Part 50

According to Beck, there was in his case of Shell-shock Rombergism no ear disease or any evidence of cerebellar or cerebral disease.

Walking with the eyes open yields in marked instances a sidewise bending or even the classical staggering called the duck’s walk and drunken gait upon a broad base. The most delicate test, according to Bourgeois and Sourdille, is the Babinski-Weil test of walking with the eyes shut. A man with labyrinthine disease deviates from the straight path (he is made to walk forwards and backwards ten times in a clear space); bends pretty constantly to one side when walking forward, and pretty constantly to the other side when walking backwards. Spontaneous and Babinski’s induced nystagmus (rotation; caloric) and Babinski’s voltaic vertigo test are the other tests commonly employed in equilibrium investigation.

Otology and neuropsychiatry should go hand in hand.

=Case 440.= (ROUSSY and BOISSEAU, May, 1917.)

A soldier in the engineers, 29, entered the neuropsychiatric center at Scey-sur-Saône, August 23, 1916. His diagnosis was: organic shock syndrome with right-side deafness and tremors. He carried a ticket showing an otological examination: tympanum normal; Rombergism absent; walks with eyes closed swerving to right; tends to fall, eyes closed, on standing on one foot; vertigo produced by rotation in either direction; no nystagmus either spontaneous or by test; deafness especially on the right side; equilibrium function insufficient.

The patient had undergone shock in April, 1915, being buried and then losing consciousness for twenty-four hours. The tremors appeared next day, and also deafness but without speech disorder. Nine comrades are said to have been killed beside him. The hospital ticket, April 13, said: deafness and multiple contusions from shell explosion. The patient was evacuated to Clarmont-Ferrand and went back to service with the same tremor and auditory disorder. He was shortly sent back to the interior for six months and returned improved to the front August, 1915. But he heard the cannon in the distance, and, under the influence of emotion and the fatigue of the journey, the tremors and deafness reappeared.

The tremor was generalized, involving both arms and legs and a slight lateral movement of negation of the head every ten or twelve seconds. Occasionally tonic contracture of the face, lips, cheeks, forehead; tremors of tongue; winking. The tremors were somewhat suggestive of toxic tremors.

The deafness was evidently exaggerated. Voltaic vertigo tested normal. Reflexes normal.

The diagnosis psychoneurosis was made and the patient was rigorously isolated, given a long psychotherapeutic talk concerning the nonreality of his deafness and his vertigo and the possibility of cure by means of a very disagreeable electrical treatment. He made improvement upon psycho-electrical treatment and the next day both tremors and deafness had greatly diminished. September 4, the patient was considered completely well. There was a slight diminution of hearing in the right ear, the whispered voice was heard at 50 centimeters on the right side, the watch at 25 centimeters on the right and 60 on the left.

October 5 the patient was sent back to his corps. On the evening of his departure, angry at not having received leave, he boasted to his comrades of having passed but three days at the front since his injury.

It is remarkable, according to Roussy and Boisseau that this patient had passed sixteen months without ever having been taken for a neuropath or treated as one. The otologists gave the diagnosis of labyrinthine shock, but did not attend to the tremors. The pseudo-symptoms disappeared in six days at the neurological center and the cure had lasted six weeks at the time of report.

_Re_ otology in these cases, see Bourgeois and Sourdille’s book mentioned under Case No. 439, particularly Chapter III, upon the functional examination of hearing. In the present instance, it will be noted that voltaic vertigo tested out normal. According to Bourgeois and Sourdille, the Babinski electrical test is the most convenient one to begin with, to learn in a few moments whether the vestibular system is working normally or not. These authors found amongst twelve patients, three normal reactions and one instance of hypo-excitability amongst four subjects who, by other tests, failed to show vestibular disturbance. Inexcitability as to voltaic vertigo was found in one man with a destroyed labyrinth. There were four instances of hyperexcitability in Babinski’s cases with marked equilibrium disorder. A case of Ménière’s disease yielded the same results. According to the intensity of the current, the following phenomena (in addition to the pricking sensation) are noted; (_a_) salty taste; (_b_) sidewise swaying with slight vertigo; (_c_) nystagmus with more pronounced vertigo; (_d_) sensations of sound. In short, nerve branches that go through the petrous bone, namely, the chorda tympani, the vestibular nerve, and the cochlear nerve, have been successively stimulated. Babinski’s test was published before the Barany work on induced nystagmus, but Barany’s rotation test for the physiological excitation of the semi-circular canals, and his caloric test for the investigation of the ears and canals separately are to be utilized in addition to the Babinski voltaic test. Babinski’s law of voltaic vertigo is that a normal subject inclines to the side of the positive pole; a pathologic subject falls to the side to which he tends to incline spontaneously. If the labyrinth has been destroyed, there has been no reaction.

_Re_ Case 440, Roussy and Boisseau in their capacity as neuropsychiatrists, point out the inadequacy of an otological examination taken by itself. They insist that neuropsychiatrists should be called in. It is probably equally true that neuropsychiatric work upon deaf cases is often inadequate on account of the lack of otological examinations. According to Bourgeois and Sourdille, the expert otologist’s problems are as follows: (_a_) Deafmutism; here Gault’s cochleopalpebral reflex is of value. The hearing of a sudden noise causes contraction of the orbicularis palpebrarum on the side upon which the noise is suddenly and unexpectedly made. Eyelash tips are particularly watched.

(_b_) Complete bilateral deafness. This is practically never organic; complete bilateral deafness is a phenomenon either of traumatic hysteria or of simulation. Sundry methods of surprising the patient into hearing have been adopted. The practice of teaching lip-reading to simulators and hysterics has led to some difficulties in diagnosis, but tests have been produced by Gosset (of one sound with the lips set to form another, and the like) which are of service.

(_c_) Extreme bilateral dulness of hearing.

(_d_) Total unilateral deafness. For the minutiae of tests for these types of hearing disorder and their simulation and exaggeration, see the War Manual of Bourgeois and Sourdille.

Jacksonian syndrome: Hysterical.

=Case 441.= (JEANSELME and HUET, July, 1915.)

A Lieutenant of Infantry, 32, was struck by a bullet September 6, 1914, in the upper part of the left temporal fossa 4 cm. above the external auditory meatus. He did not lose consciousness, but had the sensation as if his head had been shot off, and about three minutes later he turned about, fell down, and lost consciousness. However, he regained consciousness a few minutes later and walked with support for about an hour. At the ambulance, he lost consciousness again, for half an hour. He was then carried to Amalie-les-Bains. The trip lasted 108 hours. The left side of the face was now swollen so that he could not open the eye nor could he chew from swollen mucosa folded between the jaws. The bullet was removed Sept. 12, from just below the scalp outside the bone, the point being slightly bent back. The bone had been depressed slightly for an area the size of a franc piece, and pressure at this point yielded a feeling of pain and discomfort. There was no suppuration. After a week, the man got up. He returned to his dépôt October 3 or 4 and was about to rejoin his corps when he had a sensation of pressure in the head and fell. When he came to himself he found that there was a frothy saliva at the left side of the mouth and that the whole left side of the body felt weak. The tongue had not been bitten nor had urine been passed, and twenty minutes later he felt as well as ever. He returned to the front in the Argonne, having from time to time similar crises,--at least once a week. Ordered to take a trench the night of January 17, he failed the first time, about midnight, but succeeded at four in the morning,--just afterward falling exhausted in another crisis, with unconsciousness. The stretcher bearers took him back and he was evacuated to Perpignan. He had two convulsions.

While with his family the crises grew in number to three or four a week, and sometimes twice a day. Upon request, he was sent to hospital in the Pantheon May 5.

There was always a sensory aura, consisting in a violent shock felt in the left side of the cranium like a blow of a club. There immediately followed a crawling sensation in the fingers and hand of the left side, running up the arm, with loss of consciousness coming on before the crawling reached the elbow. The seizure would last two or three minutes. There was no initial cry. The face grew pale. There was apnea, and frothy fluid running out of the left side of the mouth. There was no jerking of face or limbs; at the end of the seizure there were no deep inspirations. The extremities of the left side were rather flaccid during the attack.

A hemianesthesia was found affecting both skin and mucosae of the left side, and a slight retraction of the visual field on the left side was found. There were no other sensory disorders; the knee-jerks were lively on both sides but not actually exaggerated. Plantar stimulation was not perceived on the left side. The toes, except the great toe, were slightly extended. The fascia lata reflex failed to demonstrate itself. On the right side the great toe went into flexion on forcibly stimulating the sole. Sometimes the abdominal reflex on the left side was weak or even absent. The patient, who had never been nervous, had now become so since his attacks. He had had nocturia up to 12. There was no evidence of neurosis or psychosis in the family. Bromides diminished the crises a little in number. Static electricity was given from January 8,--no attacks for 8 to 10 days.

According to Jeanselme and Huet, this is a case of Jacksonian syndrome of an hysterical nature, about which it may be noted that the bullet struck the left side of the skull and the hemianesthesia and muscular resolution appeared on the same side as the injury.

Leg tic: Phobia against crabs.

=Case 442.= (DUPRAT, October, 1917.)

A man, shell-shocked in 1916 (with loss of consciousness, disorientation and confusion followed by nightmares, memory disorder, attention disorder, irritability, mental instability and over-emotionalism) later still showed a choreiform tic. He had a knife-grinding movement of the left leg which made standing and walking difficult. There were no signs in the reflexes or reactions of organic disease. The man himself said that he felt a sensation like little electric shocks when his foot touched the ground, a sensation like pinching. He also had certain hysteriform crises. He was able to remember nightmares in which he felt as if he had fallen into a hole where there were crabs. In point of fact, he had a true phobia against crabs, crayfish, lobsters and the like; if he saw one, he always felt as if he were going to have a new crisis. The defense movement of the leg and foot was against a supposed pinch of the crab. At rest, there was no trace of the choreiform movement. The tic was especially marked when the man was suddenly asked to get up and walk. In a few days, when he had become more clearly conscious of his phobia and had slept better, the tic grew appreciably less.

Convulsions reminiscent of fright.

=Case 443.= (DUPRAT, October, 1917.)

A soldier, 28, was blown up February 8, 1915, by a shell burst. He sustained no contusions but became completely mute. On July 3, he began to speak in a low voice. The _torpillage_ treatment was unsuccessful because the man felt a morbid apprehension that the vibration of a loud voice or even of a rapid walk would resound in his brain. He had a sort of noise phobia, probably maintained by nightmares which frequently woke him up with a jerk though he could not remember their content. On the way back to his dépôt this man got off the train at the first station and went to a hospital complaining that the vibration of the train was going to be transmitted to his brain. Hysteriform crises developed in a few days.

According to Duprat these crises are nothing but a psychomotor development of the initial complex. The clonic and tonic convulsions are reminders of his states of extreme fright, a phenomenon of revival of the ideo-affective process, aggravated however by the oniric or post-oniric images.

_Re_ diagnosis of hysterical fits, the absence of facial cyanosis, sub-conjunctival hemorrhages, petechiae of skin, and the Babinski reflex are suggestive for hysteria. Babinski points out that the initial cry, the fall, the loss of consciousness, the tongue-biting, the bloody frothing at the mouth, the urinary incontinence, and the post-convulsive prostration can all be consciously or unconsciously imitated. Hysterical convulsive movements are apt to be of wide range, gesticulatory, and opisthotonic.

Babinski announces to the supposed hysteric that he is going to reproduce the attack, as he is perfectly able to do by electricity. A mild current or mere electrode application suggests a fit in a hysteric, often very quickly. Babinski now announces that he can arrest the fit; carries out some selected procedure, and stops the fit. During the hysterical fit, the patient of course hears what is being said and during this time wrong suggestions must not be offered.

Fugue in a motor cyclist, with prodromal fatigue and subsequent delusions--recovery in six weeks.

=Case 444.= (MALLET, July, 1917.)

A motor-cyclist, 36, with the colors from the outbreak of the war, about April, 1916, grew very weary, suffering from headache and seizures without loss of consciousness. Finally there was a voice: “Sleep, you must sleep.” Then other voices; then ideas of thought transference with people around him.

Observed in the psychiatric center, May 12, 1916, he had the same ideas of thought transference, and he made as if to talk with the attendants by responsive-looking gestures. Sometimes, he said, fluid struck his forehead, calling on his thought. Whereupon he listened. The man made no complaints about his plight, was not astonished in any wise at what was happening, nor did he seek to explain it. There was nothing in his history to suggest psychopathy except perhaps that his father was unknown.

The diagnosis of a chronic hallucinatory psychosis was made, but the outcome promptly overset the diagnosis. The man talked with ward-mates, and particularly with another patient who also talked about thought transference. This shook the man in his convictions, and he decided that it was but imagination and delirium.

He now told his story: How it seemed that he had in his thoughts the phrase, “Sleep, you must sleep;” how he had gotten up, saying, “No;” had noticed the others paying no attention to him; had gone back to his work and from that moment had begun to go into delirium. During this delirium or delusional state, his whole life from birth up, came back to him, as if some one were telling him. The headaches, which he at first felt due to Hertzian waves, suddenly ceased.

Shortly, however, a new phase had set in, in which he felt himself surrounded by spies and that others had control of his thoughts and were reading them. In fact, he grew a little proud of the fact that people reading newspapers all around him were actually reading his own thoughts. The letters he wrote were being dictated. May 9, he spent a night with a succession of nightmares, and woke up with the firm purpose of going back to Paris by motor cycle to find the spies. He described his fugue and the thousand ideas he had on the way, his arrest, his imprisonment in a cell of Hertzian waves with a smell of sulphur and poisoned bread--a necessary fate on account of the spies.

On arrival at hospital, he had not known what was going forward. The nurses were giving him milk to destroy the taste of sulphur; the delirium then grew less and less. The room-mates were neutrals, war-weary; he seemed to be reading the newspapers before his mates, and they seemed to be talking of thought transference. May 20, the ward was changed. The new ward-mates did not believe in thought transference and laughed, causing the man to doubt.

June 2, the cure was in full process, and the ward was changed again; but in the new ward was a patient who had the same ideas of thought transference as the patient. At this time, the man’s autocritique saw through the delusion. He talked with his telepathic comrade and pretended to engage in a fake conversation about it. The delusions shortly disappeared, having lasted about six weeks.

Ordinary gunner’s life; a few days’ feeling of moral and physical discomfort: Obsession leading to fugue.

=Case 445.= (MALLET, July, 1917.)

An artilleryman, 32, gave himself up a few kilometers back of the lines, three days after deserting his post. The man was a very good gunner and had never been punished once. Moreover, the battery was not under any special bombardment, and he had been in the same place a number of weeks.

He explained that he had gotten tired during the last few days. Everything was well at home and in the regiment, but he felt sad, his head felt bad, and he couldn’t sleep. Something drew him to leave, but then “_sang froid_ came back to me, and I gave myself up.” He had lived the three days without eating and without sleeping. He was very emotional over what he had done, but he began to work and asked that he be sent back.

His mother had been very nervous. There was a marked facial asymmetry and faulty arrangement of teeth. The man was not alcoholic.

According to Mallet, in these cases of fugue, and in other cases of absolute delirium of apparently sudden onset, there is a feeling of moral and physical discomfort for some days before the outbreak. The outbreak itself is sudden on the occasion of some idea, either an obsession or a hallucination. Of all the prodromal signs, headache is the most striking. According to Mallet, such fugues are the expression of a mental imbalance allied to the onirism of Régis.

Aprosexia and bird-like movements.

=Case 446.= (CHAVIGNY, October, 1915.)

A soldier of the dragoons, 25, entered Chavigny’s service May 30, 1915. He acted like a mechanical figure, requiring guidance. The face was without expression except for the mobile eyes, and sudden bird-like movements of the head, continually attracted to new noises and objects. An interlocutor was glanced at but not responded to. If an intense electrical shock was passed through his abdomen, for example, the man would look for a moment in that direction, but only the most fugitive defence reaction would be made, and the stimulus could be repeated with the same result, a moment later.

After three days, this aprosexia began to clear, and in four or five days, answers to questions and ordinary associations set in. Memory reappeared. It seems that he had been in concealment in the loft of a barn, when he saw his commanding officer carried by, having lost an arm and a leg. He lost consciousness and fell three meters, through the trapdoor of the loft. There was thus a combination of trauma and emotional shock. No external lesion was produced in the fall. His memory showed a very sharply defined gap for the period of his aprosexia with the bird-like movements, of eight days, and his memory was perfectly good up to the time of the fall. This is one of five cases observed by Chavigny, who remarks that there is something in the attitude of the young child which recalls the aprosexia of these patients. (Perhaps the phrase of James, “buzzing, blooming confusion” might be used.) One must go back to a period in the child’s development when he is not yet able to smile or keep his glance fixed on a shining object. On the whole, the resemblance is closer to the attitude of certain caged birds.

_Re_ aprosexia and bird-like movements, see discussion under Case 353. See also Case 334.

Shell-shock; unconsciousness (45 days): Mutism (monosymptomatic).

=Case 447.= (LIÉBAULT, 1916.)

A soldier, 32, had a large caliber shell burst one meter from him September 26, 1915, lost consciousness and remained comatose 45 days. He then got progressively better but did not recover speech. He was neither blind nor deaf. He was examined at the neurological center at Nantes and there Mirallié called him a case of hysterical mutism, finding no paralytic disorder of any sort and finding the patient able to write his story, to read and to understand what he read, but without much power of retention. He was placed in the phonetic reëducation service March 30, but made no progress. In the effort to speak the patient made strong generalized contractions, including contractions of his face and winking of his eyes, contractions of the jaw, and movements of the neck muscles. In fact, he seemed to be agitated by a sort of cervico-facial tic, and sometimes, although not always, he succeeded in getting out a loud voice sound, in which one could imagine the syllable that he was trying to utter.

In this case the mutism was evidently secondary to motor disorder. It is an example of functional dyskinesia (Benon). As long as this functional dyskinesia remains, the patient will not speak. The respiratory muscles are disordered, since the respiratory capacity does not go over 3 liters. This approaches the normal, however, and if the subject cannot speak it is because his diaphragm is subject to jerky or cramplike movements and because the lips and tongue do not execute the proper movements either for sounds, syllables or words. Such a patient cannot protrude the tongue or even bring it beyond the teeth.

Shell-explosion: Recurrent amnesia.

=Case 448.= (MAIRET AND PIÉRON, April, 1917.)

A shock case of Mairet and Piéron had a disorder of memory. Association paths were open one day and closed the next. Subjected to shell-shock, September 18, 1915, he was found wandering in the woods a few days later, having completely lost his memory, even for his name. In November he recovered his surname but not his given name. On stimulation he was gotten to remember his city, his father, the street, and the like. Shortly he could get back his memories more quickly; after a week it took only 35 seconds to remember that he was born at Paris. However, his recollection of the Trocadero and of the Eiffel Tower, which had come back to him in November, 1915, was lost again in April, 1916, to return once more in August. December, 1915, he could not write to dictation, but copied writing as he would a design. He suddenly felt himself able to write in the Morse code (he was a telegrapher); then ordinary writing returned. February, 1916, however, he had forgotten what the Morse code was. In April, he was taught numbers. One day he would know left from right, but had forgotten it by evening.

Shell-explosion: Comrade killed: Amnesia.

=Case 449.= (GAUPP, April, 1915.)