the district. He traveled, but never heard whether his victim had died.

When these two dreams were traced back to their origin they disappeared: the patient made a rapid recovery and was able afterwards to bear a severe trial satisfactorily.

See remarks under Case 342.

War dreams, including hunger and thirst.

=Case 344.= (MOTT, February, 1918.)

(_Recorded Dream of a Second Lieutenant._)

“During the five days spent in the village of Roeux I was continually under our own shell fire and also continually liable to be discovered by the enemy, who was also occupying the village. Each night I attempted to get through his lines without being observed, but failed. On the fourth day my sergeant was killed at my side by a shell. On the fifth day I was rescued by our troops while I was unconscious. During this time I had had nothing to drink or eat, with the exception of about a pint of water.

“At the present time I am subject to dreams in which I hear these shells bursting and whistling through the air. I also continually see my sergeant, both alive and dead, and also my attempts to return are vividly pictured. I sometimes have in my dreams that feeling of intense hunger and thirst which I had in the village. When I awaken I feel as though all strength had left me and am in a cold sweat.

“For a time after awaking I fail to realize where I am and the surroundings take on the form of the ruins in which I remained hidden for so long.

“Sometimes I do not think that I thoroughly awaken, as I seem to doze off, and there are the conflicting ideas that I am in the hospital, and again that I am in France.

“During the day, if I sit doing nothing in particular and I find myself dozing, my mind seems to immediately begin to fly back to France.

“A dream that keeps on coming up in my mind is one that brings back a motor accident I had about six years ago, which gave me a severe nervous shock. I had, of course, entirely forgotten about it, except when in a motor, when I always thought of it.

“Of the fifth day I have absolutely no recollections.”

This is the one instance in which a man has dreamt the experience of hunger and thirst in addition to battle experience.

Olfactory dreams: Hysterical vomiting.

=Case 345.= (WILTSHIRE, June, 1916.)

A lieutenant in the infantry (mother, of a nervous disposition) had been at the front for 3½ months when he started vomiting everything he ate.

He was transferred a fortnight later to a base hospital as “gastritis.” Physical examination proved negative, but the man complained of his nerves. He slept badly owing to trench-life dreams, from which he would wake in a sweat. He was quite unwilling to refer to these dreams.

In point of fact he had had to supervise the burial of many decomposing bodies, after which he had been haunted “by that awful smell of the dead.” Then developed states of abstraction, in which he went over and over the burying experience. He cried by himself.

It seems that the vomiting was secondary to hysterical hallucinations.

_Re_ affections of smell and taste, Roussy and Lhermitte remark that they are rare following shock or trauma in war. Medical suggestion may produce a hemiageusia or a hemianosmia. Mott’s case above (344) showed unusual dreams with hunger and thirst. For another olfactory case, see Case 510 (Rivers) in the Treatment Section of the book, a case in which Rivers was able to find no redeeming feature upon which to ground his re-educative suggestions.

_Re_ vomiting, Roussy and Lhermitte state that this relatively common condition is diagnosticated readily enough but that pyloric ulcer and other organic causes must be eliminated. They remark that there is no tendency to spontaneous cure of neuropathic vomiting, and commend strict dietetic régime and psychotherapy. They ally the condition in its nature and genesis with so-called false or hysterical incontinence of urine in soldiers. Wiltshire’s case early received the diagnosis “gastritis.” It is remarkable how little emaciation need follow such vomiting.

Shell-shock: Amnesia; dreams of falling. POST-ONIRIC suggestion--surprise produced fear of falling.

=Case 346.= (DUPRAT, October, 1917.)

A man was subjected to shell-shock August 11, 1916, at the Somme. He lost consciousness for five hours and was picked up stuporous with verbal amnesia, which soon passed leaving only a difficulty in getting the right word promptly. He began to have frightful dreams of falling into a hole and of exertions to avoid falling, whereupon he would awake with a feeling of anxiety that would last some time. Treatment caused the dreams to disappear.

There remained, however, a powerful _post-oniric_ suggestion. Any slight surprise would cause the fear of falling to reappear. There was a sort of derived phobia, against any military act that would need to be performed upon sudden order. He developed a blind anger against any commanding officer who gave a brusque order. After the crisis of anger he would fall into tears and a feeling of profound depression coupled with precordial anxiety. There was also a chronic aortitis physically determined. The man himself had a vague idea of the relationship of his fear of surprise to the old nightmares.

_Re_ persistence of fear and its relationship to nightmares, see remarks under Case 342 (ROWS).

Four months’ SERVICE IN THE REAR: Depression; war HALLUCINATIONS (not based upon actual experiences); psychasthenic symptoms.

=Case 347.= (GERVER, 1915.)

A Russian lieutenant, 32, arrived at the front in November, 1914, but never served on the front line, or had occasion to visit the line or the trenches. Toward the close of February, mental symptoms appeared, which caused the man’s evacuation to the interior.

He was a tall, well-built, well-nourished man, who was physically normal except for sharp twitching movements of the tongue, eyelids, and face; tremors of extended hands, occasionally spreading to the whole body; well-defined dermatographia (in places, stereodermatographia); exaggerated tendon reflexes; tenderness of skull and spine; hyperesthesia of chest; pulse 120.

Mentally, the patient was markedly depressed, irritable, at times lacrimose. His complaints were of a psychasthenic tinge. He feared incurable disease. He feared to go to the front, and was terrified at what he might do there. He feared crowds of soldiers; he was afraid of forests and mountains; the Germans were going to break through and capture him; shells were about to burst over his head. He was also disturbed about his family, regarding his wife and son as helpless, sometimes even as dead. Suicidal thoughts at times.

At night, though he had never been at the front, he had hallucinations of shots and the voices of soldiers, as well as those of his wife and son. He smelt an unpleasant corpse-like odor. He was unable to distinguish these hallucinations in any respect from reality. He complained of general weakness, headaches, palpitation of the heart, vertigo, and insomnia, and of a variety of pains.

He was non-alcoholic and non-syphilitic, and had been in perfect health before the war.

_Re_ war hallucinations with service back of the line, compare remarks of Régis (see under Case 333).

A case of hysterical astasia-abasia develops “big belly” (“catiemophrenosis”), perhaps by hetero-suggestion from a ward neighbor.

=Case 348.= (ROUSSY, BOISSEAU and CORNIL, May, 1917.)

A farmer, 22, of the foot chasseurs, who had been in various hospitals with a variety of diseases before his injury, was evacuated June 2, 1916, for “contusion of back,” to the temporary hospital at Bussant, from which he was evacuated to Pontarlier for “contusion of back and cerebellar shock” and thence, July 21, to Besançon for “internal contusion and cerebellar shock”; thence to four other hospitals from July 31 to February 17, 1917; finally to the Hospital at Veilpicard with “functional disorders, paraplegia, trepidant astasia-abasia.”

It seems that he had lost consciousness for fifteen days and had thereafter been paraplegic with retention of urine. The abdomen had then increased in size in such wise as to be termed a nervous pregnancy, _grossesse nerveuse_. The evolution of this pseudotympanites was probably related to the presence of the same so-called “big belly” of a patient who had been in a neighboring bed from May, 1916, onwards. The feet were in equine position with toes flexed, suggestive in all ways of hysterical paraplegia. The abdomen looked like that of a woman six months pregnant and measured 78 centimeters in a plane passing through the anterosuperior iliac spines and the umbilicus. The abdomen was hard, tense, swollen, and on palpation, gave out a low, tympanic note. When the diaphragm was mobilized progressively and slowly, the tympanites could be made to disappear. Slow pressure on the abdomen with flat hands effaced the swelling for the time being; but upon release of the hands the abdomen would swell up again as before. Pressure on the abdomen produced a contracture of the recti. Forced flexion of thighs on pelvis (as suggested by Denéchau and Matrais) also caused the swelling to go down. Faradization of the phrenic nerves in the neck caused respiratory movements with a slight diminution in the volume of the abdomen. There was an obstinate constipation requiring daily lavage. Respiratory movements were short and rapid and of the thoracic type. Abdominal compression caused the respiration to assume almost a normal rhythm. X-ray examination of the abdomen, after 50 grams of bismuth carbonate had been taken in three spaced doses the evening before, showed the intestine to be distended by gas in such wise that the lower border of the liver became clearly visible, as after insufflation of the stomach. The bismuth was found in the large intestine. The splenic angle filled with bismuth was low. On compression the splenic angle was raised with the diaphragm.

The main features of this disease are the large abdomen, simulating what has hitherto been found chiefly in females under the name of nervous pregnancy, but also suggesting a tuberculous peritonitis (one patient was actually evacuated to a hospital for tuberculosis with this disease); gastro-intestinal disorder with aerophagy, aerocoly, and obstinate constipation (one case also showed almost daily vomiting). The genesis of the condition appears to be a contracture of the diaphragm in a low position of forced inspiration. The condition may be termed a diaphragmatic neurosis.

Psychotherapy was applied, the patient was requested to walk, and the movements made in walking required such an intense respiration that the diaphragm was forced to function, whereupon the “big belly” disappeared. The digestive disorders then rapidly disappeared. These authors suggest the name of _catiemophrenosis_.

War stress; collapse going over the top: Neurasthenia (hereditary taint; alcoholism).

=Case 349.= (JOLLY, January, 1916.)