Part 42

An infantryman, 20, boxer by profession, was brought with other wounded, in the night, to Saint Nicolas Hospital and was seen next morning, August 24, in bed, lying motionless on his back, eyes open, fixed, eyelids not winking. No reply was got to questions. The arm lifted fell back upon the bed, although slowly and not heavily as in apoplexy. There was no catalepsy. The patient was taken from his bed and put upright. In this position he remained immobile, hands at side, head bent forward, eyes fixed on the ground. The eyelids did not move upon approach of the finger or a lighted candle, unless there was a fine beginning of movement. If he was pushed, he made two or three steps forward, with eyes fixed on the ground and head bent forward. The only spontaneous movement was carrying the left hand back to the side as if to take the bayonet. He got into bed alone.

Next day the patient could walk better and began to talk, but preserved the same absorbed attitude. He told, in monotonous voice, of the shells that his squad had received and of the dead that he saw about him. August 27 he woke up and was unable to tell how he had come to the hospital. He told how the regiment had been bombarded for a time and how a shell burst near him; how he got a splinter in the buttock (of which the contusion was still visible); and how he had been thrown down by the windage of the shell. His sack had been torn from his shoulders. He had lost consciousness, he thought, for a short time, anyhow he could not find his regiment. He passed the night near Longuyon and next day looked for his regiment again. Shrapnel burst near him, and from that time forward he had lost memory. August 27, at his express request, he started back for his corps. There was no stigma of degeneration or hysteria.

Burial; struck in head by beam; overcome by gas: Tremors, convulsive movements, confusion, flight toward enemy.

=Case 367.= (CONSIGLIO, 1916.)

An Italian private, 28, of meager build (infantile eclampsia; brother epileptic) was buried by a shell explosion and overcome by gas. After a month’s leave he went back to the trenches.

But now, whenever a shell burst, he fell into irresistible terror and made convulsive movements which he forgot afterwards. He could not sleep. The mere memory of the scene would throw him into terror. He was tremulous, developed asymmetrical innervation of his face, was generally hypesthetic and mentally blocked.

In the midst of convulsive tremors he fled towards the enemy. He was stopped and brought back, and remained for two days confused and hallucinated.

In the original accident he had been struck in the head by a beam.

_Re_ this Italian’s flight toward the enemy, see various cases of fugue. Clinically and medico-legally, Roussy and Lhermitte remark that these confusional escapades are of great interest, and that many cases are encountered near the front line, put under trial by court-martial, and handed over to specialists. The dream is being lived through. Such a case as this of Consiglio recalls the hystero-emotional psychoses of Claude, Dide, and Lejonne. The relation of oniric delirium to mental confusion is still a matter of polemic. According to Régis, however, the common oniric delirium of toxic or infectious origin is nothing more than a sort of somnambulism. The retrograde amnesia which follows toxic delirium is the same in principle as that which follows hysterical delirium. Régis pointed out that suggestive hypnosis could bring back the memories in both types of disease, as well as from the toxic delirium as from the hysterical somnambulism. However, the differential diagnosis between onirism and hysteria is not easy. Alcoholism and actual brain trauma need to be excluded.

Shell-shock; windage; unconsciousness: Carried on with fugue tendencies. Variety of hysterical symptoms. Fit for garrison duty four months from explosion.

=Case 368.= (BINSWANGER, July, 1915.)

A non-commissioned officer, 22, entered service at 20, went into the artillery and had been advanced repeatedly. There was no heredity; the man had been a moderately good scholar. It appears that he had had at 17 a febrile angina with delirium.

September 25, 1914, a big shell load for a cannon was exploded by the enemy. All the men about the cannon were thrown to the ground by air pressure, and the officer became unconscious. On awaking, he had headache, dizziness, and vomiting. There were many corpses lying about him.

He resumed work at once, but in the evening his headache and dizziness increased and there was “a feeling inside as if he had to run away.” This feeling appeared to come from the heart; it was an oppressive feeling, running to the head. On the next day he did gun duty, noticing, however, that every shot he fired caused him a sharp pain. He was relieved from work at 11 A.M., and was declared ill by the physician. His comrades told him that he had often been noticed trying to run away, but about this he himself declared he knew nothing.

He was received at the Jena Hospital, October 9, 1914, a very strongly built and well-nourished man. Neurologically, he showed a marked dermatographia; knee-jerks were obtainable only on reinforcement; Achilles jerks somewhat more marked; there was a weakly positive Oppenheim reflex. The abdominal reflex on the left side was greater than that on the right; and this was also true of the cremaster reflex. Percussion of the head was extremely painful; and there were painful points on pressure of the spine and head.

Touch was poor on the entire left side of the body; but there was no diminution of sensibility to pain. There was a fine static tremor of the hands. The strength of both hands appeared to be decreased (dynamometer). Gait was unsteady and stiff; Romberg sign was positive; the patient fell over backward. Hearing was greatly diminished, ordinary speech being heard only close to the ear.

Toward evening of the second day after admission, there was a marked attack of dizziness while the patient was lying on his back in bed. During this attack the face was very red. It lasted two or three minutes. Hearing was remarkably improved on the left side for some time after the attack. The ear clinic examination, October 19, showed much disturbance of hearing on the right side (direct injury of the vestibular apparatus in both ears).

Headaches continued, radiating from the orbit to the top of the head, and sensitiveness to pressure at the exit point of the upper branch of the right trigeminal. The whole of the forehead was somewhat red and swollen (neuralgia of the frontalis). The patient wore dark goggles on account of his marked photophobia.

Improvement was gradual; there was a transient slight swelling and a venous hyperemia of the nasal mucosa, which was treated in the nose clinic. The impairment of hearing was quite gone in two months’ time, though buzzing was now and then heard in the right ear. The supersensitiveness in the right upper trigeminal region vanished also. The patient was discharged January 21, 1915, fit for garrison duty. Later he went into the field again.

Burial: Dissociation of personality.

=Case 369.= (FEILING, July, 1915.)

The following are some stories told by a “lost personality” under hypnosis.

The patient, aged 24, was a bandsman in the Second Battalion Wiltshire Regiment, who sometime near the end of October 1914, was buried in a trench near Ypres. This is his account:

“I was dug out at night and taken to a dressing station; it was cold and dark. Then I went on to a hospital at Ypres; it was really a convent, and there were a lot of nuns about, dressed in dark robes with white hats; some of them spoke English. I stopped there for a night and a day. There were a lot of wounded there. Then I was sent on by train; I lay down all the way on a seat in the carriage; we took the whole day to get to ----, and kept on stopping at stations. I was at ---- about ten days; I don’t know what hospital it was, but there were English doctors and nurses. It was near the harbor. We came over to England in a hospital ship, the _Arethusa_; I went straight on to Manchester by train. The hospital there was really a school turned into a hospital.”

Here is a brief account of a scrap with some Uhlans.

Q. Did you see any Uhlans? Yes.

Q. What are they like? They’ve got no guts. One time 30 of them were against 8 of us infantry, and they “done a bunk.” Their horses were not bad. They wore helmets with a double eagle on the front.

He was asked to describe the country round the trenches and to give some account of the fighting there:

“It’s agricultural land, ploughed fields. There were two farms in front of us. One day we saw an old cow between our trenches and the Germans, and we all had pot shots at it. Once the Germans rushed our trenches; we killed hundreds, bayoneted them mostly, and hit them over the heads with the butts of our rifles. It was hellish. The British were all shouting. I saw a German officer behind with a sword and a revolver. I saw a lot of French soldiers, too; they wore long coats with the corners turned back; some had blue and some had red trousers. The French dragoons are like Life Guards, with big steel breastplates and brass helmets with a long plume; they carried swords and rifles and a few had lances.”

He was asked to mention some of his impressions in Belgium and what he thought of the manners and customs of the French and Belgians.

“We cut off all our buttons and gave them to the French girls. The French cigarettes are muck; you buy them in little blue packets; the tobacco is rather dark and strong. When we bivouacked on the march at night we were not allowed any lights, but you could smoke by digging a hole in the ground with your bayonet and smoking into that.”

The following are some of his remarks about his stay at Gibraltar.

“Gibraltar’s like a great big rock; the steep side looks toward Spain. I was in barracks there, and used to spend a lot of time in the band-room practicing. Sometimes we bathed in the sea. I went to Spain two or three times and saw some bull-fights; they were very exciting, but rather too cruel for my taste. They used to kill six or seven bulls a day. The horses got fearfully cut about.”

This bandsman showed what Feiling calls dissociation of personality. There was an amnesia of such degree that all conscious memories of the patient’s life, as well as all memory of letters, objects, and life in general, were suppressed. The patient was brought, after the burial above noted, to the hospital for epilepsy and paralysis at Maida Vale, January 21, 1915. After his experience, he had been transferred to the Second Western General Hospital, Manchester, where he spoke sensibly, understood and was able to remember things since the burial. His mind was a complete blank for all previous experience. He was unable to recognize his own father or relatives. He was slightly deaf for a time but this defect disappeared.

At Maida Vale he showed a nervous twitching of eyelids and facial muscles; otherwise he was neurologically and physically normal, dreamless, without complaints, and straightforward about all experiences since coming to himself in the hospital at Manchester. He took his parents on trust. “I don’t know if I ever went to school.” “A bayonet is like a knife; you see soldiers with them on their rifles. I have never seen a bullet.” His memory for recent events was also not good. He once recognized a single tune played at a concert.

Suspected of malingering, he was tried out in various ways. He was told that an elephant was a little furry animal and shown a little 6 inch toy sample. On going to the zoo he was greatly astonished at seeing a real elephant. He did not know what the war was about and he had no interest therein.

March 10 he was hypnotized and proved an easy subject. Powerful suggestions that lost memories would return were unavailing. The next day, during hypnosis, it was found that his previous experience could be readily tapped, and a history of his family, schooling, running away, and eventual enlistment was told. He had been at Gibraltar when war broke out. He was at the first battle at Ypres, and was for ten days in severe trench fighting, and was finally buried in the mud and débris of a trench blown in by a high explosive shell. He had been buried for about 12 hours, was dug out at night, and (according to his father) remained unconscious 24 hours, and deaf and dumb three days. He was transferred to another hospital and then to Manchester, where he came to himself.

Only during the first few sittings did the patient lie with eyes closed. Later, during hypnosis, he behaved exactly like a normal person. The fact came to light that when hypnotized the patient returned to the personality that possessed him just before awakening in Manchester, and accordingly during hypnosis, he had to become acquainted again with his hypnotizer. Maida Vale astonished him, as it should have been Manchester. Thus there were two personalities: No. 1: The personality since the date of the Manchester awakening; No. 2: The personality containing all the memories of the past life as well as the more recent Flanders memories. In State No. 1, the manner was jaunty and cocksure. In State No. 2, the man was more modest and less loud. Moreover, though in State No. 1 he spoke with a Lancashire accent, in State No. 2 his speech was in the West Country dialect--a strange observation, confirmed by several observers. He was asked to write down the answers to questions, and on awakening from hypnosis was shown the things written; whereupon he laughed and said, “Why, that’s not my writing.” On writing out the same sentences again, various minor points of difference were apparent. Hypnotized in the presence of his father, in whom in State No. 1 he took no great interest, he showed every sign of joy, causing his father to think that in State No. 2, his son had “come all right again.” In State No. 2 he could play a euphonium better than in State No. 1; but after practicing in State No. 1 he rapidly became as expert as in the hypnotic state.

If the patient were left for some time before being awaked by a previously-arranged method of counting three, he would experience disturbed dreams, with clenched hands, snarling lips, and muttered phrases, “Give it them,” etc.

Twenty-five hypnotic sittings were given but no improvement took place and the patient was discharged May 5. May 25 there had been no further change and he remained in State No. 1, in which state he was invalided from the service by a medical board, May 28.

Ear complications and hysteria.

=Case 370.= (BUSCAINO AND COPPOLA, 1916.)

An infantryman, 22 (father and mother quite normal; patient showed slight convulsions, attributed to worms, from which he actually suffered; was malarial from 9 to 15; had otitis media and lost hearing completely at 11; had suffered from 9 onwards with joint pains; as an adult had no convulsions), was called to arms August, 1914, and sent to the front May 2, 1915. About the end of August, in a water-filled trench by Monte San Michele, he was covered with mud from a shell explosion, lost consciousness, and in some way got back to the second line. He was told that blood had flowed from the right ear, and on recovery he found himself unable to hear with that ear, although it was the left in which he had had otitis. There were continual noises in the ear. He was, however, sent back to the front line. By mistake, one day, he got with companions in the midst of the enemy’s barbed wire, saw sparks from the guns, heard no shots, saw comrades fall, and threw himself instinctively into the wire network. Leaving the food kettles, he finally got back to the trenches. He was sent to the hospital at Legnano for his ear pains, and was treated by leeches, which he could not feel. He began to hear a little more. Flies walked on the left cheek without being felt. This anesthesia had begun a few days after the shell explosion. He was transferred to a military hospital at Florence.

One day he wedged a toothpick in cotton into his left ear and was charged with simulation, though he had been absolutely deaf in his left ear since childhood. From the moment the military surgeon told him he would be denounced for simulation, he lost his memory. Reports indicate that he had headache and delirious dreams (October 30), and suddenly he became furious (October 31), about three hours later going into severe collapse, for which camphor injections were given.

November 1 he had battle dreams and lumbar puncture had to be given up as he was in the midst of an attack. A hypodermic injection was interpreted by the patient as a wound, and he cried as if he were being abandoned on the battle-field. At one point he woke up from his hallucination and asked where he was and shortly relapsed into stupor. November 2, the patient was slightly bewildered and felt pains where the lumbar puncture needle had been tried the previous day. November 5, he was disoriented, thinking himself still at Legnano. The pupils were throughout dilated. November 6, confused and dreamy; November 7, he soiled his bed, was somewhat disoriented, immediately corrected himself; oculo-cardiac reflex 64 full compression, 62 during compression. November 11, headache; November 12, a slight bewilderment reappeared; November 13, remembered for the first time having been stunned by shell explosion, and this day got up and wrote home. November 14, complained of pains in muscles and weariness. Pupils still dilated. November 16, pulse 86; a gradual increase from 50 to 60 during previous days. November 17, patient had begun to remember facts that preceded the dream syndrome. November 18, pulse standing 88; November 20, pulse standing 120. This day cried when he remembered having been suspected of simulation. November 22 and 23, aches in joints and intense otalgia; pulse 86. November 24, diarrhea; deafness somewhat diminished; 26, diarrhea; looked as if he were about to have a new hallucinatory episode. This, however, did not come about until December 1, when he heard cannonading and knew the regiment was near. Next day he had forgotten the cannonading. December 14, the patient had become entirely tranquil and lucid and was able to give his entire history. December 16 and 17 he was given a systematic neurological examination, which showed on the left side complete anesthesia, hyperesthesia to pressure, thermanesthesia, analgesia, loss of bone, tendon, and muscle sensation. Vision was diminished more on the right side than on the left, and the visual fields on this side were more contracted. During examination, the fields became still more tubular. There was complete deafness, anosmia, and ageusia on the left side. On the right side there was a slight diminution of hearing. The pharyngeal reflex was abolished; the cremasteric reflex was somewhat less on the left than the right; and the defensor reflexes of the left leg were less marked than those of the right. There was no clonus or Babinski. The dynamometer grasp on the right was 37; on the left 18; and on this side there was a limitation of voluntary movements.

CHART 10

ETIOLOGY OF SHELL-SHOCK

WOUNDS 14 of 150

PHYSICAL EXHAUSTION FROM EXPOSURE, HARDSHIP (all neuropaths) 3 of 142 CONCUSSION 52 of 142

CHEMICAL--SHELL GAS 3 of 150

PSYCHIC GRADUAL EXHAUSTION, PREDISPOSING (43 neuropaths) 51 of 132 SAME, ACTING PER SE (patients chiefly neuropaths) SUDDEN SHOCK HORRIBLE SIGHTS 51 of 142 LOSSES OF COMPANIONS FRIGHT NEAR EXPLOSION (one neuropath) SOUNDS (a few neuropaths)

RELAPSES (41 of 150 observed, three-quarters neuropaths)

After Wiltshire

C. THE DIAGNOSIS OF SHELL-SHOCK

Chè non è impresa da pigliare a gabbo descriver fondo a tutto l’universo, nè da lingua che chiami mamma e babbo.

For to describe the bottom of all the universe is not an enterprise for being taken up in sport, nor for a tongue that cries mamma and papa.

Inferno, Canto XXXII, 7-9.

In the course of our study of psychoses incidental in the war (Section A) and especially of Shell-shock’s nature and causes (Section B), we have naturally met most if not all of the major diagnostic difficulties. In the present Section we shall study cases for the light they may throw on the more technical troubles of the diagnostician. Who would _à priori_ have felt that such diseases as tetanus, rabies, malaria, would produce practical difficulties in clinical diagnosis in the field of Shell-shock?

Mayhap there was no need to emphasize further the values of lumbar puncture fluid examination. Yet the admixture of “functional” and “organic” symptoms in numerous puzzling cases can hardly be over-emphasized.

But the interpolation, through the ingenious inquiries of Babinski, of a new or but vaguely suspected series of “reflex” (“physiopathic”) troubles between the organic neuropathic disorders on the one hand and the hysterical psychopathic disorders on the other--the result of these observations, sampled only in Section B, is given more in detail in the present Section. What a split in therapeutic method a recognition of this new group of “physiopathic” disorders might entail is seen also in further cases in the Section that follows this (Section D on Treatment and Results).

A number of simulation cases has been added.

CHART 11

ETIOLOGICAL GROUPING OF WAR PSYCHONEUROSES

I. NEUROSO-ORGANIC ASSOCIATION (NO CAUSAL NEXUS)

II. REFLEX NEUROSES (LESION DISPROPORTIONATELY SLIGHT BY COMPARISON WITH PSYCHONEUROSIS)

III. NEUROSO-SOMATIC ASSOCIATION (TRENCH FOOT, NEURITIS, RADICULITIS)

IV. FATIGUE OR EMOTIONAL PSYCHONEUROSES (CONSIDER EFFECTS OF PSYCHIC CONTAGION, EDUCATION)

V. PSYCHONEUROSES ON ANTEBELLUM BASIS

After Grasset

CHART 12

WAR PSYCHONEUROSES

SYMPTOMATIC GROUPS

I. EMOTIONAL (HYPER- HYPO- PARA-)

II. CONFUSIONAL (ATTENTION AND MEMORY DISORDER, DREAM STATES; DELIRIA)

III. CONVULSIVE AND PITHIATIC (HYSTERICAL)

IV. NEURASTHENIC AND PSYCHASTHENIC

V. SENSITIVOMOTOR AND SENSORIMOTOR--_e.g._, LIMITED PARALYSES, CONTRACTURES, DEAF-MUTISM

VI. COMPLEX

VII. PHYSIOPATHIC (BABINSKI)

After Grasset

Value of lumbar puncture.

=Case 371.= (SOUQUES and DONNET, October, 1915.)

A colonial soldier arrived at Paul-Brousse Hospital with a hospital ticket showing that ten days before he had had _commotio cerebri_. He was dull, had a fixed stare, held his head in his hands, was disoriented for time and place, and had lost memory for everything that had happened for eighteen months. There was no sign of wound. There was no motor disorder save that walking was a bit slow and uncertain. Perhaps the right knee-jerk was stronger than the left. Percussion of the right Achilles tendon produced tremor. The plantar reflexes were flexor on both sides; flexion lasted longer right than left. The cremasteric and abdominal reflexes were a little weaker on the right. Arm reflexes were lively. Sensations proved normal. Complaint of headache, frontal and vertical.

Lumbar puncture October 7, that is, on the thirteenth day after the shell-shock, yielded a transparent, slightly greenish fluid, with 92 cells per cm. (lymphocytes with one or two large mononuclear cells and a few sometimes degenerated endothelial cells) and hyperalbuminosis.